Practice Management Alert

Practices that perform new procedures, or use new medical devices and products, often find getting paid for them difficult. Many carriers automatically reject unlisted-procedure codes, temporary codes, and codes with some modifiers. To ensure your doctors get reimbursed for these procedures, the first time you file a claim you should submit supporting documentation.

When Adrienne Rabinowitz, CPC, billing manager for Western Monmouth Orthopedic Associates, a three-physician practice in Freehold, N.J., bills a new procedure, such as an open surgical procedure performed arthroscopi-cally, she submits a paper claim with an unlisted-procedure code, the physician's operative note, and a letter explaining in layman's terms what was done. You should include in the letter:

the closest CPT code for the procedure what the doctor did why it was more difficult why more time was required why more risk was involved. You may also want to explain any benefits of the method, such as a faster recuperation rate or less physical therapy. Rabinowitz says her practice usually receives 80 to 100 percent of the reimbursement requested. Make Sure Documentation Is Clear For such a plan to work, however, your physicians need to provide accurate and detailed documentation. Note: See the image for an example of a letter Rabinowitz used for an osteochondral allograft transplant procedure when the procedure did not have a CPT code and was billed as an unlisted procedure. When submitting a paper claim with an explanation letter and the operative note, you should write in red ink the patient's policy number on the top right-hand corner of each page. "You'd be amazed at how often things that are attached can become detached," Rabinowitz observes. Putting the policy number on every page in red helps it stand out and makes it easier for claims examiners to determine which pages go together, she adds. Electronic Filing May Be Possible With Medicare For Medicare claims with unlisted-procedure codes, you may be able to fax the documentation and seven days later file electronically, with a note that documentation was already sent. Rabinowitz says this system cut her reimbursement time from 60 to 90 days to "a fraction of that." However, not all Medicare carriers accept this method. You should ask your carrier for its preferences. For insurers that prefer paper claims, set up your computer-billing system to suppress electronic submission of unlisted- and new procedure codes, and force the claims to be printed on paper. Although using an existing code for a similar procedure rather than reporting an unlisted-procedure code may seem easier, this contradicts CPT's directive and prevents new codes from being established. "It's only when an unlisted code is used frequently enough for a procedure that it gets a temporary code, and eventually a permanent [...]