Surgical package Coders need to understand what is included in the general surgical package. If the patient does not have the required benefits, you will get a denial.
It is absolutely essential to make sure the patient actually has coverage before undergoing a procedure, Mr. Understanding your managed care contract is essential. This should be a total listing of what the physician did, but does not determine whether the item can be coded and billed, Pegram said.
Make sure you have your contracts on hand and refer to them frequently. The physician should clearly outline all procedures performed and provide details including: Sometimes both are the same, but not always. However, she does not append it unless the physician documents at least one hour of additional work.
During this conversation, the carrier can tell you the best way to submit the claim and where to send it to ensure it is paid. Knowing the pathway of claims can also give billers a better idea of how long claims will take to reach payors, says Ms.
The longer the path the claim takes, the more opportunity for errors.
Each facility or practice should have some type of guidelines for what is considered additional work. Is there any indication that the patient is subject to an existing global period?
Rock says your biller should have a copy of every managed care contract and understand the details of each one.
The pre-operative diagnosis is not necessarily the reason for all the procedures the physician performed during a visit. Remember to verify and authorize insurance. Anatomy of an operative report Coders will generally see certain elements in all OP reports, so it helps to understand what those elements are.
Modifier preferences can differ by carrier and by state, so coders need to do their research to avoid denied claims. If that is the case, the EDI company would send the claim to a trading partner, which may or may not have a direct contract with the payor. It is why the patient has now presented for the planned procedure.
Flesner says some insurance companies track high-volume surgeries to ensure surgery is necessary for the condition. To correctly assign codes for any surgical procedure, coders need to have an operative OP report.
Coders should never code from the title of the procedure. Subscribe to JustCoding News: The title of the procedure is a brief description of what procedures the physician performed and helps coders know what is going on.
Coders also must be able to read the OP report and pick out the important information. While you check on benefits, you should always check the deductible to see if the patient has a "trash plan," meaning a very low premium and a very high deductible.
Rock recommends doing it right the first time to save yourself a lot of hassle. Use modifiers that meet payor guidelines. The pre-operative diagnosis is the reason the patient is in on a particular day.
If they do not, ask where they send the claims next," says Ms.
Understanding the ins and outs of your contract can help you save money and make you more aware of which procedures are most profitable to your center. It may be possible to correct your reimbursement if you make this mistake, but Ms.
For example, if a physician inserts a non-tunneled centrally inserted central venous catheter into a patient younger than age 5 codethe conscious sedation is included and cannot be billed separately.
Are there indications that this may be a more difficult procedure?5 Surgery Center Coding and Billing Tips. Flesner recommends you also remember to verify benefits in an outpatient surgery center rather than just outpatient — there is a difference.
Once you've referenced the operative report and you know which codes to bill, it's essential to put your codes in the right order, Ms.
Rock says. Subscribe to JustCoding News: Outpatient! To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report.
But simply having an OP report isn’t enough. Coders also must be able to read. This operative report follows the standards set by the JCAHO and AAAHC • CPT code _____ Blair General Hospital Main Street Anytown, USA Location of surgery: Riverview Surgical Center Main Street Hometown, USA Preoperative Diagnosis: Facial and neck skin ptosis.
If a pathology report is available, use the findings from the pathology report for the diagnosis. Start with the procedures listed—Read the note in its entirety to verify the procedures listed in the header.
Procedures in the header may not be listed correctly, and procedures documented within the body of the report may not be listed in the header. Outpatient Surgery Magazine is a national monthly magazine for physicians, nurses and administrators involved in the rapidly growing field of outpatient surgery.
The publication reaches individuals involved in the operation of freestanding ambulatory surgery centers, hospital outpatient surgery departments, and office-based surgery suites. Ambulatory Surgical Center Coding and Billing I. INTRODUCTION This coding paper will introduce AAOMS members and an operative report.
The coding language that is used is CPT. This needs to be supplemented with an appropriate ICDCM diagnosis code in order to complete the data.Download