Anesthesia Coding Alert

A proper diagnosis and diagnosis code are key to your reimbursement claims. Yet on occasion, easy errors send a claim straight back to your practice. Check out two ways to reduce these denials.

Reporting the correct diagnosis for a procedure is just as important as correctly coding the procedure.Some procedures have warning flags and a list of approved diagnoses, says Jann Lienhard, CPC, a coder in New Jersey. If the payer doesn't believe your diagnosis supports medical necessity of the procedure, the payer will deny your claim.

Watch for these common diagnosis mistakes in your coding:

diagnosis. For example, administering an epidural or blocks with a vague diagnosis such as "back pain" can result in quick denials.

• Changes in an obstetric patient's status. For example, an expectant mom comes to the hospital in labor. After 14 hours, her labor stops and she returns home. She returns three days later and delivers. The payer will deny your claim if you report both cases with 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery [this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]) with diagnosis 650 (Normal delivery).

• An incorrect diagnosis for post-op pain management. Many payers have specific guidelines for the diagnoses they consider acceptable for acute postoperative pain management, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y.

National Government Services (NGS) MAC J13, for example, lists only four diagnoses to justify 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) and epidural codes 62310-62319. NGS MAC J13 accepts 338.11 (Acute pain due to trauma), 338.12 (Acute post-thoracotomy pain), 338.18 (Other acute postoperative pain), and 338.19 (Other acute pain), which providers are directed to use for obstetric pain management. Because of these types of stipulations, always verify your payer's policy for post-op pain management.

Helpful: Some mistakes can be a simple matter of keying the wrong diagnosis, Lienhard says. If you receive a diagnosis-based denial, verify that you didn't submit a claim with a typo. If the diagnosis you submitted was correct but isn't on the payer's list, talk with your physician. A secondary diagnosis he documented might work just as well.

You don't need an ABN for an uncovered service. ABNs are necessary when you believe a claim might be denied for reasons of medical necessity -- that is, a procedure presumed to be medically unnecessary. Medicare will only pay if the patient and your provider did not know -- or  should not have known -- the service wouldn't be covered.

If you have reason to expect a service will be denied by Medicare you must show evidence that the patient was aware of this. This is the role of the ABN. They are not necessary when services are statutorily excluded or do not meet the definition of any Medicare benefit.

Ideally, most of the services your physician provides will be reimbursable. Watch for services that Medicare doesn't cover (such as acupuncture or intradiscal thermal procedures) and keep these pointers in mind:

• If you believe your physician has scheduled a noncovered service, talk to the patient beforehand. Explain the procedure and the payment situation, and ask the patient to sign an Advance Beneficiary Notice stating that she will personally pay for the service if the carrier refuses. Share a ballpark figure for the procedure so the patient knows what she's agreeing to.

• Denials that are in this category often are due to performing too many services within a timeframe, Lienhard says, such as exceeding your limit for trigger point injections (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s], and 20553, ... single or multiple trigger point[s], three or more muscles). Know the payer's requirements and work to gain preapproval for additional procedures if you expect to exceed the payer's limit.

• Fight for the patient and your funds from the carrier. Many times, the carrier will review the case manually and approve the payment.

• Even if you know Medicare doesn't cover a service, you must still report it if secondary carriers will only pay when you can show an initial denial. For instance, if a patient has cosmetic surgery, this is non-covered and Medicare does not have to be billed unless you need a denial for other insurance payment. If this is the case use modifier GY (Service statutorily excluded or does not meet the definition of any Medicare benefit) so that Medicare knows you want a quick rejection and doesn't think you are trying to collect for a service you should know they don't pay. Since these are not covered benefits with or without a GY modifier the patient is liable for all charges.

Remember: Not every insurance denial automatically means your practice made an error. If you scrutinize your EOBs carefully, you might find that you are wrong some of the time and that the insurer is wrong sometimes. In some instances, you might simply need to notify the payer why it was wrong to reject your claim.