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5 Challenges for Coding & Billing Compliance

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Healthcare reform and technological advances constantly add new tasks for ambulatory surgery center billers and coders and make compliance a challenge.

George Kaplinksi is the vice president of operations for ASC billing services at SourceMedical. He works with surgery centers to improve billing and coding services.

Here are Mr. Kaplinksi's five challenges for coding and billing compliance and how to properly handle them.

1. Staying up-to-date. The most difficult challenge for compliance is often staying up-to-date with code changes, Mr. Kaplinksi says. Codes are constantly changing, and even slight alterations can impact compliance for a claim.

For instance, this year several knee arthroscopy codes were altered to also include chondroplasty, which under certain conditions could previously be billed separately. Also, last year several pain management codes changed to also include fluoroscopy. Coders who continue to bill these elements separately would be at risk for compliance violations, such as upcoding or unbundling.

Much national attention has been brought to upcoding through using electronic records and systems, but in ASC’s unbundling codes is a more common coding mistake, he says. Coders should know what is included in each code they submit so they do not include unnecessary codes. The penalties for unbundling can be severe, he says.

"We make sure we have certified coders that have ASC experience and deal with the codes every day," he says.

Mr. Kaplinksi also recommends making sure proper Correct Coding Initiative edits are being used by your coders.

2. HIPAA. Though not directly related to coding compliance, HIPAA compliance is also important to monitor in ASCs and can come into play when coding and billing information is requested by other healthcare providers. Physicians or other administrative personnel may email documents back and forth, but they need to take specific precautions.

Data that contains patient protected health information needs to be encrypted when being sent over the Internet, Mr. Kaplinksi says. Also, patient information or names should never be in an email header, which especially comes into play when surgery centers and physician offices are trying to schedule a procedure, exchange patient demographic information or double check on billing specifics.

3. ICD-10. The switch from ICD-9 to ICD-10 in 2014 will be the next major hurdle for coders. Coders who previously worked with about 14,000 procedural codes will now have approximately 69,000 available.

Mr. Kaplinski recommends coders get specific training three to six months prior to the Oct. 1, 2014, implementation deadline. Many coders are anticipating 20 to 30 hours of additional training to be prepared to use the new system, but he suggests expecting the learning curve to take longer.

Another challenge with ICD-10 will be getting the correct documentation from physicians. The updated classification system requires more specific information from providers to code correctly using the correct diagnosis, he says.  

"It's going to take some back and forth with physicians at first," he says. "We are working with our surgery centers and letting them know that they should be talking to physicians now and looking at their records. They have to be ready for the change."

4. Quality codes. Changes are on the horizon for compliance with Medicare quality codes, known as G-codes, and coders will need to be aware.

Currently, billers are responsible for including G-codes for Medicare claims. Often clinical personnel will enter G-codes into the billing system for all patients, but billers must work to ensure only Medicare claims are submitted with quality reporting.

"We think if you start putting these G-codes on non-Medicare claims, you will have issues with other payers, as they will not recognize them as legitimate codes," he says.

In October through December of 2012, 50 percent compliance will be required or Medicare will reduce an ASC’s payments by 2 percent in 2014, Mr. Kaplinksi says. Currently, the G-codes are only required for claims where Medicare is the primary payer.  In 2013, the codes will be required for claims with Medicare as the secondary payor in addition to the primary payor.

It's crucial to submit claims with applicable quality codes the first time because Medicare will not allow resubmissions for missing G-codes.

5. Coding speed. Coders often feel the push to have cases coded and submitted within 24 hours for optimal cost and time efficiency, but that metric isn't taking the entire process into consideration, Mr. Kaplinksi says.

“Our goal is always to have the case out as quickly as possible but it’s worth the time to be sure that all information is correct, rather than risk missing coding errors which can cause claim denials, receiving a reduce reimbursement or other issues that might delay payment," he says.

Often, coders will have questions about physician dictation or need more information about exact procedures performed. Twenty-four hours is not always enough time to gather all necessary information and ensure the claim is error-free.

If claims are submitted with errors — including about pathology, diagnosis codes that do not meet a payers medical necessity guidelines or implants costs — surgery centers can have substantial costs to correct the information.  It's worth it to make sure all of the information is present prior to submission.

"Our goal is coded and out-the-door in 48 to72 hours, but we want to make sure we are doing things right the first time, not just fast," he says.

More Articles on Coding, Billing and Collections:
10 Leading Payors by Dollars Collected
4 Ways Physician Involvement Will Improve ICD-10 Implementation
AMA Opposes ICD-10 Implementation, Pushes for ICD-11


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