Ob-Gyn Coding Alert

Most ob/gyn practices have their RNs precertify their surgeriesthat is, the nurses call the insurance company with the proposed plan of treatment to verify coverage. Then, after the surgery is completed, the coders are given the surgical reports to initiate the billing process.

Our billing department doesnt handle coding for precertification. Our nurses do that, says Connie Borgialli, a billing clerk for Ob/Gyn Associates in Marquette, MI. We dont get anything until after the surgery when we get the procedure report. We code off of that.

This system works for her, says Borgialli, because billing clerks in her office dont have the time to do precertifications. Precertified surgeries are billed electronically to commercial insurers, so payment typically comes in within 2-3 weeks.

However, not all ob/gyn practices are successful with the traditional model for coding and billing surgeries. In some practices, particularly those that dont send claims electronically, it is difficult to collect payment after the surgery and, often, the accounts receivable (A/R) turnaround time is too long.

One solution to streamlining the surgical billing process is for the billing department to pre-code all of the possible surgical procedures that may be done for every surgical patient. That way, says Denise Maestas, supervisor of patient accounting at Infertility, Gynecology & Obstetrics Medical Group in San Diego, you can make sure that insurance covers all of the surgical options. In addition, patients know ahead of time what portion of the bill they will have to pay. You can begin to collect payment up front, and you can reduce your A/R days because much of the coding work is done before the surgery.

Maestas follows a very specific procedure each time that a patient needs surgery:

Before the Surgery

First, she receives the physicians progress notes from the preoperative examination, in which he or she describes the problem, the exam findings and the intended treatment. It is from this document that Maestas determines both the diagnosis codes and the CPT surgical codes.

For example, she explains, a 62-year-old woman presents in the office with occasional vaginal bleeding. The physician performs an examination, after which he recommends a hysteroscopy and an endometrial biopsy of the cervix. Maestas identifies the proposed procedure with the CPT code 56351 (hysteroscopy), and links it with the ICD-9 code for postmenopausal bleeding (627.1). Charges for the procedure are determined using coding software.

Second, Maestas contacts the patients insurance carrier, and, based on her background as a certified medical assistant, she describes the situation and the proposed surgical plan. You have to be knowledgeable of the medical terminology, Maestas says. However, she does not believe that a clinician must do surgical precertfications. Ive trained all the women in my office to do the same thing that I do, she says.

After determining what is covered by the patients insurance, Maestas calls the patient to inform her of the charges that she should expect to incur. If the patient agrees to the surgery and to the pay for her portion of the bill, Maestas schedules the surgery. The patient is also asked to make a deposit of funds towards the procedure.

Unlike the traditional billing system, Maestas does not even schedule the surgery until the CPT codes are determined, the insurance company approves the procedure
(s), and the patient agrees to cover any uninsured amount.

I contact the patient with the amount that will be her responsibility, Maestas says. If she agrees to what she has to pay, then I schedule the surgery.

Tina Mirabito, a billing clerk with Lehigh Valley Womens Medical Specialists in Allentown, PA, also uses CPT codes in her precertification process. However, her office does not require payment up front. Sometimes we collect before the surgery, sometimes after, she says. Mirabito also does not delay scheduling the surgery until precertification is completed. We schedule the surgery, then precertify it, she explains.

After the Surgery

After the surgery, Maestas uses the surgical report to verify the procedures that were performed and to make sure that the codes she selected prior to surgery actually reflect what was done. In some instances, the actual procedures performed are different. But usually, Maestas says, she has included all of the possible procedures in her precertification process so that her only chore after surgery is to eliminate those procedures that were not performed.

Borgialli agrees that nine out of 10 times, physicians perform the procedures that they expect to. Even so, Maestas says that the insurance companies do not penalize coders for precertifying procedures that differ from those that are performed. The insurance companies wont punish you for changes, she says.

In the case described above, Maestas determined the CPT code correctly for the hysteroscopy. But, during the procedure, the physician also decided to perform a dilation and curettage (D&C) prior to taking the biopsy. Thus, the final bill included the same ICD-9 code and the D&C is included in the 56351.

The benefits of pre-coding are clear to Maestas, whose A/R turnaround time is 3-5 days in the office, and, like Borgialli, only 2-3 weeks total. Another benefit is that the physician receives a copy of the precoded insurance verification sheet in addition to the surgical report sheet that is included in the patients chart. The physician then knows that the surgery is covered by the payer, and that the patient has agreed to pay the balance, Maestas says. Finally, there is a benefit to ancillary providers, such as anesthesiologists. Maestas sends the ICD-9 and CPT codes to them, which speeds up their billing process as well.