Procedural coding errors can lead to lost revenue or unintentional upcoding at ambulatory surgery centers.
Bill Gilbert is the vice president of marketing, and Brice Voithofer is the vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions. Lolita M. Jones, RHIA, CSS, is an independent coding and billing consultant.
Here are Mr. Gilbert, Mr. Voithofer and Ms. Jones' six best practices for coders to maintain accuracy.
1. Host additional training. The fast pace of an ASC setting can hurt coding accuracy, Ms. Jones says. Centers may need to do periodic one-hour clinical overview sessions with physicians and coders. At the review sessions, physicians can go over techniques, medical necessity and documentation so the coders can understand what goes into certain operations and thus how to properly code them.
"You can go online and do research, but if a physician explains it to you, that's an extra layer of education that an ASC can sometimes prohibit from happening," Ms. Jones says.
2. Set and meet accuracy standards. The only way to know if your coders are staying accurate and timely is by setting an accuracy target and doing periodic audits to measure the accuracy rate.
Mr. Voithofer suggests coders be asked to maintain at least a 95 percent accuracy rate and says up to 98 percent is reasonable and attainable.
Whenever a new coder joins your center, he or she should be audited more frequently until all parties are confident in the coder's abilities to perform at an expected level.
Accuracy may also be taking a hit if coders are simply entering what the physician has checked off on the charge ticket, rather than actually coding the claim. Coders cannot rely on the ticket, Ms. Jones says. They can validate against the physician notes, but they should be coding as well.
3. Stay up-to-date with payor policies. Payors can change certain policies yearly, Ms. Jones says. Coders should be diligent to check the payor websites for any coverage determination or medical necessity policy changes.
"Your center can take a hit if the diagnosis that would justify a procedure isn't there for the particular payor," she says.
While patients may still need a procedure to be performed even if it will no longer fall under the purview of a payor's coverage, by staying educated with policies the coders are avoiding the shock of a denied claim.
"At least you'll know on the front end that you may be in trouble," she says. "You may be able to go to the physician and see if there is an aspect of the diagnosis they forgot to include. Even perfect coding could get dinged by a medical necessity problem."
4. Learn from denials. Mr. Gilbert suggests looking at all denials as they come in and developing a feedback loop for coders and physicians to understand what went wrong.
"If a denial comes in because the code was in the wrong sequence or the wrong modifier was in place, you can't appeal the denial, but you can make sure not to make the same mistake again," he says.
Studying denials is as important for high-volume cases as it is for high-dollar cases. In some GI procedures, for example, the lost money for one claim may not be significant, but a pattern of denials can add up, he says.
Communication is always the key to bridging the gap between the coder and the physician.
5. Know the managed care contracts. Many times, the payor and managed care contract in place will determine how a procedure should be coded, Mr. Voithofer says. For instance, one contract might pay for all screws over a certain diameter, whereas another contract might have a different threshold. "What's billable and what's not varies by contract because there are carve-outs and exceptions," he says.
To avoid losing revenue or having a claim denied by a payor, surgery centers should work with coders to ensure they know contract specifics, especially for high-volume procedures.
Implants with procedures can also be difficult to code since payable items on an implant procedure can change quickly. Coders should stay up-to-date on all payor regulations regarding implants to avoid costly denials.
6. Look at claims critically. Coders should not be afraid to question a physician's operative note if something does not make sense or appears to be incorrect.
"If something doesn't look right, put the brakes on it and ask questions," Mr. Voithofer says.
Physicians can make mistakes, but they also can change their methodology. When a physician learns a new technique or approach to care, it may require different documentation than the same procedure did in the past. Rather than risk miscoding, take the time to ask the physician about the change to see if it's related to an approach that requires different coding.
"Just ask questions," he says. "The worst case scenario is they tell the coder there is no problem and go on. In the best case scenario, the coder finds where they are losing revenue or stops the center from submitting a fraudulent claim."
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