Refine your coding for better reimbursement

The surest way to improve reimbursement is to improve claims coding.

"You can code it right the first time and get paid, or you can try to fix things up after aclaim is rejected and hope to get paid, said Emily Hill, PA, president of coding consultants Hill &Associates in Wilmington, North Carolina. "You really need to look at your CPT book when you gethome."

One of the biggest obstacles for family physicians is the concept of global packaging, Hillsaid during a Saturday seminar at the American Academy of Family Physicians 2007 Scientific Assemblyin Chicago. Global packaging means that Medicare or a private payer is providing a singlereimbursement to cover all of the time and costs associated with a particular procedure.

Definitions and requirements vary from payer to payer, but the global package typicallyincludes payment for the skin-to-skin procedure and the equipment typically used in that procedure, apre-operative visit and any equipment or supplies typically used, and a post-operative visit plus anyequipment of supplies typically used. Precisely what is included in the global package varies by CPTcode, but physicians cannot bill for standard items, such as surgical trays that are used as a matterof course.

That's the bad news about global packaging. The good news is that following the rules canboost revenues. Medicare and other payers offer higher reimbursement for procedures done in theoffice than for the same procedures done in a hospital, Hill explained.

That is because the payer is covering a portion of office overhead when a procedure is donein the office. If the same procedure is done in the hospital, the payer assumes that the hospital'soverhead is already covered in other reimbursements.

Another tip: study the fine print that defines precisely what is and is not included in theglobal package for CPT codes the practice uses, then compare the package elements with every service,supply, and product actually used in the procedure as performed on every patient.

"If it is not built into the global package, you can bill for it," Hill said.

Every CPT code affected by global packaging also has a global period, the time periodincluded in the reimbursement for a specific procedure. Minor procedures, such as a skin biopsy orthe application of a cast, have a zero-day global period, she continued. That means that all servicesor visits provided as part of the procedure on the same day of the procedure are included in theglobal package.

If the patient comes back the same day after a skin biopsy to have the biopsy site checkedfor example, the physician cannot bill for a separate visit. But if the patient comes in the dayafter the biopsy, the visit can be billed.

More complex procedures, such as incision and drainage of a cyst or removal of skin tags,have a 10-day global period. The longer global period allows for an expected follow-up visit, Hillexplained. If a patient has skin tags removed and returns on day 9 for a follow-up visit, there is noadditional billing. If the patient returns on day 15, it can be billed as a second visit.

Major surgical procedures that are unlikely to be performed in an office setting have a90-day global period, she added.

Another complicated area is unrelated visits that occur during the global period. The globalperiod applies only to a specific procedure, Hill noted. So if a patient comes in to have a lesionremoved, which has a 10-day global period, and comes back the next day to have a skin tag on anotherpart of the body removed, both procedures should be billed. The 10-day global period for the lesionremoval has no effect on the skin tag removal. The skin tag could even be removed on the same day andbe eligible for a separate billing.

The key to good coding is good documentation, Hill said. Claims processing software isdesigned to assume that any services and procedures performed within a global period are related tothe same procedure and approve only a single payment.

That means that any additional services or procedures need to carry a modifier thatidentifies it as a separate billable event. Billing staff will need complete documentation to codecorrectly, she explained. And if the practice is ever audited, the auditor will expect to seecomplete documentation to support every code.

"You have to have the documentation to support what you bill," she said.