Part B Insider (Multispecialty) Coding Alert

Published on Sun Jun 11, 2006 PDF

Don't be afraid to bill for your rightful reimbursement

Are you a chronic undercoder? The tell-tale signs include a phobia of the lesser-used codes and a tendency to bill for what you know will be covered instead of the correct codes.

Two of the biggest syndromes that afflict the chronic undercoder are:

1. Pre-operative clearances. Many coders bill for a level-four office visit (99214) instead of a consult code (99241-99245) when a physician sees a patient for a pre-operative clearance, says Mary Falbo, president of Millennium Healthcare Consulting in Lansdale, PA. "Coding convention states that pre-op clearances/consultations are billed with office consults," she says.

"The doctor should state the medically necessary reason for the consult," such as asthma or hypertension, Falbo adds. Then you should add a "V" code, such as V72.83 , to identify the consult as a pre-op clearance. If there's no medically necessary reason for a pre-op checkup, then just bill the "V" code, and the claim may or may not get paid. But you shouldn't bill 99214 instead just because you hope it's more likely to be paid.

The Medicare Carriers Manual states at 15506 that the carriers should pay for a consult for pre-operative clearance as long as the usual consult requirements are met, Falbo notes.

2. Time-based coding. In particular, coders often don't realize when they can bill for prolonged services, says Brenda Beabout, coder with Medical Consultants in Muncie, IN.

Many coders "are afraid to use them because they're not familiar with them," says Cathy Brink, president of Healthcare Resource Management in Spring Lake, NJ.

Remember: Prolonged services codes can take account of either face-to-face patient time or time spent reviewing records or communicating with the patient's family, says Brink. But make sure the documentation supports the extra time the physician spent and explains what the physician was doing during that time.

Editor's Note: For examples of more underused codes, see article later in this issue.