Cardiology Coding Alert

Money- (and Sanity-) Saving Tips for Decreasing Denials

Some coders, who want claims off their desk as soon as possible, tend to file first and deal with denials later, points out Debbie Rhodes, reimbursement director for Atlanta Cardiology Group. But she does not agree with this wait-and-see philosophy, particularly when it comes to issues of medical necessity.

We dont want to have to do clean-up after the fact, because every time we make a phone call to check on the status of a claim it costs us money, she explains. It actually saves money to take the time to get it right the first time.

Rhodes gives several keys to submitting a clean cardiology claim:

1. Keep the Goal in Sight.

In smaller cardiology practices, one coder may do it all, while in larger practices, charge entry clerks may input the data. If your situation is the latter, be careful the job description doesnt become so compartmentalized that the overall goal of the clean claim is forgotten.

If your charge clerks attitude is My job is just to enter data, then youre setting yourself up for denials, Rhodes warns.

She advises practice managers to make sure anyone working with reimbursement has a general knowledge of coding principles, Medicare regulations and carrier limitations.

Otherwise, they may take what the physician puts on the superbill or op report and automatically enter it, she says.

For example, in Georgia, nine diagnostic codes support medical necessity for a cardiac event recorder. But Medicare will not pay for a recorder to diagnose and treat suspected arrhythmia if it is a routine substitute for conventional methods of diagnosis, such as an EKG.

So if your entry clerks know which diagnosis codes can and cant be used for certain procedures, then they can prevent the wrong code from being entered, and thus decrease denials, Rhodes explains.

2. Educate, Educate, Educate.

Rhodes admits that in a busy cardiology practice, its difficult to find time to send staff off-site to seminars. But we have to remember that coding and reimbursement is becoming increasingly complex and is ever-changing, she says.

So even if your coding staff cannot attend the instructional classes, set up a mechanism by which they can benefit from the information you gleaned as a participant. This process also includes sharing printed material on reimbursement, regulations, and compliance, she adds.

For example, Rhodes circulates the states Medicare updates, managed care bulletins and other payer information to her staff and requires that they initial it after they have completed the reading.

Its very time-consuming to keep up with the information, yet its vital to do so. Make sure someone serves as gatekeeper, to screen the material, highlight the critical points, and make sure it is distributed andmost importantlyread, she says.

For example, after the Atlanta Cardiology charge entry clerks were kept in the information loop, they understood the importance of medical necessity, recognizing and questioning incorrect codes, rather than automatically entering them. Such knowledge can cut down immensely on denials, she says.

3. Develop an Edit System for Medical Necessity.

Instead of holding up cash flow while you wait to see if your payers will reject the claim, pre-screen your own submissions, recommends Rhodes. This strategy saves on denials by eliminating as many as possible before you actually transmit the claim, Rhodes says.

For example, at Atlanta Cardiology, Rhodes has assembled a notebook for every coder/biller with listings of common cardiology procedures that require a certain diagnosis to support medical necessity. The notebook, which also contains other reference material, allows coders to have information at their fingertips on linking codes.

Note: You can compile your own reference notebook by following the outline provided on page 21.

In addition, the staff keep lists of medical necessity codes that managed care companies wont pay. So, either we dont bill it, or if we do, we know to be looking out for the denial so we can send a letter or call and get it reversed on the first appeal, she says.

However, Rhodes notes that with this pre-screening system and employee education, the practice rarely receives a medical necessity denial.

When we do get one [a denial], its usually because of frequency, she says. For example, if a cardiologist performs two ECHOs within 21 days, Georgia Medicare will deny it.

The carrier has a screen in place to prevent practices from automatically rebilling this procedure without a valid reason, she says. But if you can show you have a valid medical reason for the test, they will reprocess and pay for it.

4. Check EOBs.

This step is the most vital, but often the most neglected, points out Bradley Reiner, assistant director of health care financing at the Texas Medical Association.

Its difficult to operate profitably in the managed care environment without checking your EOBs, he stresses. You have to make sure you are being appropriately paid according to your contracted fee schedule as well as checking for downcoding or inappropriate bundling.

At Atlanta Cardiology, two clerks track the denials when the checks are posted, says Rhodes.

Because I do the Medicare receipts, I also see the flow of denials and can research why they were denied, explains Gala Stewart, formerly financial coordinator at Atlanta Cardiology.

Reiner confirms such a method not only saves a practice money by uncovering services that should have been reimbursed in the past but saves it money in the future by preventing denials.

Every practice should be reviewing the EOB on a daily basis. It is time well spent, he stresses.

5. Look for Patterns of Denials.

Rhodes and Reiner point out that reducing denials requires more than monitoring them on an individual basis. You must look for trends, Rhodes explains.

An easy way to track denial trends is to develop a hassle log similar to the one used by members of the Texas Medical Association (TMA), says Reiner. (See box below.)

On this form, the office staff and physician note the problem [or reason for the denial] by quickly filling in the blank and checking off a block, he says.
For example, the form contains spaces to record:

the name and type of payer (i.e. managed care or
government-regulated plan such as Medicare or Medicaid, other insurance carrier);

type of reimbursement problems (i.e. delay in
payment, pre-authorization, referral, downcoding,bundling, denial due to medical necessity).

If you create your own hassle log, make sure you leave a space to describe the reimbursement problem in detail. (TMA members then attach documentation such as the op, lab, or path report to the form and send the packet to the association for investigation. The TMA then meets with payers to advocate for policy change.)

Granted, one cardiology practice doesnt have the power of a medical association. But you can use evidence amassed on a similar form to garner confirmation that your EOBs are signaling a problem, to track claim denials, and to organize appeal information.

6. Dont Take No for an Answer.

When you do have to make a Medicare appeal for medical necessity, dont give up easily, advises Rhodes. The payers operators see their jobs as getting you off the line as soon as possible, so dont take their immediate response at face value, she warns. Ask them for proofWhere exactly is that policy [that justifies the denial] stated? If they cant provide that information, ask to speak to a supervisor who can, she adds.

For example, when Rhodes inquired if an ECHO for a diagnosis of 436 (cerebral vascular accident) was payable, the initial contact at the payer said no.

But I felt sure it was, so I continued to pursue the matter until I received verification that it was a payable diagnosis, she says. If youre 85 percent sure you are right, dont give up until they provide evidence that you are wrong.

Tip: Heres another reason it pays to develop and maintain your internal pre-screening system for medical necessity: This years plan of work for the Office of Inspector General (OIG) calls for close checks of whether the diagnosis code supports the medical necessity for ordering and performing the service. For example, the OIG will begin to compare Medicare claims with the Medicare beneficiaries records to determine whether the diagnosis codes on the claims indicate medically necessary reasons for procedures or services. So clean claims can pay in more ways than one!