Modifier -50 is used to indicate that a procedure has been performed on both sides of the body during the same operative session. However, the modifier can present challenges to coders who are unsure about which specific procedures its use applies to.
Dawn Waibel, director of operations at Serbin Surgery Center Billing, and Laurie Spinner, compliance and quality improvement specialist at SCB, provide two tips for using modifier -50.
One of the biggest mistakes made by coders concerning the use of this modifier is adding it to procedures that are already understood as bilateral, says Ms. Waibel. For example, CPT 58671 (occlusion of oviducts by device) should not include modifier -50 as the procedure is the occlusion of both oviducts, therefore making it bilateral.
The proper way to report a bilateral procedure varies by state and payor, according to Ms. Spinner. Although most payors call for the straightforward use of modifier -50, reported after the CPT code on one line, some may prefer that the modifier is reported on two separate lines. Typically, a “1” in the unit box is used after the modifier; however, some payors may require the use of a “2” in the unit box. Therefore, it is important that coders know the reporting preferences of each payor so that claims are not denied due to coding errors.
When initial claims to payors are denied, billers may either appeal the claim or submit a corrected claim in order to seek reimbursement for the services rendered. In order to ensure that providers receive reimbursement, billers must be aware of the differences between appealed and corrected claims and follow state and payor guidelines for submitting both.
Ms. Waibel and Ms. Spinner address three questions regarding appealed and corrected claims.
A: Sending a claim through the appeals processes when it could have been sent as a corrected claim is common. Also, when submitting appeals, billers must include enough documentation to support the reason for the appeal. Often, billers do not include enough documentation in these claims.
A: When appealing a claim, you are advising the carrier that the codes billed are correct, and you are providing documentation showing that the codes are reimbursable as billed. When filing a corrected claim, you are advising the carrier that you would like to amend the CPT, ICD-9 and HCPCS codes originally billed. Knowing the difference and using the correct claim form are important so that the claim is reprocessed correctly and in a timely manner.
A: For a corrected claim, the appropriate changes should be made to the CPT, ICD-9 or HCPCS codes, and the bill type should be changed to reflect a corrected claim. Claim form 837 is typically used for corrected claims. If the bill type is not changed, it could be denied as a duplicate bill. The corrected claim should then be submitted electronically to ensure the quickest processing.
For an appealed claim, you must supply documentation to support your appeal. Make sure to include the operative note, any relevant CCI edits, the invoice, your official letter of appeal and a copy of the original claim. There are state-specific guidelines that can be used as well as payor-specific appeal processes.
Lisa Rock, president and CEO of National Medical Billing Services, says that rejection of claims due to errors in the electronic submission process can be reduced by three simple practices.
Ms. Rock recommends that billing managers chart the path of electronic claim submissions for each payor. Electronic claims are sent from providers to the provider’s EDI company and, in some cases, on to several trading partners before the claim reaches the payor. The longer the path the claim takes, the more opportunity for errors. For example, an ASC may use an EDI company that does not have a direct contract with a certain payor. 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. If the trading partner does not have a direct contract, the claim would go to yet another trading partner before reaching the payor. Knowing the pathway of claims can also give billers a better idea of how long claims will take to reach payors, says Ms. Rock.
Billing managers can begin to chart the path by following a claim from the healthcare provider to the provider’s EDI company and then determine if the claim goes directly to the payor or to an additional clearing house or trading partner. “For each payor, call your EDI provider and ask if they have a direct contract with that payor. If they do not, ask where they send the claims next,” says Ms. Rock. “After you determine where it goes next, call there and ask if they have a direct contract with the payor, and so on.”
Ms. Rock recommends that in order to reduce the number of steps in these pathways, ASCs should seek out EDI companies that have direct contracting agreements with most, if not all, of the facility’s primary payors.
Ms. Rock also recommends the ASCs review all electronic claim rejection reports daily so that they can determine where in the pathway the claim was rejected. Reviewing reports will allow billers to determine if the cause for the rejection was in-house or with a certain clearinghouse and trading partner. For example, reviewing the report would allow a biller to see that a claim was rejected due to an error by the provider’s billing team rather than along the pathway. If errors are made along the pathway, reviewing the report will highlight where along the pathway the claim failed to move forward.
“Maybe a claim was rejected because of an ID error by your receptionist, but if you don’t read the rejection report, you don’t know that it was rejected out of the first stage. It didn’t even make it out of the gate,” says Ms. Rock.
If errors were indeed introduced by the provider’s staff, billing managers can take steps to improve processes and reduce in-house errors. If errors appear elsewhere along the pathway, billing managers should determine why the claims were rejected at that point and call the clearinghouse or trading partner to investigate further, if necessary.
Ms. Rock says that the most common rejections are for invalid subscriber ID numbers; missing subscriber date of birth if different from patient; invalid diagnosis code; and demographic errors, such as misspelled names.
Finally, Ms. Rock suggests that if providers notice several rejections at the same point along the pathway for a particular payor, they should actively investigate the issue.
“There was one instance where there was a problem between our clearinghouse and a trading partner, and our claims weren’t getting to the trading partner,” says Ms. Rock. “We received confirmation that they were received by the EDI company, so we assumed they were going through. There ended up being a glitch in their system that was holding up our claims.”
Ms. Rock says that without regularly reviewing rejection reports, the provider would not have been aware of the error in a timely manner as the clearinghouse did not contact the provider. By being aware of errors and actively investigating them, providers help to ensure that their claims reach payors in a timely and can take steps to change pathways or claims processes if errors continually occur.
Simple billing, coding or collection mistakes can affect the overall profitability and efficiency of an ASC. Brice Voithofer, vice president of anesthesia and ASC services for AdvantEdge Healthcare Solutions, shares his insight on the top three billing, coding and collection mistakes he sees at ASCs.
Receiving denials from payors is one aspect of the billing and collections process surgery centers deal with on a routine basis. However, Mr. Voithofer says many ASCs fail to implement a system of tracking and trending for these denials, which is, in his opinion, the most common mistake ASCs make when it comes to their billing practices.
“Most surgery centers will fix the individual denial, resubmit the claim and in many cases eventually receive payment,” Mr. Voithofer says. “But, they don’t aggregate these denials in a report to see what the root causes of the denials are.”
Mr. Voithofer suggests developing denial reports so that the center can look at denials by payor, surgeon, referring physician, procedure, etc. “Centers can use these reports to pinpoint where errors and omissions that most frequently result in denials occur and then attempt to reduce those mistakes through education,” he says.
Gathering data on the number and dollar amounts of denials can also provide ASCs with additional information when discussing problems with payors or surgeons.
“If one payor is consistently denying claims, arrange to meet with that payor to change the activity,” Mr. Voithofer says.
Surgery centers often only employ one or two coders and/or billers to handle all of the functions of the billing office. According to Mr. Voithofer, this can lead to errors due to the volume and variety of work the billers are required to do.
“Typically, centers find one or two employees to perform all functions, and they expect that single person to be an expert in all of them,” Mr. Voithofer says. “This rarely works. We typically see that they will excel at some, but fail at others; a Jack of all trades is a master of none.”
While some centers are able to work well with just a few billers and coders, Mr. Voithofer notes that in other centers something — compliance, cash collections, etc. — will usually suffer as a result. Adding staff or outsourcing some operations may be justifiable if a decrease in errors and increase in efficiency leads to improved financial results that cover these costs.
Coders rely on the accurate dictation of procedures from surgeons so they can bill appropriately for them. Mr. Voithofer says that many times coders will bill correctly for the main procedures but miss add-ons if the report is not clear.
“Dictation and transcription are often done quickly so they can get to billing,” Mr. Voithofer says. “However, ASCs can take these missed add-ons as opportunities to educate staff members and find more revenue.”
Mr. Voithofer suggests having coders sit down and look over reports with the surgeons every six months.
“The coder can say to the surgeon, ‘When you do this procedure, you missed these steps in the report,’” he says. “Or the coder can help to point out trends in the surgeon’s procedures. By looking over the reports, the coder and the surgeon can try to create a thorough report so that centers are not over- or under-billing.”
Mr. Voithofer does caution that the purpose of this analysis is to address deficiencies in documentation, not to look for an opportunity to “pile on the charges.” Clinically appropriate documentation and coding is the objective.
Providers who want to improve their revenue cycle should follow the following five best practices, offered by SmartFund Medical, a complete revenue cycle management solution, for their coding, billing, and collections.
As patients’ deductibles increase and more patients enroll in high-deductible health plans, healthcare providers will see more patients who will be forced to pay a significant portion of their healthcare costs out of pocket. As a result, healthcare providers should prepare for this change and work to educate patients about how much money they will owe for a procedure before the day of surgery.
“Set the expectation on the front end that they’re going to owe a balance. Patients, in general, want to pay for their share of the services. However, if you send them a bill for several thousand dollars in the mail 4-5 months after a surgery, the bill is unexpected and they may not have the means to pay it,” says Dennis Keaton, patient payment program manager for Smart- Fund Medical.
According to Jennifer McLeod, medical implementation manager, many providers try to avoid discussing costs upfront in fear that it will deter patients. However, she says that educating the patient upfront is one of the easiest ways that providers can improve their collections on the back-end.
After explaining to patients what they will owe, ASCs should offer payment plans before services are rendered. Payment plans allow patients to pay their out of- pocket expenses over time and budget for these expenses each month.
“With payment plans, patients are set up for defined payments. They are expecting the bill each month, and they can budget for it, along with their other monthly expenses, such as a car or house note,” says Mr. Keaton.
SmartFund Medical uses the phrase “scrubbing out claims” to describe their process of reviewing claims for errors before submitting them to payors. “Reviewing all claims for compliance issues, diagnosis issues and other possible coding errors greatly improves the chance of having a clean claim, which reduces days in A/R and increases your receivables,” says Ms. McLeod.
Many healthcare providers who outsource claims fail to monitor the status of individual claims and instead rely only on monthly statements to assess their revenue cycle. “When you’re turning over your billing and coding to a third party, sometimes you may not ever see a claim again until it shows up on a monthly statement,” says Casey Sullivan, marketing director. “Providers should try to find outsourced solutions that allow them to see the status of claims at any time they wish. This gives practices a much better idea about their cash flow.”
Many healthcare providers are quick to blame poor collections processes for outstanding A/R. “In reality, however, issues with billing are usually the problem. If you have $500,000 in outstanding insurance A/R, you clearly have a billing problem,” says Mr. Keaton. “Providers can improve their revenue cycle by not denying the problem and begin to look at what’s going wrong on the billing side.”
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of inpidual commercial and MAC/FI carriers prior to claim submissions.
CPT copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Ref. Becker’s Healthcare