If not, you may be at risk for claim denials or lost revenue

Is your billing team or third-party billing service using the right resources, rules, and guidelines when assembling claims and managing denials?

When substantiating coding or appealing claims, you must base your reasons on standard resources, applied in the correct order. Several recent projects highlight the importance of properly utilizing the guidelines found in the Current Procedural Terminology (CPT), AAOS Global Service Data, National Correct Coding Initiative (NCCI), and other coding tools. If your coding team improperly follows these guidelines, your billing patterns could incite a potential review of records or result in incorrect code combinations, resulting in denials or lost revenue.

The following guidance can reduce unnecessary denials and reduce the risk of an audit.

CPT: The official coding source

The CPT book is, of course, every practice’s must-have tool. CPT descriptors are the official source for information about codes for procedures and services. The American Medical Association (AMA) updates CPT every year. This means your practice must purchase the latest edition every year. The good news is that Code-X, the AAOS electronic coding product, includes the CPT book.

The KarenZupko & Associates, Inc. (KZA) consulting team uses and recommends two additional AMA tools:

RBRVS DataManager: Developed by AMA, this online reference tool includes clinical vignettes that are officially approved by national specialty societies and AMA as accurately describing services. If physicians frequently question why a service is not separately reportable, this resource can be used to explain the intraoperative details of a service in the form of a sample operative note.

CPT Assistant: KZA considers this excellent AMA publication to be an extension of CPT. The journal includes explanatory information that is not present in the CPT book and uses a monthly Q&A format to clarify how selected codes should be used. For more information, visit https://commerce.ama-assn.org/store.

AAOS Complete Global Service Data for Orthopaedic Surgery

Found in Code-X or available in book format, this resource contains explanatory lists that outline the components of care that are included or excluded from orthopaedic CPT codes. The criteria in the Global Service Data are used by the Centers for Medicare & Medicaid Services (CMS) when new CPT codes are developed and when CPT codes are valued for the resource-based relative value scale, which determines how much is paid for each.

There are several reasons why billing teams must use the Global Service Data as an extension of CPT. For starters, AAOS works with AMA to develop CPT codes. As it does with other specialty societies, AMA relies on AAOS and physicians on the Coding, Coverage, and Reimbursement Committee to determine and provide information on what is considered standard clinical practice for procedures. Because this expertise is reflected in the standard parameters of AMA’s CPT descriptors, the AAOS Global Service Data applies to all payers.

In other words, the application of the Global Service Data guidelines when coding orthopaedic claims is not optional. Billing additional codes for services considered inclusive to another billed service under the Global Service Data guidelines is not correct coding, even if a payer opts to pay for it.

For example, while reviewing records in a large health system, KZA identified multiple incidences of a third-party billing service submitting claims for fluoroscopy in addition to a surgical procedure, which the AAOS Global Service Data guidelines disallow. The company asserted that they had never been questioned by payers for these claims. During an audit, this would not be a valid defense. KZA frequently finds that payers take retrospective refunds or make recoupment requests after they have identified that they should not have paid.

NCCI rules

NCCI is a CMS program designed to prevent improper payments for procedures that should not be submitted together. In that certain NCCI guidelines conflict with CPT and AAOS guidelines, this CMS initiative presents a challenge for orthopaedic practices. Most notably, guideline conflicts occur within claims for multiple closed nondisplaced fractures treated with the same cast or splint, knee arthroscopy, shoulder, or spine procedures.

Because NCCI originally was developed for CMS as a set of reimbursement policies for Medicare, KZA advises practices to adhere to the NCCI guidelines for Medicare and Medicare Advantage plans. In addition, practices should adhere to NCCI guidelines for payers that specify the use of NCCI edits and guidelines in their contracts. For all other payers, CPT and AAOS guidelines should be used as the standard resources.

This distinction is important both from a correct coding and revenue perspective. The differences between NCCI and AAOS guidelines may result in a 30 percent reduction in reimbursement for some shoulder procedures if a practice follows NCCI guidelines.

Other payer rules

Commercial plans can decide to use their own editing parameters, which often are more restrictive than CPT and AAOS guidelines. The greater challenge is that their rules are not always published.

Orthopaedic practices always should apply correct coding guidelines under CPT and AAOS Global Service Data first. If they do not, and a plan allows a service that AAOS Global Service Data guidelines consider inclusive, that claim will be a risk for the practice. Payers routinely conduct retrospective payment reviews by analyzing paid claims data. If a practice has a pattern that indicates implying incorrect coding, it may be on the list for records review or payback in the future.

Sarah Wiskerchen, MBA, CPC, is a senior consultant at KZA. She develops and delivers the annual AAOS Coding and Reimbursement workshops and conducts documentation reviews and onsite training for orthopaedic practices nationwide.