Today’s medical technology is complex and expensive. Robotic surgical systems, new implants, novel instruments, and many more are released on seemingly a daily basis. Coding accurately for this new technology is critical, as carriers have a keen interest in auditing for coding accuracy and reimbursement.
While these products often represent exciting clinical advances, getting paid appropriately or in-full for using them is another story altogether. Vendors often provide reimbursement information for the latest medical device. Then, only later do the surgeons find out that the CPT codes aren’t authorized for the product and/or service, which leaves them on the hook for lost revenue.
It's easy for ambulatory surgery centers (ASCs) to get swept up in the idea of using new technology. It’s also important, however, to understand fully from the outset the financial impact of implementing these innovations. Medical coding is a time-sensitive operation, and coding issues can delay billing, adversely affect claims processing and derail reimbursement.
Performing due diligence before exploring new or advanced medical technologies will help avoid improper payment and unwelcome financial outcomes. Here’s where to start:
Uncover unlisted codes
No one likes using unlisted codes. These codes may lead to lost revenue.
For example, a well-known absorbable implant is often coded incorrectly as a nasal valve stenosis collapse—an invasive open procedure that requires cutting of bone. In this common scenario that occurs across many specialties, vendors may use unlisted codes and payable codes in their marketing material, leaving the provider to guess what will actually be reimbursable.
Unlike some commercial payers, Medicare doesn’t reimburse for unlisted codes. Be sure to work with your vendor representative to vet the code that properly matches the new technology or procedure, and verify that all new tools and procedures are linked to documented codes. Does the use of the new technology change the way the procedure is being performed? For example, you cannot use a tenotomy code when the tendon is completely removed. You also may want to discuss with coding experts to ensure the manufacturers are giving you accurate coding and reimbursement information.
Review CPT descriptions
Before approving a procedure, it’s important to review CPT descriptions thoroughly. If the operation makes use of a new technology, start by verifying that the procedure still matches the original description. And if not suitable, the importance of reconciling any issues before greenlighting a new product or technique cannot be overstated.
It’s also essential to determine how much the payer will be charged and what will be reimbursed. Be sure to review the contract, and revise it if the proper verbiage or corresponding CPT codes aren’t included.
Ideally, medical manufacturers would go to the American Medical Association (AMA) and discuss the release of their new product or procedure to develop a Category III code that can be put in place for up to five years. Later on, these products and procedures potentially can be transitioned into Category I codes if it’s determined there’s enough common use. Unfortunately, technology often moves faster than the AMA, and old codes are frequently reassigned to address the issue. But by working together, industry stakeholders can collaborate with the AMA and find a solution to this common problem.
Request supporting information
Ask vendors for supporting information from the AMA or specialty associations and talk to managed care companies to verify proper language is included in contracts. This will ensure adequate contract coverage and payment. It’s also important to review coverage offered for public and private payer options, and request that vendors provide all available supporting documentation. Keep in mind, it’s much more complicated to attempt an appeal letter after a purchase has already been made.
Remember: A comprehensive understanding of all payer contract language and vendor information will create a comfort level when billing. Often times, device makers will have a disclaimer deep in the marketing materials that warns providers that they’re ultimately liable for any coding errors—and they’re right. Payers, too, should be consulted to determine if they consider a new implant, device or procedure “investigational” or “experimental,” which often affects reimbursement down the road.
For surgery centers thinking about bringing new tools online, many times they need expert guidance to help navigate the process. Acute examination of a vendor through a professional coding company can ensure compliance, optimize reimbursement and establish a financially successful process.
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