Urology Coding Alert

When you run data reports, look for specific information.

At the 2021 HEALTHCON session “How to Perform Internal Billing Audits,” instructor Stephanie Thomas, CPC, CANPC, shared important information you should know when performing internal audits in your practice. For example, she identified specific problems that cause claims denials, as well as how you can use denials to improve your processes.

Read the following tips to learn more.

Common Issues That Cause Denials

Some common issues cause claims denials, according to Thomas. They are as follows:

Problem 1: Eligibility issues: Problems with Medicare Advantage plans are common, according to Thomas. “I probably fix on average 25 a day,” Thomas said. For example, a patient will come into the office with two cards, and they think they have Medicare and Medicare Advantage, but they don’t. The front desk might just accept this and enter the information in because they don’t want to argue with the patient.

We need to teach our front desk, Thomas said. We need to educate everyone involved so we don’t continue to see those types of problems because it’s important to get those claims out the first time.

“We should check while the patient’s eligibility while they are there so we can deal with those issues up front and face-to-face,” Thomas said.

Problem 2: Coding related denials: Issues include non-covered services or services not deemed medically necessary. Other situations include that the procedure is incidental to the primary service or there is a missing/incomplete/inappropriate/invalid place of service (POS).

Problem 3: Coverage limitations: You should identify the problem, Thomas said. Where is the problem? Is this a limited plan that only covers emergencies? Educate your front desk staff for what to look for.

For example, infertility and erectile dysfunction diagnoses are often not covered by many carriers, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. You should know this information before your physician’s visit.

Treat These Issues as Denials

In some cases, the claim won’t even make it to the processing system of the payer because an error holds it back. Thomas said. In those instances, you should treat this as a denial and work those claims daily. Some examples of these errors include the following:

1. PM front-end edits (Also known as scrubbers): These claims don’t even make it out of your software. Your scrubber will clean claims and try to send them to the clearinghouse. Your system should catch mistakes such as ID #s that aren’t there or if an ID # doesn’t look right, some simple coding errors, and eligibility errors.

2. Clearinghouse edits: These claims are trying to be pushed to the payer, but they are stopped at the clearinghouse level. Common problems seen here are electronic data exchange (EDI) errors, eligibility errors, and some simple coding errors.

3. Payer edits: These claims make it to the payer, but not to their adjudication system. Common mistakes seen here include some eligibility errors, the wrong payer, and coding errors.

Use Denials for Improvement

You should use denials in your practice to improve your internal processes when you are auditing, Thomas said. You don’t want these issues to keep happening.

“If we get denials, we need to work hard and fast.,” Thomas said. Meet the timely deadlines for appeals or corrected claims and remember the denial time starts when your payer denied it.

Documentation is key, according to Thomas.

“Document. Document. Document,” Thomas said. “Anytime you touch a claim, you should document what you did.”

Anytime you get a status on the claim, review something related to the claim, or talk to a physician, you should document your actions, according to Thomas.

“If that employee working on the denial was to leave and you had to figure out what was going on with those claims, it is a really hard situation you’ve put yourself in,” Thomas added. “Tell your team and anybody who is touching claims, to document what you do because we need to know everything that is being done.”

You should also follow up consistently on denied claims, Thomas said. Do this at least every 30 days if not more frequently until paid.

Look for This Data

As an auditor, you should gather specific data monthly and compare it month to month. This data includes the following:

• Patient payments at the time of service: How many payments are we getting and how can we improve? Thomas said. Are they coming in through the portal, in person, or through the mail?
• Payments by insurance: You should break out these payments into primary, secondary, and tertiary, Thomas said. Run a denial report. Is there a trend with certain payer? If so, educate and figure out how to decrease mistakes.
• Denials for reason codes (each type): If this isn’t possible, you should keep a log somehow, Thomas added.
• Accounts receivable (AR) for patients
• Accounts receivable for insurance

When you audit and compile your monthly data, you should look for specific details, Thomas said. These include the following:

• Coding and claims submission
• Responses from payers. We should know what we are doing with the responses, Thomas said. When you are auditing, pull up a claim, even if it is a paid claim, and figure out when you received payment. Then you can look at when did we get payment? When did we post payment? Thomas asked. How long did that take?
• Accounts Receivable (AR) work: You can pick an old claim and see what’s been done. You want to know when the first touch was done on the claim, Thomas said. You also need to know when you heard from your payer and what you did with that information.

Editor’s note: Want more great info like this? You can now register for the upcoming 2021 HCON regional conferences: https://www.aapc.com/medical-coding-education/conferences/. Visit www.aapc.com for more info.