It is mind boggling to witness the number of medical claims that are denied each quarter for invalid diagnosis codes. Indeed, one leading cause of our country's current healthcare crisis is the vast number of procedures and tests performed each year without validity. This amount to millions, if not billions, of dollars in reimbursement and is part of the excessive cost of healthcare coverage in the United States.
Physicians who refuse to educate themselves on approved diagnosis codes can lose upwards of 50% of claims billed for testing and procedures. It is unimaginable when the system is so easy to understand.
First of all, Medicare's website will outline every test and procedure that you might perform, along with a list of the diagnosis codes that meet the requirements for payment. You may not believe this, but I have seen physicians bill an echocardiogram with the diagnosis code for asthma !!!! Of course, the claim was denied..
No procedure or test should ever lose reimbursement if the correct guidelines are followed. Organ systems must have a relationship to the procedure performed. Before you schedule, such as an echocardiogram, you better suspect, and have some evidence that there is a heart valve problem. While this may sound logical, it is amazing to witness some of the codes I have seen to justify this procedure. It is even more amazing to see the physicians reaction when their claims are denied again and again. There is no test or procedure that should be considered routine in your practice, and if you are not able to follow the established guidelines for the test or procedure, you should consider another option.
One way to avoid diagnosis errors is to download the Medicare Local Coverage Determinations (LCD) that you can find @ www.ngs.medicare.com. A good tip after downloading these LCD's is to make a billing sheet that contains at least 4-5 diagnosis codes that your physician may use for that procedure.
These codes should be listed on your billing sheet or encounter directly below the procedure code. For automated billing sheets, follow the same guideline. The approved codes will help the physician to determine if the procedure meets the criteria for billing purposes and will assure clean claim transmission.
Changes to diagnosis coding will appear in the Medicare guidelines and help you keep current with changes or codes that are changed or deleted. Don't just order the Part B news. Read it, highlight any changes that might affect your practice, and send a memo to each of your physicians notifying them that the change has occurred.
If pre-certification is required, you will want to make sure that you use an approved diagnosis code when requesting authorization, or you will just waste time spinning your wheels trying to get a procedure or test approved. Even if your physician has a sound rationale for ordering the test, without an approved diagnosis code, it's just not happening....
Many EMR systems have a list of approved codes built in to assure claim reimbursement, and will notify you if you choose a diagnosis that does not fit the procedure. Caution should be exercised to make sure that your software is not choosing a diagnosis code for your doctors, so a basic knowledge of approved codes is still a requirement for all physicians.
One of the hot topics for a recommended monthly meetings with your physician staff should involve a discussion of any recent changes in the Medicare and private insurance arena. Seeing these changes in writing and discussing any lost revenue is essential to assuring that your practice moves forward.
Tomorrow : Timely Filing - Another Big Problem...
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