Practice Management Alert

Question: We have been receiving denials or reduced payment for bilateral procedures. What can we do to ensure appropriate reimbursement for these?

Vermont Subscriber

Answer: 1. Know Carrier Rules. Proper billing to ensure full payment on a bilateral procedure varies by insurance carrier. Some insurers have computer systems that do not recognize modifiers. Some prefer that you use a single line item with two units and a modifier, and most prefer modifier -50 to indicate a bilateral procedure. Others want two line items and a modifier for each, one indicating the procedure was done on the left side, the other indicating the right side. The key to receiving full payment on a bilateral procedure that involves two sides of the body, such as knee replacement done on both the left and right knees during the same surgical procedure, is knowing how each carrier wants the procedure detailed on the claim. To find that out, ask the carriers claims reviewer or claims supervisor.

2. Double-Check EOBs. Another way to learn whether youve billed a bilateral procedure correctly with a particular carrier is to review your denials and payments regularly. Unfortunately, many physician practices do not work their denials, which costs them thousands of dollars in revenue. Instead, they simply take the check they receive with the explanation of benefits (EOB) from the carrier, enter what payment was received in their computer accounting program, and write off whatever the carrier failed to pay. As a result, they never notice, for example, that the carrier paid for only one knee replacement procedure when two were billed.

Denials and payments ideally should be reviewed daily. Designate someone in your office to review EOBs and the payment received, and compare them to what was billed. If you coded and billed for two procedures and sent in documentation supporting two procedures, but you were paid on only one line item, ask the carrier why the claim was paid for only one procedure and how to resubmit or appeal. Thats when youll find out how to bill the claim with that carrier properly.
 
3. Precertification. During the precertification process, ask the carrier how it wants a bilateral procedure billed. For example, if you are calling to precertify a bilateral knee replacement, speak with the claims reviewer or claims supervisor regarding the best way to bill the procedure. Then, ask whether it should be billed as two different line items or as the same line item with a modifier, and what codes and modifiers the carrier recognizes.

If you receive advice on filing the claim from the carriers representative before you submit the bill, such as in a precertification for surgery, make sure you document in the patients chart who gave you advice on the claim and the date it was given. If you discover in your denial and payment review that the claim was improperly paid, you will have evidence that you submitted the claim pursuant to the carriers instructions, and you should include that evidence when you resubmit or appeal the claim.