Part B Insider (Multispecialty) Coding Alert

Published on Sat Aug 28, 2004 PDF

But GAO answers its own questions wrong as well

Carrier customer service representatives (CSRs) provided wrong or incomplete information in response to a stunning 96 percent of test calls, the General Accountability Office reveals in a recent report.

On one question, about two procedures performed on the same day in separate sessions, 36 CSRs provided "partially correct or incomplete" responses, and 38 provided incorrect responses. Only one out of 75 CSRs answered correctly, the GAO said. The GAO believed that providers should bill using the -22 modifier (Unusual services) in this situation, but the CSRs recommended -51 (Multiple surgeries, same day), -59 (Distinct procedure), -58 (Staged procedure), -76 (Repeat procedure by same physician) or -78 (Return to operating room for a related procedure).

In response to a question about billing an office visit and surgical procedure on the same day, 35 CSRs answered incompletely and 36 incorrectly, with four getting it right.

Even more damning, in responding to these two questions, only 16 out of 150 responses mentioned a specific modifier. And nine out of those 16 named an incorrect modifier, the GAO said. And there was no way to answer questions about multiple procedures or procedures alongside office visits without mentioning a modifier, the GAO argued.

High turn-over among CSRs and lack of effective carrier monitoring of call centers' performance are to blame, according to the report, which was requested by Rep. Fortney "Pete" Stark (D-CA), ranking member with the House Commerce Health Subcommittee. Such monitoring has mostly focused on the amount of time callers spent on hold, not on the correctness of the information CSRs provide. And while the Centers for Medicare & Medicaid Services' staff can listen in on calls, they can't see the materials the CSRs are looking at.

As a result of this report, you'll see some changes in the call-center setup soon. CMS agreed to set up a tiered process to "screen and triage" calls and send complicated policy questions to staffers with expertise. CMS also agreed to develop easier-to-read policy-oriented materials for CSRs to reference, in response to criticisms that its policy documents were too confusing.

But the GAO may have answered one of its own test questions wrong, according to coding expert Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, NJ. If a physician performs two procedures in different sessions, she'd advocate using modifier -59, not modifier -22 as the GAO claims. "They would have marked me wrong," she says. "I know I'm right."

The GAO's question specified two procedures in separate sessions on the same day. For example, a patient has a colonoscopy with biopsy in the morning, and then starts hemorrhaging in the afternoon. You bring the patient back in for a colonoscopy with control of hemorrhage. Because this is a separate session and not a separate site, the -59 is the proper modifier. "You don't use the -22 for a separate session," Cobuzzi maintains.

The GAO's problem is the same as the CSRs': "They're not coders," says Cobuzzi. "I would question the qualifications of the people doing this study."

It's certainly true that CMS' policy documentation is too confusing, Cobuzzi adds. "You can call CMS four times and get four different answers" on a coding issue. And yet physicians can go to jail for incorrect billing, possibly along with their coders. Cobuzzi recommends improved coding knowledge among carrier staff. For example, one of the professional services employees at Part B carrier Empire Medicare Services has obtained a CPC qualification and comes to local American Association of Professional Coders chapter meetings.