Bill Gilbert, vice president of marketing, and Brice Voithofer, vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions, discuss tips for reducing denied GI claims and what surgery centers can do to receive proper reimbursement if a claim is denied.
Common causes of denials
1. Changes in GI codes. Starting in 2010, many GI procedures previously covered under one CPT are now broken out into multiple codes to provide greater specificity of the actual procedure being performed. According to Mr. Voithofer, these changes will be one of the key factors affecting GI claims in the coming year.
“Different approaches [by physicians in the procedure room] require different CPTs and diagnosis codes, which can cause denials if not coded correctly,” Mr. Voithofer says.
2. Misused modifiers. Another common mistake in GI claims leading to denials is the appropriate use of modifiers. According to Mr. Voithofer, modifiers need to be used if a case is canceled prior to a procedure, for bilateral procedures and if multiple procedures are performed at one time (e.g., modifiers -50 and -51). Many ASCs do not use modifiers appropriately, which can lead to inaccurate reimbursement and/or increases in denials.
“Claims are often denied if these aren’t coded correctly. For example, some payors may pay only 50 percent for secondary procedures performed at the same time as another, and they will deny an ASC’s claim for full payment,” Mr. Voithofer says.
Accurate documentation is needed for these cases, as it can help billing staff determine what was done in the OR if and when they need to follow up on a denied claim. “An important part of coding and acting on denied claims is understanding the root cause of the denials and effectively communicating not only to the billing staff, but also to the source of the denials,” Mr. Voithofer says.
3. Incomplete notes from surgeons. As mentioned, different surgical approaches for certain GI procedures now have greater specificity and failure to document the approach, and the reason for the specific approach, can lead to denials. Mr. Voithofer and Mr. Gilbert note that it is important for ASCs to have documentation of precisely what was performed in the procedure room/operating room in order for the report to stand up to a denied claims appeals process.
“You want to make sure that the surgeon’s clinical documentation is thorough and clear so that you have a good picture of the way a diagnosis or a procedure is done,” Mr. Voithofer says. “This is especially important when a surgeon has to take an approach that is not the standard of care in GI, or, when a specific approach is based on a particular patient’s clinical situation. Surgeons need to make sure they explain why this approach was required versus the standard.”
Documentation also plays a critical role in pathology reports. “When lesions or samples are sent to pathology labs, shrinkage can occur that can prevent an ASC from billing a certain code,” Mr. Voithofer says. “It’s mostly a compliance measure, but ASCs should encourage their surgeons to document the dimensions of any lesions prior to sending them to the lab.”
Anesthesia can be another tricky area in GI, as most payors tend to deny or are trying to deny payment on anesthesia used during GI procedures. “Make sure your billers and coders know what your contracts are with your payors,” Mr. Voithofer says. “For example, some payors may require proof of medical necessity to use propofol or other sedation during a procedure.” Furthermore, an ASC’s contract might include payment for anesthesia, and, as such, an arrangement will need to be made with the anesthesia providers if they are a contracted group. Failure to appropriately compensate a contracted anesthesia group for funds paid to the ASC by a payor can run afoul of Stark and other statues, such as anti-kickback statutes.
4. Inaccurate coordination of benefits information. Similar to incomplete surgeons’ notes, incomplete or inaccurate patient information and preauthorization is also another common cause of denials for GI procedures. ASCs can spend an extra $25-$30 per claim for the time it takes to search for and process information that was incorrect the first time it was submitted, according to Mr. Voithofer.
“When looking at denial management processes, we have found a recurring reason claims are denied is that the ASC did not obtain and verify the right information from the patient,” he says. “For this reason, it is important to put a mechanism in place to get correct information, either through the scheduler when first making the appointment or with the intake staff when the patient arrives at the center. As everyone knows, one digit off on an insurance number results in a denied claim.”
Included in this patient information are authorization codes and pre-certification codes required by some insurers for procedures that can only be performed so frequently in a time frame, such as screening colonoscopies. ASCs should be certain the physician’s office includes this information prior to the patient arriving at the center.
How to process and prevent denied claims
1. Act immediately on denied claims. Follow-up procedures for denials can vary from ASC to ASC, but Mr. Voithofer and Mr. Gilbert agree that immediate action is critical to maximizing claims from denials.
“The chances an ASC will receive full reimbursement on a claim decrease each day a denial sits,” Mr. Voithofer says. “Make sure that your ASC has a rigorous denial management system in place, not just a one-off procedure that is started from scratch each time a denial comes through.”
ASC billers should immediately review the medical record or contact the patient if the mistake regards demographic or insurance information. Then, if necessary, ASCs should contact physicians and request addendums for missing information.
2. Aggregating denials will allow your ASC to pinpoint problems. Mr. Gilbert and Mr. Voithofer suggest that ASCs need to look at all of their denials and determine the types of “root causes.” ASCs should aggregate their denials so they can view data by surgeon, physicians’ office, payer or procedure to determine where the bottlenecks occur. One important next step is to share the information with surgeons and their offices to address denials which are traced back to the surgeon’s office.
“The ASC needs to make sure to get the message to the surgeons [whether it is missed clinical or demographic data, etc.], which can be as simple as calling up an office and emphasizing the need for better quality in reports,” says Mr. Gilbert. “Often, ASCs may need to provide a form or other process to the offices to ensure that complete information is included.”
Mr. Gilbert suggests presenting this denial data at board meetings to inform all physicians of the problem and the impact it has on the ASC. Therefore, problems discussed at board meetings can then be communicated through the members to other physicians at the ASC.
3. Inform staff members of quality processes. As with all processes at an ASC, one staff member’s actions can affect another’s. For example, incomplete surgeon’s notes can lead to denials later in the process. Mr. Voithofer and Mr. Gilbert say one way to combat denied claims is to make sure each member of the ASC team knows how their actions can impact others.
“This is the biggest piece to the puzzle,” Mr. Voithofer says. “Everyone needs to understand how their actions can impact smooth daily operations. This can extend as far back as the surgeon’s office when the patient decides to come to the ASC rather than a hospital. ASCs can educate surgeons on explaining patients’ financial responsibilities on the front end and make sure they receive the proper notification.”
Another way to ensure these processes are in place is to host meetings at the ASC with physicians who use the center. Mr. Voithofer notes that this has been successful in helping physicians understand the impact of their actions on the billing aspects of the ASC and can be educational and a great way for staff and physicians to get to know one another to further drive home the impact actions can have on other staff members.
“Quality processes definitely apply,” says Mr. Gilbert. “Errors that lead to denials often occur in the hand off of a case from one person to another, and it is important for the staff to understand this.
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