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3 Mistakes That Lead to Inappropriate Surgery Center Coding

Here are three mistakes coders make that can lead to denied claims in ambulatory surgery centers.

1. Failing to talk to physicians about coding queries. According to Lolita M. Jones, RHIA, CCS, professional coding consultant, coders may make mistakes on claims because they hesitate to follow up with the physician when an operative report is unclear. She says this hesitation may be due to a physician's historical unwillingness to clarify the operative report — or coders may just assume they can figure the problem out themselves. Either way, she says when an operative report is unclear or something is missing, the coder should call the physician to discuss the procedure. The call takes very little time and can save the ASC from an underpayment or an up-payment that violates compliance rules.

Brice Voithofer, vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions, says coders may bill correctly for main procedures but miss add-ons if the physician's report is unclear. He suggests coders sit down and look over reports with surgeons every six months to clear up any common errors. "The coder can say to the surgeon, 'When you do this procedure, you missed these steps in the report,'" he says. "Or the coder can help to point out trends in the surgeon’s procedures. By looking over the reports, the coder and the surgeon can try to create a thorough report so that centers are not over- or under-billing."

2. Ignoring updates to CPT codes. Updates to CPT codes are issued fairly regularly, and successful coders must pay attention to updates in order to code procedures correctly. Paul Cadorette, director of education for mdStrategies, says there are several resources coders can use to make sure updates are caught. For example, he says coders should sign up for the listserv with their local Medicare carrier to receive automatic updates about Medicare coding updates, which will appear in the coder's email inbox without any extra effort. He says coders can also visit the American Medical Association website on a monthly basis — particularly on Jan. 1 and July 1 of every year — to read about Category III code updates.

Finally, he recommends coders use the ASC Association website to get a list of approved ASC procedures for each year. The Association website also includes lists concerning package procedures, ancillary services and addenda to previously published lists.

3. Using modifiers that do not meet payor guidelines. Ryan Flesner, direct of A/R for National Medical Billing Services, says certain carriers have different preferences when it comes to modifiers, and coders must know which carriers prefer which modifiers before they submit a claim. Modifier preferences can differ by carrier and by state, so coders need to do their research to avoid denied claims.

If coders are unaware of a carrier's preferred modifier, he says they can contact the carrier and discuss how the claim should be submitted. He adds that once the center sees a denial, the A/R rep should be able to identify what caused the denial and let the coder know the carrier's preferred modifier.

Read more billing, coding and collections advice:

-3 Ways Health Plans Are Corralling OON Surgery Centers Into Their Networks

-4 Thoughts on the Future of OON in New Jersey

-AAPC Announces Certified Professional Compliance Officer Credential

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