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Tip: Create insurance cheat sheets

Ambulatory Surgery Reimbursement Update, October 7, 2008

Does your ASC facility have internal cheat sheets listing claim filing requirements for the payers with whom you file claims most often? If not, you need them. Cheat sheets will make it possible for staff members to be on the same page about what each payer requires. This will enable your staff members to obtain approvals and have claims correctly process the first time through.

Cheat sheets should include the following information about a payer:

• Modifier requirements
• How the payer wants bilateral procedures billed
• Whether the payer allows the use of modifier -59
• Whether the payer accepts modifiers -RT and -LT
• Whether the payer requires internal or special modifiers (i.e., Medicaid plans)
• The claims filing address and telephone numbers for the payer
• The payer's precertification requirements and telephone numbers
• Whether the payer requires CMS-1500 or UB-04 claim forms
• Whether you can file implants to this payer, and if so, which ones and what codes are to be used
• A list of any contract "carve-outs" for special arrangements for the payment of implants, fluoroscopy, etc. If you are not participating with a plan and the payer's policy is to send the check for claim payment directly to the patient, list this information, so staff members will know to follow up quickly with those claims to be aware when the payer has issued the payment

For example, some payers do not include the payment for regular intraocular lenses (IOL) in their payment for a cataract code. For those payers, it is important to bill the IOL as a separate line item using HCPCS code V2630 for Anterior Chamber IOLs, and V2632 for Posterior Chamber IOLs. (Note: do not bill these codes to Medicare.)

This tip is brought to you by Ellis Medical Consulting, Inc.

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