When it comes to billing Medicare for outpatient visits, your correct procedural terminology (CPT) had better be right or else you may not get paid at all. And if you do get paid, you may get less from Medicare than you expected. Thats the view of Trish Frumkin, RN, MS, CRNC and Susan Dabro, RN, MA, CRNC, owners of Coding Scene Investigators.
“The fact is, the CPT code drives reimbursement on the outpatient side, unlike reimbursement for inpatient medical care, where the reimbursement drives are diagnostic related groups (DRGs). And if hospitals and physicians fail to submit the correct CPT codes, Medicare can easily rule them out,” said Frumkin.
Getting CPT codes right tells only part of the story. The other part concerns matching CPT codes correctly with diagnoses of the medical problems that patients present on the day of service. This may sound simple to handle, but complications can easily arise.
For example, lets say that a patient presents a problem of hypertension, but during the examination complains of recent rectal bleeding, and the physician administers a flexible sigmoidoscopy in the office. Subsequently, the biller enters the primary diagnosis as hypertension and bills an E and M code for office visit and flexible sigmoidocsopy. The physician enters a diagnosis code for hypertension , which was what the patient presented for on that day of service. The physician coded a secondary diagnosis of rectal bleeding.
The result: Medicare pays only for the presenting problem, in this case hypertension. Medicare will then pay 35 percent of an office visit perhaps costing $93. Medicare also rejects the cost of the flexible sigmoidoscopy billed out at, say, $350. The bottom line: The physician should have arranged for the patient to return on another day, administer the flexible sigmoidoscopy then and bill Medicare for the presenting problem of rectal bleeding.
“An exception to this rule may occur if a patient presents for a non-emergent problem like hypertension, but experiences an emergent situation like an acute myocardial infarction during the examination process. In a case like this, the emergent diagnosis of myocardial infarction takes precedence,” said Dabro, a long-time billing auditor who once saved $5 million for a hospital system over four years. She now teaches coding to billing personnel from hospitals, multi-specialty physician practices, and primary care practices throughout the United States.
According to Frumkin and Dabro, Medicare stringency recently became even tighter with potentially negative financial results for hospitals and physicians alike. As of October 15, 2003, Medicare let it be known that patients would now be tracked by social security number and date of service. The upshot has been that if the diagnosis and CPT code submitted by a hospital and the diagnosis and CPT code from a physician for the same patient fail to match on the day of service, Medicare pays neither the hospital nor the physician.
This wrinkle in the Medicate coding and remittance systems has caught the attention of hospitals, given that Medicare reimbursement accounts for nearly 75 percent of hospital revenue. “Its no surprise that most hospitals now subcontract with front-end clearinghouses that run a primary edit on bills to be submitted to Medicare to make sure that primary diagnosis codes and CPT codes match,” says Dabro.
Busy surgeons may also encounter problems, when they fail to take time to dictate after procedures in multiple hospitals and submit bills to Medicare with diagnoses that differ from those of anesthesiologists. Thats because anesthesiologists often turn bills in by 6:00 p.m. to billing offices that may work until 9:00 p.m. The billing department electronically submits the bills and Medicare that same evening. If the surgeons diagnosis codes and CPT codes fail to match those of the anesthesiologists, Medicare denies the claims of the surgeons.
Trish Frumkin and Susan Dabro suggest that hospitals and physician practices alike generally recoup Medicare remittances more effectively by periodically auditing their billing procedures relative to Medicare. Such an audit requires reviewing and comparing super bills, dates of service, medical records, and explanation of benefits (EOBs) with Medicare remittances.
