Radiology Coding Alert

Keep on top of which codes your payer prefers

You can't always count on CPT guidelines to tell you how to code for the numerous payers you deal with every day. These surefire tactics keep you organized so you can choose the right code every time.

1. Chart Those Choices 
 
Set up a spreadsheet "to keep track of frequently applicable payer policies and quirky filing requirements," says Jim Collins, CPC, ACS-CA, CHCC, president of Compliant MD Inc. in Matthews, N.C.

Try this: For your "cheat sheet," Rachel Mitchell, CPC-H, an AAPC-approved PMCC instructor with Applied Medical Services in Durham, N.C, suggests the following: Note which codes each payer accepts for common procedures, which codes they never accept, which diagnosis codes they allow for each procedure code, which modifiers the payer allows, and how you should report them.
 
Example: You may have one payer that wants you to place "2" in the unit box if you use modifier -50 (Bilateral procedure) and another who asks you to place a "1" in the unit box for that modifier, and you should make sure this information is at hand in your spreadsheet.

2. Don't Let Your Guard Down

To stay current on your payers' policies, you have to dig through their newsletters and Web sites, Mitchell says. "It's legwork," she says.
 
Her company has found success by appointing one quality-assurance person to be responsible for Internet research. Since CMS has made a point of going paperless, you have to be doubly vigilant in checking for Medicare and Medicaid online bulletins, Mitchell says.

What to do: If your patient is covered by TrailBlazer Health in Texas, and you go to this Medicare carrier's Web site (www.trailblazerhealth.com), in the center of the page you'll see a "What's New" column to help you keep up with the latest information.

If you have a question about a specific policy, click on "Texas" under "Part B" on the left side of the screen. Then to find a policy for a particular procedure, click on "LCD (Local Coverage Determination)" in the left-hand column. You can search by the name of the procedure or the CPT Codes itself.
 
Example: You have a report of an MRI of the head and neck for a patient with meningitis due to the ECHO virus, and you want to make sure TrailBlazer policy says the diagnosis code you think is right proves medical necessity for this MRI. You know the procedure code is 70540 (Magnetic resonance [e.g., proton] imaging, orbit, face, and neck; without contrast material[s]).

1. Type 70540 into the search field on your page. This will bring up links to the LCDs for this code. In this case, there is only one, and when you click on that link you'll see the LCD, "Imaging of the Head, Neck and Brain."

2. Scroll down past the explanation of the procedures and you'll see lists of exactly which CPT codes you may use to report this service (including 70540) and lists of which diagnosis codes prove medical necessity. Code 047.1 (Meningitis due to enterovirus; ECHO virus) is on the list, so you can trust that you are reporting a code combination that TrailBlazer will pay.

3. Analyze Denials and Payments for Clues

 You can seize many benefits by taking the time to clarify and summarize payer policies, Collins says. "Analyze payments and investigate those that appear too low before they add up too much," he says.

You'll thrive over time if you're willing to learn from your denials, Collins says. If a payer consistently denies a specific code, you should "thoroughly investigate it, identify why the denial was triggered, and implement corrective actions to prevent it from happening again," he says. Don't automatically appeal or write off every denial - you'll lose the chance to fine tune your claim generation and submission process, Collins says.

4. Network, Network, Network

Listservs have been a lifesaver for Mitchell. They give you the chance to get answers from others in your specialty and experts in the field, she says. Mitchell recommends the specialty lists offered by The Coding Institute at www.coding911.com. You can sign up for our radiology discussion group there, and access the questions and answers from past discussions.

When Mitchell has a question about a payer's policy, she often posts her query to the list to hear from others who have dealt with the same situation.

If another coder provides you with official documentation to solve your problem, you've saved yourself about 45 minutes of waiting for customer service to take your call. And even if you don't get an official answer, you're now armed with information to help you decide if the payer rep you get is giving you an answer you can trust, Mitchell says.