Coding for cash flow and third party reimbursement

Staying up-to-date with your third party reimbursement rates

SUDDEN AND RANDOM DENIALS OF SERVICES make up many of the questions we get from providers and teams regarding third party reimbursement that were “not an issue before.” As we attempt to debug the situation, we run through standard troubleshooting questions that generally lead us to the issue.

The pattern we most commonly find is that the payer’s submission rules, or other requirements, have changed due to an update. And unfortunately, the practice missed the announcement and didn’t make the correction. This led to unnecessary denials, followed by sleuthing to find the problem and extra work to resubmit the claim.

All of this is costly … in both time and cash flow delays. Most of these concerns can be resolved by simply keeping up-to-date on billing and coding requirements. Here are some recent issues that affect coding and what you can do to avoid them in the future.

ICD-10 updates vs. implementation

What are ICD-10 instructional notes? These helpful notes in the ICD-10 coding book, or online coding service, guide the coder through proper usage of the code. They are often directing when one diagnosis is contained within another.

A recent glut of claim denials hit our help desk, and we noticed a pattern, even though the providers were spread across the country. The remark codes on the denials indicated there was an issue with the diagnosis code. In each case, we noticed the provider had the cervicalgia diagnosis code (M54.2) billed along with a cervical disc disorder code. According to the “Excludes 1” instructional note in the ICD-10 coding book, cervicalgia and the intervertebral cervical disc disorder represented by the M50 codes can’t be billed at the same time.

So why all of the sudden? This “Excludes 1” note has been there for quite some time! Payers use millions of claim edits, and they vary based on the claims processing platform or the clinical edit policy of the payer. These are often implemented over time, which can cause a claim to “pass” one month and then fail the next. The payers involved in this issue with cervicalgia codes likely updated their system to process this code correctly, even though it wasn’t at the exact time the new ICD-10 code came into play.

The solution: Stay informed as annual ICD-10 updates are published each July, for implementation Oct. 1. Run a report on the most common codes used in your software and scan the updated for changes with those codes found in the addendum section. You can review the 2022-23 changes at cms.gov/medicare/icd-10/2022-icd-10-cm.

Modifier updates: Not all are created equal

Billing and coding can be frustrating and confusing. What makes it worse is when each payer makes its own rules, to be implemented on its own time schedule.

Dealing with third party reimbursement payers means devoting time and energy to each one to stay up-to-date. Over the past year, many changes have been implemented around therapy codes. Some payers applied the rules two years ago, while others have been putting changes into practice since Jan. 1, 2022. The biggest culprits seem to be the GP (always therapy) and the 96 and 97 (habilitative and rehabilitative) modifiers.

These modifiers were introduced in 2018, and in many cases updated in third party reimbursement reimbursement payer policies over two years ago, but many providers have yet to review the requirements. Most payers have been notifying providers since 2020 of the requirements to append the GP modifier on all therapy codes. Other payers started notifying providers of the need to append modifiers 96 or 97 to therapy codes since midyear 2020.

The 97 modifier is the most likely to be used in chiropractic practice as it describes “rehabilitative treatment.” It’s defined as “all treatments that help a patient to return to a level of functioning prior to an injury or regain a skill, movement, or function that was lost due to injury or illness.” United Healthcare (UHC) initiated a code edit to deny all claims as of Jan. 1, 2022, that do not append the correct modifier.

For example, here is a recent help desk question we got, and how the member could have already known this if they’d only signed up for updates:

Q: We got a rejection in our clearinghouse for code 97110. We have only used 59 and GP modifiers to date — do I need to use a different modifier when billing 97110?

A: It appears you missed a recent HUMANA policy update. Humana releases their code edits the first Friday of every month. In February, they released training on appending modifiers 96 and 97. You can access those resources at: humana.com/provider/medical-resources/claims-payments/making-it-easier.

The Solution: Enroll with each payer through their portal to receive updates at a unique email address, such as billing@youroffice.com. That way, the system remains even if an employee leaves. Also, set a reminder to check third party reimbursement payer portals and “Blue Reviews” quarterly as part of your office’s compliance program.

Managing code edit denials for third party reimbursements

The National Correct Coding Initiative (NCCI) edits have been around for a long time. Most major payers have adopted these edits and created dedicated site pages to manage updates, notices and reimbursement policies.

Even better, they usually provide a practice with 90-day notice before implementing a change. As frustrating as these types of denials can be, they are preventable. We often hear, “We  have  always  been  paid  for  that  code  before.”  A deeper look reveals that the practice didn’t have a system for staying up-to-date with the extensive resources available online.

The Solution: Appeal or resubmit for reconsideration.

Follow these easy steps:

1. Log in to the payer portal and locate the reimbursement policies.
2. Search newsletters and other updates for the keywords “modifier 96” or “spinal manipulation.” Look for a code edit simulator or claim editing tool on the payer portal and assess the procedure code with and without a modifier.
3. Review the claim after you have confirmed the payer’s coding requirements. Was the claim billed correctly? Be sure to confirm that a clean claim was submitted. That means all fields are filled out correctly, including diagnosis codes, diagnosis pointers, other modifiers and Box 14, date of onset.

Once these issues are corrected, if your claim was coded and modified correctly, always follow up with an appeal. If the updated rules were not followed, resubmit according to the payer’s corrected claim process.

Be prepared

This is not just a great motto for the Boy Scouts, but also for every practice looking to stay ahead of changes in this very highly regulated profession of health care and third party reimbursements. Simple initiative-taking steps help meet the requirements of proper billing and coding and keep your cash flow … flowing!

KATHY (KMC) WEIDNER, MCS-P, CCPC, CCCA, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist (MCS-P), a Certified Professional Compliance Officer (CPCO), and a Certified Chiropractic Professional Coder. Since 1983 she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Nearing her benchmark of serving this profession for 40 years, she leads the largest team of certified specialists under one roof in the profession, at KMC University, and is known as one of our profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM-KMC or info@KMCUniversity.com.