Payer transmittals—the electronic or mail-out disclosures sent by insurance companies when they’ve identified an error or problem or when an update is needed—are a dime a dozen. Your billing team receives them regularly and typically sets them aside after reading them—especially when the message is like this recent example from a Medicare Administrative Contractor (MAC):
We have identified claim issues for dates of service 1/1/2013 through 1/11/2013. The Centers for Medicare and Medicaid Services (CMS) informed Medicare claims administration contractors to hold Medicare Physician Fee Schedule (MPFS) claims with January 2013 dates of service for up to 10 business days (ie, through 1/15/2013) until implementation and testing of the 0 percent updated MPFS was completed, and to release claims that did not pay from the MPFS.
Certain claim scenarios failed to suspend on this systems hold, and incorrectly completed processing. As a result of this system issue, we have identified the following issues:
- claims containing procedure codes with non-payable MPFS statuses finalized with the incorrect denial message
- modifiers 26, 50, 51, 54, 55, 78, 79, and TC were incorrectly removed and therefore may have denied or paid incorrectly
We will identify and correct the affected claims. No action is required by the provider community.
Turning ‘wrongs’ into ‘rights’
Even though the MAC is telling practices to ‘do nothing,’ transmittals like this one are opportunities to do something smart. Here’s how to turn payer ‘wrongs’ into practice ‘rights’ by fine-tuning systems and addressing training needs.
1. Review transmittals as a team. Employees can’t resolve these issues alone at their desks. Regular billing team meetings are a must. Include a standing meeting agenda item for reviewing payer disclosures and updates to ensure all employees are fully informed of issues and changes and can address them as a group.
2. Discuss the business processes related to the issue, and confirm internal protocols and knowledge. At first glance, this error seems like only a coding issue. But a strategic analysis reveals several related business protocol issues that might need a tune-up, including the following:
- Did the practice’s business systems identify and correct the MAC errors in the first 11 days of the year? Did staff appeal them? The answers should be yes. If it’s no, discuss why the claims were not appealed. Is it a system problem or a training need?
- If staff mistakenly wrote off these claims, what needs to change so this does not happen in the future? In this example, staff should have realized the denial was incorrect and not written off the charges. If they did, the practice’s write-off policies should be reviewed. Who has the authority for writing-off to that reason code, and what steps are required prior to doing so? Which write-off reason code was selected? This may signal a need for further staff training or better managerial oversight.
3. Assess whether staff are coding right. Don’t assume that staff are coding correctly, just because someone attended a coding workshop 3 years ago. Rules and codes change. Employees come and go. It’s essential to ask targeted questions and verify that everyone on the billing team is following the same rules.
The MAC’s transmittal lists a series of modifiers that were dropped incorrectly from claims, resulting in denials or incorrect payments. This is an opportunity for managers to verify that staff is using modifiers correctly in the first place. Among the questions that might be asked are the following:
- Do claims for services delivered in a Skilled Nursing Facility have a 26 modifier attached?
- Are bilateral joint injections consistently reported with a modifier 50?
- Was modifier 51 applied appropriately to the laminectomy code (63047) when reported with a posterolateral fusion (22612)? (This assumes that the MAC requires the use of modifier 51 for multiple procedures.)
- Is modifier 78 used appropriately when the patient must return to the operating room for removal of an infected hip prosthesis during the global period (27091-78)?
- Is modifier 79, ‘unrelated procedures,’ applied appropriately when a patient is seen for an open reduction and internal fixation of an ankle fracture-dislocation during the global period of a wrist reduction?
4. Make a plan for areas that need fine-tuning. Use what is learned during this process to make system and policy improvements. For instance, if you identify that the write-off policy needs to be refreshed, assign someone the task of revising it. If reason codes need more granularity, develop additional ones and set a timeline for adding them in the practice management system and requiring staff to use them.
5. Add any significant changes or updates to your compliance plan. This doesn’t have to be time-consuming or complicated. Simply include minutes from the meeting, along with a list of decisions and changes made.
6. Fill training gaps with an AAOS-sponsored coding and reimbursement workshop. These workshops go beyond coding updates and case examples. They also cover how to evaluate the practice’s reimbursement systems and protocols, improve financial and coding-related policies, and analyze denial patterns and reports to help spot trends before they become acute. Remember, business processes and coding knowledge go hand-in-hand to support timely reimbursement. One cannot work optimally without the other.
Payers and billing staff can make mistakes. Problems arise only if no one addresses or corrects the issues. Use payer transmittals and other disclosures as an opportunity for improving staff knowledge and business procedures, and you’ll build strong reimbursement systems that support practice profits.
Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.