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Sarah Wiskerchen, MBA, CPC, is a consultant with Karen Zupko and Associates in Chicago. She has worked with more than 230 clients, representing more than 1,300 physicians in 24 specialties, but she focuses on orthopedics, otolaryngology and neurosurgery. She offers the following 10 best practices to improve billing and collections for orthopedic and spine practices.
1. Little things add up. Denials worth $50 or $60 may not seem like much, but they can add up when the same simple error is repeated many times. If there is pattern of rejected bills, this should immediately indicate that the person handling the bills needs more training. Letting it go means that someone has to go in and correct the error every time, which can be a big drain on work time.
2. Spot-check employees' work. Someone should be overseeing the work of billing employees by regularly spot-checking the "explanation of benefits" reports coming back from insurers. Ms. Wiskerchen recommends doing this weekly. "This shows the staff that you're paying attention and that you expect timely appeals and corrections," she says.
3. Understand rules on global services. Orthopedics and spine practices need to be up-to-date on rules dealing with when services must be bundled into global service codes and when they can be billed separately. AAOS publishes global payment guidelines every year, covering both orthopedic and spine procedures. Services that meet CPT criteria as a "distinct procedural service" need to be supported with modifier -59. Also consult CMS' Correct Coding Initiative edits, which apply only to Medicare.
4. Don’t bog down the system with incorrect coding. "Don't fight for billing practices that AAOS guidelines indicate will be denied," Ms. Wiskerchen advises. "You will just be wasting your time." For example, fluoroscopic guidance is included in most surgical procedures, so coding it separately is an obvious mistake that could easily be avoided by closely reading the AAOS guidelines.
5. Getting paid in full requires knowing the rules. While some practices bill too many services separately, others lean too much the other way and bundle more than they need to. This means they won't get the full amount they deserve. The AAOS guidelines help physicians and staff members understand what is included and excluded in each surgical procedure code.
This concept also applies to orthopedic and spine office services as well. For example, when surgeons encounter a new problem within the 90-day global period, they should use modifier -24 and an appropriate diagnosis to support the new problem. In another example, some payors inappropriately deny cast application charges that occur in the global period of fracture care, which should be paid separately.
6. Educate billing staff on payor guidelines. Since payor guidelines vary, sometimes in subtle ways, staff members need to closely study the differences. Some differences are major, such as timely filing deadlines. One payor might require filing within as little as 60 days or it won't pay, while another may allow as much as a year.
7. Meet deadlines for appeals. Medicare has a 120-day deadline between denial and follow-up. Four months seems like a lot of time but if no one is directly responsible, the notice may sit on someone's desk for weeks and miss the deadline. Since it's easy to put denial notices aside, it's important to designate someone to be responsible for them.
8. Know each plan's authorization requirements. When an orthopedics and spine practice adds an ancillary service like physical therapy or in-house MRI scanning, it's helpful to know the administrative rules that each plan has for these services, such as a pre-authorization requirement. Otherwise, the practice will only learn this when it starts receiving denials.
9. Pay attention to published Medicare policies. Be aware of changes in medical necessity guidelines and the local carrier's own particular policies. Local carrier determination (LCD) guidelines can vary by carrier.
For example, only certain diagnoses support the medical necessity of trigger-point injections. If the injection falls outside of those diagnoses, the practice will not be paid. The patient can be asked to pay, but only if he or she is advised of the service and fills out require the advance beneficiary notice form in advance.
When an orthopedics practice bills for cast supplies and DME, it also needs to follow the Medicare jurisdiction list, which is updated annually, to determine whether the Part B Carrier or DME Regional Carrier are responsible for the service.
10. Track changes in billing status with unique codes. As a particular bill's status changes over time, the practice should use unique tracking codes in order to quantify denials and assess the frequency and source of internal problems. For example, when inquiries on a denied claim run their course and it becomes clear that the practice will not be paid, use a unique adjustment code to report the reason for the lack of payment. This allows for easy reference when this same code is used again in the future.
Ms. Wiskerchen can be contacted at swisk@karenzupko.com.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Sarah Wiskerchen, MBA, CPC, is a consultant with Karen Zupko and Associates in Chicago. She has worked with more than 230 clients, representing more than 1,300 physicians in 24 specialties, but she focuses on orthopedics, otolaryngology and neurosurgery. She offers the following 10 best practices to improve billing and collections for orthopedic and spine practices.
1. Little things add up. Denials worth $50 or $60 may not seem like much, but they can add up when the same simple error is repeated many times. If there is pattern of rejected bills, this should immediately indicate that the person handling the bills needs more training. Letting it go means that someone has to go in and correct the error every time, which can be a big drain on work time.
2. Spot-check employees' work. Someone should be overseeing the work of billing employees by regularly spot-checking the "explanation of benefits" reports coming back from insurers. Ms. Wiskerchen recommends doing this weekly. "This shows the staff that you're paying attention and that you expect timely appeals and corrections," she says.
3. Understand rules on global services. Orthopedics and spine practices need to be up-to-date on rules dealing with when services must be bundled into global service codes and when they can be billed separately. AAOS publishes global payment guidelines every year, covering both orthopedic and spine procedures. Services that meet CPT criteria as a "distinct procedural service" need to be supported with modifier -59. Also consult CMS' Correct Coding Initiative edits, which apply only to Medicare.
4. Don’t bog down the system with incorrect coding. "Don't fight for billing practices that AAOS guidelines indicate will be denied," Ms. Wiskerchen advises. "You will just be wasting your time." For example, fluoroscopic guidance is included in most surgical procedures, so coding it separately is an obvious mistake that could easily be avoided by closely reading the AAOS guidelines.
5. Getting paid in full requires knowing the rules. While some practices bill too many services separately, others lean too much the other way and bundle more than they need to. This means they won't get the full amount they deserve. The AAOS guidelines help physicians and staff members understand what is included and excluded in each surgical procedure code.
This concept also applies to orthopedic and spine office services as well. For example, when surgeons encounter a new problem within the 90-day global period, they should use modifier -24 and an appropriate diagnosis to support the new problem. In another example, some payors inappropriately deny cast application charges that occur in the global period of fracture care, which should be paid separately.
6. Educate billing staff on payor guidelines. Since payor guidelines vary, sometimes in subtle ways, staff members need to closely study the differences. Some differences are major, such as timely filing deadlines. One payor might require filing within as little as 60 days or it won't pay, while another may allow as much as a year.
7. Meet deadlines for appeals. Medicare has a 120-day deadline between denial and follow-up. Four months seems like a lot of time but if no one is directly responsible, the notice may sit on someone's desk for weeks and miss the deadline. Since it's easy to put denial notices aside, it's important to designate someone to be responsible for them.
8. Know each plan's authorization requirements. When an orthopedics and spine practice adds an ancillary service like physical therapy or in-house MRI scanning, it's helpful to know the administrative rules that each plan has for these services, such as a pre-authorization requirement. Otherwise, the practice will only learn this when it starts receiving denials.
9. Pay attention to published Medicare policies. Be aware of changes in medical necessity guidelines and the local carrier's own particular policies. Local carrier determination (LCD) guidelines can vary by carrier.
For example, only certain diagnoses support the medical necessity of trigger-point injections. If the injection falls outside of those diagnoses, the practice will not be paid. The patient can be asked to pay, but only if he or she is advised of the service and fills out require the advance beneficiary notice form in advance.
When an orthopedics practice bills for cast supplies and DME, it also needs to follow the Medicare jurisdiction list, which is updated annually, to determine whether the Part B Carrier or DME Regional Carrier are responsible for the service.
10. Track changes in billing status with unique codes. As a particular bill's status changes over time, the practice should use unique tracking codes in order to quantify denials and assess the frequency and source of internal problems. For example, when inquiries on a denied claim run their course and it becomes clear that the practice will not be paid, use a unique adjustment code to report the reason for the lack of payment. This allows for easy reference when this same code is used again in the future.
Ms. Wiskerchen can be contacted at swisk@karenzupko.com.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.