Orthopedic Coding Alert

Coders who write off x-ray fees for SNF patients could be forfeiting thousands by not following up on the technical component of the x-ray fee.

If you saw $1,000 sitting on the sidewalk, would you pick it up? Most people would answer a resounding "Yes!" to this question. But many orthopedic practices have grown so tired of trying to collect the technical portion of x-rays from SNFs that they no longer attempt to capture those dollars. If this describes your practice, don't give up hope.

We-ve gathered success stories from orthopedic coders in the field whose tenacity paid off, and they are bringing in x-ray money without a struggle. Follow their seven steps to put your SNF x-ray collections in the black.

The problem: When coding for skilled nursing facility (SNF) patients who present to your orthopedic practice for x-rays, you should bill the physician's x-ray interpretation to Medicare with modifier 26 (Professional component) appended, but you must bill the technical component (the radiology clinician's portion) directly to the SNF.

Many orthopedic practices find this procedure so frustrating that they tend to write off the x-rays- technical portion, which can run anywhere from $17 for 73020-TC (Radiologic examination, shoulder; one view; technical component) to $52 for 72114-TC (Radiologic examination, spine, lumbosacral; complete, including bending views).

But if your practice sees SNF patients frequently, these fees can add up, and writing them off is not a valid solution. Even at the lower end of the spectrum, if you see only 50 SNF patients for shoulder x-rays each year, you-ll forfeit $850 if you fail to ask the SNF for your rightful reimbursement. More realistically, however, you-ll perform a variety of x-ray sites and views, leaving you seeking thousands in technical component reimbursement each year.

Two practices report that they have successfully established systems to bring in these fees. Here's what they did to collect.

Often, the first hurdle is determining whether a patient is from a SNF, because a family member may bring the patient to the practice.

The ideal situation would be to determine the patient's SNF status when he calls to make the initial appointment. If the patient is in a SNF, the front-office staff should get authorization to x-ray the patient and record the name of the SNF staffer who gave authorization.

But even if your receptionist tries to identify all SNF patients during the initial phone call, you may still miss some. In those cases, "You kind of need to be a detective," says Angie Good, CPC, coder at the Orthopaedic Institute of Ohio. "Observe who brought the patient in -- are they wearing a badge from a nursing home? Some patients come with a packet of papers from the nursing home that need to be filled out for the visit. Ask, ask, ask!"

In addition, Good says, when you verify the patient's address, he might mention that he is in a nursing home. Let your front-desk staff know to keep an eye out for SNF patients so the coder will have a heads-up about billing the SNF for the technical component.

Once you establish that the patient is in a SNF, you should flag his or her chart for future claims, says Jenny Harrison, coder at N-Orthopedics PC in Gaylord, Mich.

Although some orthopedic practices believe they have to write up complex contracts with the nursing home before they can capture payment for the x-rays- technical portions, this is not accurate. "A clarification from Medicare was issued in January 2005," Harrison says. "It states that an arrangement is validated not by written documentation, but rather compliance with requirements. We have three SNFs that we mainly deal with and have had no problems with them."

Some orthopedic practices note that consolidated billing allows them to bill the SNF for a much higher amount than they would collect from Medicare. Their rationale is that because they are billing the SNF directly, they are no longer bound by Medicare's set fees for the services. In many cases, this is accurate. But many practices report that struggling to get additional dollars from the SNF over and above the fee schedule amount is not worth the time and effort, particularly if you deal with numerous SNFs.

"We probably could negotiate a higher fee, but we deal with over 60 skilled nursing facilities, and that would be quite the undertaking," Good says.

In some cases, the SNF may not know why you-re sending them a bill and may simply deny payment due to lack of awareness.

Take these experiences, and turn them into a chance to build a partnership with the SNF administrators.

"I recently had this situation with a SNF that I had never dealt with before," Harrison says. "Fortunately, this was resolved with a phone call to the SNF administrator. I simply reminded them of the Medicare guidelines and requirements for this, and I received my payment within 10 days."

As we mentioned in Tip 1 above, you should let your receptionist know to be on the lookout for SNF patients. In addition, keep your billing staff on top of the SNF patients- charts. "Our business office staff member, Barbara Ernest, does a fantastic job of keeping up on the status of the claims," Good says. If payment doesn't arrive, Ernest phones the SNF and submits another bill if necessary.

From time to time, Medicare will pay your practice the global x-ray fee, but it will almost always ask for a refund, and you should always send the technical component refund and then bill the SNF for the technical portion.

"Every once in a while, we will get one that needs a little more effort with collecting than we would like, but we have never written one completely off," Good says. "They will pay."

And remember that the SNF patients- x-ray fees add up. "Some of our SNF patients have multiple x-rays," Harrison says. "They may be small amounts, but they add up over a year. In this time of declining reimbursement, we need to collect every penny we are entitled to."