Challenges of Revenue Cycle Management

Any healthcare provider might be leaving a lot of money on the table due to inaccurate revenue cycle practices and your OB/GYN practice may not be an exception. While reimbursement for OB/GYN services seemingly should be a simple matter of submitting a claim, the reality is it’s not that easy due to a lot of revenue cycle processes involved in it. Reimbursement for any service occurs over the length of the revenue cycle for a patient encounter and involves many steps. In this article, we will focus on these revenue cycle activities and will highlight their importance in maximizing your OB/GYN payments.

The revenue cycle starts when the patient makes an appointment for services and ends when the practice receives payment from insurance and the patient. Along the way, there must be appropriate documentation and sound knowledge about the billing process, including knowledge of the CPT, HCPCS, ICD-10-CM codes, the modifiers, and, of course, the bundling issues that now accompany many coding situations. The crucial thing is everything should be contributing towards establishing medical necessity.

In addition, you must be billed to multiple payers, from federal to commercial, and must understand and adhere to each payer’s billing guidelines and reimbursement policies to maximize and retain reimbursement. Let’s focus on some revenue cycle functions from an OB/GYN billing point of view.

Maximizing Your OB/GYN Payments

Checking Eligibility and Benefits

Once a patient makes an appointment, the front-end staff handles some of the important tasks in the cycle. This includes collecting all required and updated information like patient demographics and insurance information. Your front-desk team needs to ensure that the patient’s insurance coverage information is current, informing the patient of any additional information to bring at the time of the visit (such as a patient history form for a new patient visit or a list of current prescriptions), or, if an established patient will be having a procedure, making sure that prior authorization is complete. Your front desk team plays a crucial role in assisting the clinician with documentation and ensures that incorrect or missing information does not cause a claim to be denied or not be filed in a timely manner.

Accurate Code Selection

As discussed earlier, you must have an experienced coding team who has done OB/GYN billing for a long time and is well-versed in the services, procedures, and diagnoses reported for their OB/GYN practice. The actual code selection is a joint venture between the clinician and the coding team to ensure that accurate information will be entered into the claim. Good and frequent clinician-coding team communication on the billing of services can transform average reimbursement into maximized reimbursement. Sometimes more than one service or procedure is listed on a claim on the same date of service. However, it is important to identify all potential bundles before billing to ensure correct payment. For instance, payers like to bundle an E/M service and a procedure, or you may be in the global period of surgery but need to report an unrelated service.

Manage the Modifiers

Coding staff must ensure the claim is submitted with the correct modifiers, sometimes the code billed requires a modifier to ensure payment. For example, some payers will not reimburse both the insertion and removal of an intrauterine device (IUD) on the same date of service. If that happens, a modifier on the removal code might save the day, rather than billing 2 codes. Commonly used modifiers in an OB/GYN office setting includes modifier -22, -24, -25, -52, -57, -59, and modifier-79.

Order of Services on the Claim

For an outpatient claim that includes both an E/M service and procedures, the order of the services, not the order in which they were performed, may be important to obtain maximum reimbursement. In general, payers will pay in full for a supported E/M service no matter where it appears on the claim, but they apply reductions only for multiple procedures. For instance, if you insert levonorgestrel implants on the same date as you remove a large polyp from the cervix, you would want to report the code with the highest relative value unit (RVU) first. In case of removal and insertion of IUDs on the same date, the order of the codes, assuming the payer reimburses for both, will be even more important since removal usually has a higher payment.

Understanding Global Package Billing

Understanding of global package concept can be crucial to getting paid for additional services during this time period and correct billing for any E/M services performed prior to surgery. In general, the routine history and physical examination performed prior to major surgery are considered included in the work and should not be billed separately. Surgical clearance for a patient’s condition, such as hypertension, a heart condition, or lung issues, can be billed separately, but these generally are performed by someone other than the operating surgeon. Procedures performed in the hospital setting generally will have a 10- or 90-day global period. During this time, any related E/M service should not be billed separately, and the use of modifiers becomes even more important than with office services.

Wherever applicable you can use appropriate modifiers to maximize your OB/GYN payments. Some of the applicable modifiers are, modifier -50, bilateral procedure (for which you may be paid up to 150 percent of the allowable); modifier -58, staged or related procedure during the postoperative period (this may be paid at the full allowable); modifier -62, co-surgeons (both surgeons bill the same CPT code and both document their involvement in the surgery). Medicare will reimburse each surgeon 62.5 percent of the allowable; modifier -78, return to the operating room for an unplanned related procedure (the full allowable may be reduced by some payers owing to their belief that this is soon after the original procedure so intraoperative time only is considered).

Appropriate Documentation

Good documentation before, during, and after a patient’s office visit is essential, along with accurate codes, modifiers, and order of services on the claims you submit. If both an E/M and a procedure are performed on the same date of service, the E/M must be documented to show it was separate from the procedure and that the work was significantly more than would be required to accomplish the procedure. Documentation of the procedure should include the indication, steps performed, findings, the patient’s condition afterward, and instructions for aftercare or follow-up. Select the most accurate CPT codes, and link them to a supporting diagnosis for each service that will be billed.  If more than one diagnosis is applicable, the first one linked to any given service should represent the most important justification, as not all payers will accept more than one diagnosis code on the claim per service billed.

Bottom line

Maximizing your OB/GYN payments involves correct CPT codes linked to specific and accurate medical indications, the use of appropriate modifiers, listing codes in order of their relative values from highest to lowest, backed by supporting documentation, and must justify medical necessity. If you receive a denial or unfair reduction in payment, analyze the claim denial to determine the cause and make billing and reporting changes as needed to improve your future reimbursements. Practices often make the mistake of billing for all procedures separately to maximize their OB/GYN payments, which is inaccurate billing.

The procedures at the time of surgery that generally are not paid for include, examination under anesthesia; any procedure done to check the surgeon’s work (for example, cystoscopy, especially when done after urinary or pelvic reconstruction procedures, or chromotubation following extensive ovariolysis); placement of catheters; and placement of devices to alleviate postsurgical pain.

Outsourcing your billing and coding operations to an experienced medical billing company also could help in maximizing your OB/GYN payments. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. Our expert billers and coders ensure that each and every procedure is coded properly to ensure maximum payments.

With our complete billing and coding services, you can focus only on patient care without worries about timely and accurate payment collections. To know more about our OB/GYN billing and coding services, email us at: or call us at: 888-357-3226.

Published By - Medical Billers and Coders
Published Date - Nov-11-2022 Back

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