Maximizing Reimbursement, Minimizing Penalties

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  Templates for the level of procedure complexity help both physicians and coders make accurate choices for maximal reimbursement. Source: Tammy Gott, CPC, Wellmont Holston Valley Hospital, Kingsport, Tenn.

In today’s healthcare reimbursement scene, reimbursement in cardiology per procedure code tends to be declining. Along with flat or declining volumes and increasing overhead costs, many shareholders are experiencing a downslope in income. Thousands of dollars can be recouped, as well as costly penalties avoided, by paying close attention to billing and coding.

When Brian Rutledge became the manager of business and clinical operations in the Division of Cardiovascular Diseases at the University of Mississippi Medical Center in Jackson in 2006, he found a division that had not changed much in nearly 30 years. The coding, in particular, was problematic as the system and personnel had not kept up with the rapidly changing nature of cardiovascular procedures and coding.

Rutledge found coding errors in complex as well as simple cases. He found problems with peripheral vascular and electrophysiology (EP) cases. Some complex procedures can have up to 15 different codes, each potentially reimbursing $1,500. “Missing just a few of these over the course of the year can mean tens of thousands of dollars in lost charges,” Rutledge says.

He also encountered communication issues with the billing office, which tended to not give feedback regarding denied claims. “You can’t recover what you don’t know you lost,” he says.

When he looked for new personnel, he found it difficult to locate highly qualified coders. He heard about CodeRyte, a computer-assisted coding company based in Bethesda, Md., and decided to give them a chance. He crunched some numbers and found that CodeRyte’s cost would be half that of a full-time coder, including fringe benefits, salary, overtime and “the headaches of managing an employee.”

Now more than ever Rutledge needs to recoup every legally earned dollar. They are in a growth phase, expecting to double the size of their practice by year’s end. Three interventionalists and two electrophysiologists have recently joined the existing practice of 10.

He began using CodeRyte in November 2007. An audit of the first 25 patient encounters handled by the new service revealed that the old manual coding system was potentially losing hundreds of thousands of dollars a year.

While it’s difficult to compare this year’s numbers with last year’s, given a practice plan consolidation and an increase in the practice’s fee schedule, Rutledge says his codes are more complete, more accurate and charges are up. In March 2008, the department had the largest month of gross charges ever, which could be partially due to the increase in the fee schedule, but Rutledge gives a lot of credit to the automated coding system.

Besides the cost savings, he points to an improved turn-around time. They have gone from a four- to five-day lag time, which involved several handoffs to various departments and making copies along the way, to a 24-hour turnaround ending with an electronic submission to the billing office.

Periodic audits

If a practice is performing its own coding, it’s imperative to conduct periodic audits to determine what if anything is out of the ordinary. One thing to check is coding ratios. For example, a coronary catheterization procedure involves a code for injecting the coronary arteries (93545), along with a corresponding supervision and interpretation code (93556). If those two codes are not close to a one-to-one ratio during an audit, something is not right, according to Marjorie A. Amato, MBA, director of the Business Office Coding Network at MedAxiom, a professional organization based in Neptune, Fla., specializing in helping cardiology practices perform at a higher level. “When we see that expected ratios aren’t met, we teach our clients to dig deeper,” Amato says.

In order to be paid for what you do, you first have to ensure that you are billing for every code you can—and at the highest level of the code, Amato says. She culled data from 100 member cardiology practices to determine if they were coding at the proper level. She looked at the E &M (evaluation and management) levels for hospital admissions, hospital consultations, new office visits and office consultations—the four categories available for first-time patients. Each category has various code levels, each level representing a more comprehensive evaluation