After your consultation and examination, you decide your patient requires a cold pack (97010), electrical muscle stimulation (97014), manual therapy techniques/myofascial release (97140), and chiropractic manipulative therapy/1-2 regions (98940). Your claim total is $125. The insurance company sends you a check for meager $22 and you wonder why.
In this type of situation, the explanation of benefits may say your services were inappropriate because they were “unbundled” incorrectly. The payment may then reflect a “bundling” of services, in which all procedures are paid under one CPT code. You could also receive a denial for the entire claim if you did not link the correct CPT code with the proper diagnosis code.
Does this scenario sound familiar? If it does, knowing more about insurance coding and billing could be the answer you’ve been looking for. When you have the ammunition you need to battle insurance companies, you can actually get paid fairly for the services you provide. Strategic billing and coding can help you thrive in today’s managed-care environment.
In order to fully understand billing and coding strategies, you need to be informed about the related regulatory issues. On December 19, 1989, the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239) was enacted and added a new section (section 1848), Payment for Physicians’ Services. This section of the act provided for replacing the previous reasonable charge mechanism of actual, customary and prevailing charges with a resource-based relative value scale (RBRVS) fee schedule that began in 1992.
With the implementation of the Medicare Fee Schedule, it has become increasingly important to assure that uniform payment policies and procedures are followed by all carriers, so when the same service is rendered in various parts of the country, it is paid for in the same way. In addition, accurate coding and reporting of services has become a major concern to guarantee proper payment.
Most Medicare carriers have already included in their claims-processing system various computerized edits to detect improper coding of procedures. Many of these edits are designed to detect “fragmentation,” or separate coding of the component parts of a procedure, instead of reporting a single code that includes the entire procedure. Unfor-tunately, there has not been consistency or uniformity among the carriers in correct coding edits.
There are two main types of coding combinations:
- Mutually Exclusive Procedures: These are procedures that cannot be performed during the same session. A few examples of these procedure code combinations are shown in Figure 1. They are divided into Column 1 and Column 2 procedures. The Column 2 procedure will not be reimbursed if it is rendered by the same provider on the same date of service, since it cannot be performed during the same operative session as the Column 1 procedure.
- Comprehensive and Compound Procedures: A few examples of these procedure code combinations are shown in Figure 2. They are divided into comprehensive code (Column 1) and component code (Column 2) procedures. The component procedure (Column 2) will not be reimbursed when it is rendered by the same provider on the same date of service, because it is a part of the comprehensive procedure.
Many insurance companies (especially the “Blues”) require the CPT codes to “link” with the appropriate diagnosis codes. In Figure 3, a few examples of common clinical diagnostic scenarios are linked up with the appropriate procedures.
Treatment Example: Patient enters office complaining of low back pain and leg pain. X-rays reveal degeneration of the lumbosacral disc. Treatment consists of mechanical traction, electrical muscle stimulation and therapeutic exercises. Diagnosis is low back pain, sciatica and degeneration of lumbosacral disc. HCFA form must show that only mechanical traction is linked to the degeneration of lumbosacral disc diagnosis. The HCFA form must show that mechanical traction, electrical stimulation and therapeutic exercises are linked to the low back pain and sciatica diagnosis.
Insurance billing and coding doesn’t have to be overwhelming. The most important aspect of delivering quality services in a managed-care environment is to provide a thorough evaluation examination and render the necessary treatment.
Your focus should be on delivering the care you feel is necessary to help the patient attain optimal results, and then your billing and coding strategy should match the services rendered.
If you prove medical necessity and take the time to bill and code thoroughly and accurately, you will be more likely to get paid for what you do. It’s as simple as that.