3 Coding Mistakes That Decrease Surgery Center Profits

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Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, of AskMueller Consulting in Lenzburg, Ill., discusses three critical coding errors that cut into ambulatory surgery center profitability.

1. Lack of documentation around size and location. Ms. Mueller says coding errors often come down to improper physician documentation on the details of the procedure. For example, the size of a removed lesion has to be specifically documented in the operative report by the surgeon so the coder can code the correct size. "If you don't have the size documented, you are limited to only billing the lowest level as far as size goes," Ms. Mueller says.

She says location is another detail that often goes missing from operative reports. "Make sure that no matter what type of specialty you're dealing with — urology, orthopedics or anything else — that the physician has documented the [procedure] location," she says. "The location is essential if you're going to bill for multiple procedures." She says the charges for every procedure should be scrubbed with the CCI Edits to make sure the claim will be paid.

Aside from scrubbing each claim through CCI Edits, Ms. Mueller says the billing staff for an ASC should speak with physicians who chronically leave information off the operative report. If the physician still doesn't listen, it can help to bring in an outside consultant, she says. "It seems that physicians seem to listen to an outside source more closely than to somebody within the practice or center," she says.

2. Diagnosis code doesn't support the procedure.
Ms. Mueller says claims are often rejected because the diagnosis code doesn't support the procedure or lacks a certain level of specificity. For example, Medicare has outlined local coverage determinations for certain procedures, and if a provider submits a diagnosis code not covered by that local coverage determination, the claim will be denied for "lacking medical necessity."

For GI-driven centers, most states have policies on colonoscopies that lay out when a colonoscopy is medically necessary. In some states, a diagnosis code for "anemia" is not covered, but a diagnosis code for "iron deficiency anemia" is covered. Since iron deficiency anemia requires a lab study to determine whether the patient truly has the condition, the coder cannot simply fill in "iron deficiency anemia" instead of "anemia" and submit the claim. Coders should communicate to physicians that if a diagnosis code is not appropriate for a procedure, the procedure will not be paid.  

3. Improper use of modifiers. Ms. Mueller says the third most common mistake she sees in surgery center coding is the improper use of modifiers to alter a procedure code. Ms. Mueller recommends facilities look closely at the CCI Edits to determine whether a modifier can be used to bill procedures separately.

For example, CPT 29823 indicates arthroscopy of the shoulder, debridement extensive, while CPT 29825 indicates arthroscopy with lysis and resection of adhesions. If the physician performs both procedures on the left shoulder and the coder bills the procedures together, they're considered bundled services.

"If these two are billed together, the only one that would get paid is the lesser procedure," she says. "The coder should always check procedures for bundling issues. In this situation, the only way that both procedures could get paid is if one was done on the right side and the other on the left side, utilizing the RT and LT modifiers. However, this is not common." 

The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

Related Articles on Surgery Center Coding, Billing and Collections:
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Montana Health Insurance Co-op Applies for Federal Funding

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