This article previously ran in the Q2 2023 issue of A2Zzz.
Reimbursement challenges have tested a program’s profitability in the past, and today is no exception. This year there are additional factors which will impact clinical and financial practices: the expanding influences from the 2023 Office of Inspector General (OIG) workplan, the implementation of the Requirements Related to Surprise Billing legislation and numerous reimbursement changes. Medicare has also published many billing updates for us to review and consider as we proceed with submitting billing claims for 2023. This article will provide an overview of key billing processes, which require an audit before submission of the claim.
The 2023 Medicare Physician Fee Schedule is a key resource for all providers and may be reviewed on your regional Medicare Administrative Contractor’s (MAC) website. The MACs adjudicate or process Medical Part A and Part B claims for your geographic region and determine the Local Coverage Determination (LCD) criteria for reimbursement of the respective procedures billed using a Current Procedural Terminology (CPT) code. The LCD defines documentation requirements to meet medical necessity determination. It includes the requirements of approved technical and clinical credentials and clinical expertise and credentialing to perform and interpret the respective procedure. Each year, the Centers for Medicare & Medicaid Services (CMS) publishes the “What’s New Report” to document billing and coding changes, the indications for coverage of the procedure effective around Jan 1. It's important to verify the effective date of the revision and look for any date associated with termination of the original LCD preceding the change being referenced in the new update.
LCDs are not only for CMS or federal claims. Many commercial insurance companies follow changes in LCDs to create their own contracted coverage, reimbursement rates and documentation requirements. Another vital next step for review each year includes contract changes, which impact reimbursement for respective CPT codes.
Taking a more granular look at best practices for coding and reimbursement strategies, most denials are due to clerical errors on the claim such as wrong demographic data, incorrect birthdates, transposition of contract numbers, noncovered diagnoses codes or incorrect CPT codes.
To reduce these denials, an audit process is required before submitting the claim. Some providers use a third party — a clearinghouse — to review the claims. Published resources are also required to remain apprised of the billing rules and changes. I recommend investing in a current CPT manual published by the American Medical Association (AMA) to study code changes and new guidelines for correct coding. It will include information about the use of modifiers, which are two alpha-numeric characters appended to the CPT code, to convey additional information about the code used, any changes that occurred during the procedure or a more complicated than normal procedure performed under unusual circumstances. If denials are associated with a diagnosis, obtain a current ICD-10-CM manual, published by the World Health Organization (WHO), which classifies diagnoses and the reason for visits in all health care settings, as well as which are appropriate for reimbursement based on documentation supporting the procedure and diagnosis.
Understanding Appropriate Code Use
Is CPT code 95806 the only code to use for a home sleep test (HST) monitored for four hours, provided by a hospital in the critical care unit and ordered as an emergency procedure? Before we can answer that, we need to know if the payer requires a different CPT code or the appropriate G-code: G0398, G0399 or G0400. Since the monitoring lasted only four hours, a modifier 52 is added to the CPT code on the claim. This indicates the study is considered reduced services and does not meet the required duration of six hours as stated in the definition of CPT 95806.
Assuming the study is of adequate quality for interpretation and billing, the hospital will add another modifier, TC, to indicate the claim is submitted for the technical component of the procedure. The interpreting licensed provider will submit a claim with modifier 26 for professional services to interpret the clinical data and render a diagnosis. To learn if there are other codes or modifiers to append for the emergent condition or the location of services, a review of the CPT guidelines for 95806 is completed with analysis of the coding and billing guidelines referenced in the CMS standards, auditing for medical necessity confirmed through review of the clinical documentation and confirmation for what location of the services are approved for reimbursement. This is an important verification, as HSTs are routinely completed in the home, or a residential domicile verses the inpatient critical care unit. Careful study of the approved diagnosis confirms if the current diagnosis is excluded, since there are no guidelines to cover 95806 (the home sleep test) for emergent health conditions in inpatient settings. The scope of the HST does not conform with the current order for sleep testing.
Review of the clinical documentation is essential to identify the appropriate procedure based on the emerging health status of the patient. Consultation with the medical director or patient’s attending provider is required to define the appropriate procedure to be completed for this patient’s clinical status.
Hence, add a review of the LCD and compare this to contract changes for commercial carriers to your checklist of strategies for effective reimbursement. Include a review of the CPT codes, the guidelines assigned to respective codes, the indications for selected ICD-10-CM diagnostic codes and when to use modifiers, and validate the clinical documentation supports medical necessity for payment of the procedure and clinical diagnosis.
A key change for all programs starting in 2022 is compliance with the Surprise Billing legislation. Understanding required documentation and communication with patients is a pathway to preventing billing nightmares. The legislation requires providing the patient with a good faith estimate of charges and subsequent financial responsibilities prior to the provision of services. Some organizations have deemed themselves exempt from compliance with the legislation in error. It requires both providers and health plans to assist patients in accessing health care cost information. For a good review of the legislation, the American Hospital Association has posted a summary.
Billing and coding are not done in a silo. Enlist the assistance of the revenue integrity team, registration department, insurance contract specialists and clinical experts to complete a regular review of the sleep center’s clinical documentation standards and billing practices.
With the changing landscape for clinical services, there are other opportunities to consider in the face of all these changes. Collaboration with third party payers, the patient, your referral network and educating the community will boost reimbursement for services. Effective financial processes are built on a patient-centric care continuum, with savings realized through innovative care delivery systems and effective care coordination. It requires a partnership with key stakeholders in the facility, the primary care network and other specialists to systematically manage the patient’s care plan.
Kathryn Hansen, BS, CPC, CPMA,
is a recognized national presenter focused on the practice of sleep medicine, neurodiagnostic testing, and coding and billing compliance. She is the owner of Integration Consultants LLC, a health care consulting firm working with hospitals and medical practices to grow revenue and maintain compliance with federal and state regulatory standards. Hansen currently serves as the executive director for the Society of Behavioral Sleep Medicine, the Board of Behavioral Sleep Medicine, the Academy of Clinical Sleep Disorders Disciplines, and is a clinical author of online education with Sleep Education Partners and is the CME coordinator for the American Academy of Cardiovascular Sleep Medicine.