Coding Strategy

Pre-authorization snag may require ABN.

If your practice performs MR urograms, you need to be prepared to handle a few reimbursement roadblocks.

You may find conflicting information in researching how to code MR urograms. For example, you may come across sources that say to report both abdominal and pelvic MRIs, but you’ll have to reconcile this advice with certain payers preauthorizing only an abdominal exam.

Protect yourself: The MR urogram issue reveals several questions that need to be addressed:

1. What did the treating physician order?
2. What did your facility perform and document?
3. What did the insurance company authorize?

1. Insist on Orders for Both Exams

Be sure you have orders from the treating physician for both abdominal and pelvic MRI exams before you consider reporting both — for example, 74183 (Magnetic resonance [e.g., proton] imaging, abdomen; without contrast material[s], followed by with contrast material[s] and further sequences) and 72197 (Magnetic resonance [e.g., proton] imaging, pelvis; without contrast material[s], followed by contrast material[s] and further sequences) for exams performed without and with contrast.

Auditors will want to see precise orders, so you should not assume that an “MR urography” order refers to abdomen and pelvis. Don’t be tempted to think otherwise just because you can easily find support that physicians consider MR urography to include pelvis and abdomen studies. For instance, the American College of Radiology (ACR) “Appropriateness Criteria for Acute Onset Flank Pain,” refers to “MRI abdomen and pelvis with or without contrast (MR urography).” (To locate appropriateness criteria, go to www.acr.org. Choose the “Quality and Safety Resources” link. Then click on the “ACR Appropriateness Criteria” link.) But for your records, precise orders will offer your claim the most support.

2. Demand Distinct Documentation

To support reporting both abdomen and pelvis MRIs, also be sure the radiologist has documented both exams clearly. Ideally, the radiologist will record each in a separate paragraph, describing the organs visualized and pertinent comments and findings. For example, the abdominal MRI documentation might focus on the kidneys and urinary collecting system for anatomical or physiological abnormalities. The pelvic documentation might assess any pelvic floor defects associated with urinary incontinence.

Resource: The ACR provides online practice guidelines for pelvic and abdominal MRIs:

• Abdomen: www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/gastro/mri_abdomen.aspx
• Pelvis: www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/gastro/mri_pelvis.aspx.

3. Assess Need for ABN

If the insurer preauthorizes only an abdominal MRI, then expect the insurer to reimburse only the abdominal MRI. The treating physician still may determine that both pelvic and abdominal MRI exams are necessary for the patient. In that case, alert the patient that he may be financially responsible for the pelvic MRI. Have him read and sign a waiver or Advance Beneficiary Notice (ABN) agreeing to cover the cost if he chooses to have the exam. For Medicare, append modifier GA (Waiver of liability statement issued as required by payer policy) to the pelvic MRI code to indicate you have an ABN on file.

ABN alert: Remember that CMS updated ABN modifiers effective April 1 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6563.pdf). Modifier GA changes from “Waiver of liability statement on file,” which simply indicated that you have a signed ABN on file, says Melinda Brown, CMBS, insurance biller with H. Matt Smith, MD, in Kennewick, Wash. The new descriptor is “Waiver of liability statement issued as required by payer policy.” You should use modifier GA only “to report when a required ABN was issued for a service,” CMS states. Modifier GA indicates the possibility that Medicare may deny a service for medical necessity, and the physician may bill the patient after the claim is denied.

New modifier GX (Notice of liability issued, voluntary under payer policy) shows you provided “beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute,” CMS states.

@ Radiology Coding Alert

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Test your ob record skills with this four part challenge.

If your ob-gyn simply confirms a patient’s pregnancy during an office visit, you’ll be able to report V72.42 (Pregnancy, confirmed). But when should you start the ob record? Take this four-part ob record challenge to discover where you stand.

Scenario 1: The ob-gyn sees a patient who knows that she’s pregnant via a positive home pregnancy test and simply “confirms the confirmation.” When should you start the ob record?

Answer: At the next visit.

If the ob-gyn performed only the urine pregnancy test, you’d report 81025 (Urine pregnancy test, by visual color comparison methods) or possibly a low-level E/M service if some discussion about her health took place.

Report V72.42 (Pregnancy examination or test, positive result). You will use this code when your ob-gyn simply tests to see if the patient is pregnant. This code will go on both the E/M code and the urine test, because you’ll be coding for what you know at the end of the visit. You won’t need any other V codes.

Scenario 2: A patient comes in for an annual exam and the ob-gyn diagnoses pregnancy. When should you start the ob record?

Answer: At the next visit.

If you began the ob record during the annual exam visit, most carriers will consider the annual exam part of the global ob service. You cannot bill the global service until delivery, but you should inform the insurance company of the pregnancy.

Remember to code any complaints, such as malaise, general fatigue, spotting, nausea, vomiting, pelvic pain, etc., that the patient presents with. You can report 99384-99386 for new patient or 99394-99396 for established patients.

Rule of Thumb: Until you know that the patient wants her pregnancy to continue, you shouldn’t initiate the global care.

Scenario 3: A patient sees your ob-gyn after her family physician discovered that she’s pregnant and wants to have her ob care with your practice. She has been seen by your practice within the last 12 months. When would you start the ob record?

Answer: During this visit.

Because another physician made the diagnosis, your ob-gyn probably wouldn’t need to “confirm the confirmation.” Therefore, he would begin the ob record, which means this service is part of the global ob package.

Tip: Some practices confirm intrauterine viability before they begin the barrage of ob coordination.

What’s involved: The ob coordination is lengthy, usually lasting about 30 minutes, and involves going over procedure guidelines, including a timetable of when to do lab tests, pelvic exams, amniocenteses, etc. The ob-gyn will usually provide vitamins and iron supplements and discuss when to call him.

Scenario 4: Your practice scheduled an initial ob appointment for a pregnant patient (who confirmed her pregnancy at home), but she can’t wait to have some of her questions answered. She wants to come in earlier for counseling. The ob-gyn would perform no initial visit or ob panel blood work during this visit. When should you start the ob record?

Answer: This scenario could go either way.

Normally, carriers consider all counseling related to a pregnancy included in the global ob service. If the patient had significant health reasons to warrant counseling, you would wrap this visit into the global care of the patient.

However, if you want to report this separately, you’d report an E/M code such as 99201-99205 for a new patient, based on the time the ob-gyn spent with her. The ob-gyn must document the duration of the counseling visit. The ob-gyn might ask, ”Does the patient intend to keep her pregnancy? Are there extenuating circumstances about high-risk situations, such as drug abuse, need for genetic counseling, or current high-risk medications?”

If the patient is established, you’d report an established patient E/M visit (99211-99215). If a nurse who was not a certified nurse midwife or a nurse practitioner saw the patient, you must use 99211 for the encounter.

As for a diagnosis code, you might try V65.40 (Counseling NOS) or V65.49 (Other specified counseling), but carriers don’t usually allow you to use these codes as the primary diagnosis. Also, if the ob-gyn discusses genetics with the patient, you can use V26.3 (Genetic counseling and testing) instead.

@ Ob-gyn Coding Alert

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On Tuesday evening, the Senate passed H.R. 4691, which freezes the Medicare conversion factor at current levels through March 31.

Because of this vote, you will not face the 21% pay cut until April 1, explains Part B Insider editor, Torrey Kim. Hopefully by that point, a more permanent fix will have been introduced. “The Senate is working on a bill that would extend the current Medicare payment rate until Oct. 1,” reports this article from the AAFP site.

H. R. 4691 is a “hodgepodge” bill that contains a lot of other provisions in addition to this month’s conversion factor freeze, reports The Wall Street Journal. The bill also extends COBRA’s health insurance subsidies.

FREE WEBINAR: Are you home-growing your very own physician pay cuts with faulty E/M coding? Stop shorting yourself on E&M coding levels with this most-often-overlooked medical coding history type.

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5 tips help you recover deserved pay.

Collecting money from patients, especially during a recession, can be challenging. If your front desk is responsible for collecting copays and sometimes old balances, its success or failure has a dramatic impact on the practice’s bottom line.

Check out five ways you can improve your front desk collection efforts:

1. When calling to remind patients about their visit date, also remind them of their co-pay amount and any old balances so they come prepared to pay at the visit.

2. When a patient complains about paying a bill, send her to a manager so the bill can be reviewed and explained.

3. Most practice management software will allow front desk staff to view outstanding balances. Your front desk staff can politely remind the patient that there is a balance and say something like, “How would you like to pay your bill today?” Assume that the patient is planning to pay.

4. If the patient has a problem paying their balance or paying for the visit that day, do not discuss this at the front desk. Respect his privacy. Staff may wish to take him to a manager’s office where a payment plan or other arrangement can be established.

5. Ask your manager about offering discounts to patients with no insurance if they pay for the visit at checkout instead of sending them a bill.

And one extra tip: Involve Your Supervisor. Pearl Stafford, front office manager for an internist and gastroenterologist in Naples, FL, who also once worked for a psychiatrist where she assumed the role of the receptionist from time to time, acknowledges that old or really old AR can be difficult to collect. “A lot hinges on the physician,”says Stafford. “In this particular office, my physician provided incentive. Since the AR was so old in many cases, he offered me 25 percent of anything I collected. Most collection agencies charge 50 percent, so this was beneficial to the practice and also worked as an incentive for me.” If something is really old, it’s better to collect some money as opposed to nothing and wipe it off the books.

Carol Gibbons, CEO of CJ Consulting, helps management to set up collection targets for the front desk and then rewards staff when they reach that goal. “In one practice with seven physicians, the front desk as collecting $500 per day at the front desk. After doing training with the front desk staff, we started pushing up their collection goal and then bought lunch each time they reached a new goal. Today, at the front desk, that office collects $2,500 to $3,500 per day in co-payments, co-insurance, and old balances. The manager still buys pizza when they reach a new high in daily collections or rewards individual employees with gift cards.”

Again, your specific role in collections will vary, but these are some ideas that you may wish to present to your manager or physician if they are not yet implemented in your office.

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This 3-step checklist will boost your bottom line.

With fewer patients following through on procedures because of economic and financial struggles, and an increasing number of patients not paying their bills, your practice needs to find ways to improve your A/R and bring in deserved money. Adapting an up-front deductible collection policy is one proven way to do both — and setting up a policy can be as easy as 1-2-3.

1. Confirm the Deductible With the Payer

Insurance verification services now make it possible for practices to find out if a patient has met his deductible yet. Some services can tell you how much of the deductible remains unpaid. Because this information is available online, your practice can get this information last-minute, the day of, the day before, or several days before the patient is scheduled to come in for a service or procedure.

“I have started to look up insurance deductibles and copays on Web sites,” says Joy Bloodworth, CPC, CCS-P, office manager and coder for Surgical Associates in Cordele, Ga.

Pointer: Check with your benefits verification services, as some offer real-time information on how much of a patient’s benefits have been used to date, the deductible to date remaining, number of hospital days remaining, skilled nursing facility (SNF) days remaining, and if the patient has Medigap coverage that will cover a portion of the payment.

2. Contact the Patient Before the Procedure

Once you have the information from the payer about what the patient’s responsibility will be, you should contact the patient. Most practices are more successful when they contact the patient several days before the procedure, rather than the day of the procedure, experts say.

“We are calling patients about one to two weeks in advance if possible requesting the deductible or their percentage of the allowable of their insurance for the procedure being performed,” says Lori Owens, CPC, CGIC, insurance supervisor at Ohio Valley Surgical Specialists in Owensboro, Ky. “It is working fairly well.”

Be clear: Make sure you tell the patient where you got the information about her deductible and let her know that the amount is an estimate based on the services your physician expects to perform, Bloodworth cautions. Otherwise, you may get calls from patients after procedures “saying they paid up front and don’t owe any more after the insurance pays,” she says. “When I get the information from the insurance company, I tell the patient it is just an estimate and after insurance pays we will adjust the payment form accordingly.”

3. Consider Rescheduling When You Can’t Collect

If you cannot collect up front from a patient, you’re left with two options: Cancel the procedure or perform the procedure and hope the patient pays you afterwards when you send a bill.

“If there’s no emergency, we ask that the patient pay the copay and deductible up front,” Bloodworth. “We will reschedule if the patient does not have it and the physician says it is elective.”

Some patients may get upset that you’re asking for their money before you perform a service, especially if they don’t feel they can pay their deductible. “We feel that these patients would probably not pay anyway and it makes room for patients waiting to have procedures performed,” Owens explains.

Other patients, however, may simply need additional time to pay you. Even when you don’t collect up front, making an attempt can still help you collect eventually. A patient will know before having the procedure exactly how much she will owe your practice.

“You may not collect from all,” Owens says. If her practice doesn’t cancel the procedure, the call “just lets the patient know how much to expect” when the practicesends a bill.

Set up a payment plan: Some patients cannot come up with the entire deductible amount up front and will ask to make payments, Bloodworth explains. “They have to come up with at least half of it and sign a form showing the balance due and payments less than $200 will be paid by three months and over $200 will be paid by six months.”

Bottom line: At least attempting to collect deductibles up front is beneficial for your practice. “Our A/R is more in line now and we definitely have seen a difference,” Owens says. “It is worth the hassle.”

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