Cardiology practices have always faced distinctive coding and billing challenges. Today, rapidly declining reimbursement makes it imperative for practices to collect every legitimate charge, requiring the assistance health IT solutions.
“Bundled” CPT codes pose one of the most difficult billing hurdles. Cardiologists–especially interventionalists–typically perform more than one procedure during the same visit. Any number of interventions, for instance, might be performed immediately following a cardiac catheterization. The problem is that not all of these procedures are billed separately. Payment for one service often is considered “bundled into” payment for another performed service.
As a result, coders and billers must know when each code:
- may be billed
- may not be billed because it is bundled into other submitted codes, or
- might be billed, but only if an appropriate modifier is applied.
Gathering this information requires tracking thousands of so-called “bundling edits” that can sometimes change every quarter. They are a moving target, yet accusations of fraudulent billing loom for any practice that disregards them.
In addition, cardiology suffers from the recent movement by CPT toward creating “combination” codes that pay less than the former sum of their parts. In 2010, for instance, cardiologists face up to a 36 percent reduction in Medicare fees for SPECT myocardial perfusion imaging, due in part to the formation of a single code that includes wall motion and ejection fraction.
A similar problem is found in codes that incorporate the concept of global days. While most PCIs do not fall under the limits of traditional 10-day or 90-day global periods, recent CPT changes now require close observation of how often some other services are performed. Case-in-point: In 2009, de facto global periods were added to several CPT codes for cardiovascular device monitoring that restrict their use to once every 30 or 90 days.
Another reimbursement barrier stems from the Medicare decision to cease payment for consultation codes, with enormous consequences for consultation-heavy specialties such as cardiology. While the relative value units for office visit codes have increased, the change is not expected to recoup the loss of higher-paying consultations.
Surmounting billing obstacles with health IT
The fact that payors have differing rules regarding reimbursement for consultations, bundled codes and global periods–not to mention varying eligibility and pre-certification requirements–puts a great burden on the billing office. Tracking all of these elements within a paper-based environment is difficult at best. Successful navigation of these impediments depends, in part, on the extent to which a practice can increase efficiencies through automation.
With 45 physicians and 14 non-physician practitioners spread across nearly 40 locations, I found it increasingly arduous to effectively manage the paper-based billing process for Oklahoma City-based Oklahoma Cardiovascular Associates (OCA). My ability to manipulate data–both to gauge and improve bottom-line metrics–was severely hampered each time a piece of vital information slipped through the cracks and vanished. To state the problem simply: You can’t track what you have missed if you don’t know what you have missed. One drawback, however, was clear: too much time was wasted on non-productive responsibilities.
For instance, we received paper remittance advice–often up to 200 pages–that had to be manually scanned into our system. This forced us to dedicate two part-time employees solely to making duplicate paper copies, from which they devised appropriate worklists for each biller.
That all changed in March 2009, when OCA went live with a Web-based medical claims clearinghouse (Navicure, Atlanta), which streamlined workflow in addition to providing the team's strategic business intelligence needed to track and manage the revenue cycle.
Improved workflow and A/R days
Our billing workflow has improved significantly since implementing the new claims technology. Appropriate worklists now flow directly to each biller and claims can be assessed in real-time. Because our solution is Web-based clearinghouse, our billers can access a set of up-to-date bundling edits that include rejections experienced by other users. Overcoming the bundling obstacle is eased, which aids our first-pass rate.
Because of our improved oversight, our first-pass rate with payors has improved