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Arm your staff to avoid common coding mistakes

Radiology Administrator's Compliance and Reimbursement Insider, February 1, 2008

by Debra P. Ferenc

Radiology practice revenue is greatly affected by coding mistakes.

Claims that contain coding errors can cause payment to be delayed, denied, or reduced.

Accounts receivable staff members can generally appeal these decisions. Unfortunately, pursuing an appeal takes time and costs money.

Also, keep in mind that coding errors could trigger an audit.

How do you eliminate this problem? The answer is to submit a clean claim the first time. Be sure coding staff members have access to all the necessary resources to code accurately.

Use the following information to avoid common coding errors in three significant areas: medical necessity, unbundling, and modifiers.

Medical necessity

Medical necessity is the key to obtaining appropriate reimbursement because payers refuse to pay for services not considered medically necessary. It is the responsibility of the provider performing a study to make sure it has met medical necessity criteria prior to the study.

Therefore, physician documentation must explain the medical necessity for each service performed. Diagnosis codes are assigned to establish medical necessity for each service submitted. Coders need to identify the diagnosis, condition, problem, or other reason for the radiology exam(s), or the definitive finding of the exam, which may help to demonstrate medical necessity. Below are some basic physician/outpatient diagnosis coding guidelines to help you avoid errors related to medical necessity:

Code to the highest level of specificity. CMS instructs carriers to reject claims with invalid or truncated diagnosis codes. A diagnosis code is considered truncated when a fourth or fifth digit is available but is not submitted. A good example of this is 250.0. Diabetes can always be coded to the fifth digit.

Qualified diagnosis. Do not code probable, suspected, questionable, rule-out, or other working diagnoses. Instead report signs, symptoms, or an appropriate V code to explain the reason for the visit.

Confirmed diagnosis. Report diagnoses based on test results, as opposed to reporting the reason tests were ordered. Signs and symptoms may also be reported when appropriate.

Incidental findings. If the record contains an incidental diagnosis, it should not be listed first. However, it can be listed as a secondary diagnosis.

Coexisting conditions. These should not be listed first as the primary diagnosis; they may be reported as additional diagnoses.

Screening exams. In the absence of signs, symptoms, illness, injury, or a definitive diagnosis, a V code is required to explain the reason for the visit.

Acute versus chronic conditions. Distinguish between acute and chronic conditions. Acute conditions are listed first as primary, particularly in emergency situations (e.g., coma). Chronic conditions may be reported as needed to explain medical necessity.

Policies regarding medical necessity vary by payer; therefore, it is important to review payer-specific guidelines regarding their medical necessity criteria. Many resources can be used to accomplish this, such as payer Web sites and radiology cross coders.

Coders can gain access to medical necessity criteria for the Medicare program at www.cms.hhs.gov/mcd/overview.asp. This site contains information regarding the Medicare coverage database. It allows coders to enter specific criteria, such as key word, coverage topic, or date, to search the National Coverage Determination and Local Coverage Determination databases for coverage information.

An alphabetical listing of coverage determinations can be accessed at www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd#PC. This is an excellent resource for coders as it contains indications and limitations of coverage for the specified service.

Unbundling

Unbundling occurs when more than one procedure code is submitted to describe a service that can be reported with one code. When this happens, the payer will process reimbursement based on the bundling of the services.

Take fluoroscopy for example. CPT guidelines indicate fluoroscopy should not be reported in conjunction with a TMJ arthrography. However, CPT does not always include this type of information.

Coders can use several resources to identify inappropriate code pairs. One resource is the National Correct Coding Initiative (NCCI), which was developed by a CMS contractor, Administar Federal, “to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.”

Many payers incorporate the NCCI into their claims processing edits. The NCCI tables can be downloaded from the CMS Web site at www.cms.hhs.gov/NationalCorrectCodInitEd/. The Web site contains a link to review edits for physician claims, and another for hospital outpatient claims.

The NCCI is a listing of code pairs organized in two columns in an Excel spreadsheet.

NCCI contains two tables: “Column 1/Column 2 Correct Coding Edits Table” and “Mutually Exclusive Edits Table.” The tables outline code pairs that should not be reported together based on general correct coding policies outlined in Chapter 1 of the NCCI policy manual.

The Column 2 code will be denied when submitted with a Column 1 code. NCCI will help coders to identify inappropriate code pairs, which will help to avoid unbundling.

Modifiers

Many coding situations require the use of a modifier to further explain circumstances that are not described in the code. Inappropriate modifier assignment can cause payment to be delayed, denied, or reduced. It is important for coders to recognize coding circumstances that require a modifier.

The sidebar on p. 3 outlines some common circumstances. It is important to remember payer guidelines regarding the use of specific modifiers may vary. Therefore, it is a good idea to check with your payer to ensure you are using the modifier appropriately. Another good resource is the NCCI. The table contains a “Modifier” column that is used to indicate when a modifier is allowed.

The Medicare Physician Fee Schedule Database (MPFSDB) (see the sidebar on p. 4 of the PDF of this issue) also provides information regarding modifiers at www.cms.hhs.gov/apps/pfslookup/step0.asp? The Web site provides options to search the database for physician or for hospital procedures. Detailed explanations of the table and each column can be downloaded from the Web site.

The table includes columns for procedure code, modifier, procedure description, fee, and status, and the last three columns contain modifier indicators, which tell the coder whether the modifier is applicable or not. A complete listing of indicators for modifiers -TC, 26, 50, 51, 62, 66, and 80 can be downloaded from the MPFSDB. The table on p. 4 of the PDF of this issue highlights the common indicators for modifiers -26, -TC, -50, and -51, in addition to an abbreviated description of their meaning. The complete descriptions can be printed from the Web site.

Editor’s note: Ferenc, BS, CPC, CPC-H, CMSCS, PCS, FCS, AAPC-approved PMCC instructor and founder of the Gulf to Bay Local Chapter of the AAPC, is a senior consultant/educator at Medical Recovery & Consulting Experts, Inc., based in the Tampa, FL, area. She has more than 25 years of experience in healthcare administration in progressive leadership positions in hospital-based and private practices and auditing. She has dual coding certifications and has an extensive background in all aspects of health insurance billing and coding.

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