Your cardiology practice isn’t alone if you’re concerned about overcoming reimbursement hurdles in the coming year. Apart from nailing down CPT, ICD-10, and HCPCS code changes, you’ll also need a firm grasp on documentation requirements, quarterly CCI edits, regulatory updates, and revisions to modifiers, payer policies, the fee schedule, OIG watch list, and more.
Understand Coverage
Neither federal nor private payers will pay for all available therapies and services. Instead, each payer has set up its own complex system of rules that determine what services and therapies will be covered when. It is important to note some payers may have additional requirements such as prior authorization or notifications for certain services and procedures particularly diagnostic imaging tests and other cardiovascular procedures. Be sure to check with the insurer for these types of requirements before rendering a service.
Medicare uses a variety of mechanisms to set policies for coverage of services. At the national level, the Centers for Medicare and Medicaid Services (CMS) may issue a National Coverage Determination (NCD). Medicare contractors may issue Local Coverage Determinations (LCDs) or may choose to cover services or therapies on a case-by-case basis.
If an NCD or LCD does not exist, it does not simply mean that Medicare will not pay for the service. Most services are not addressed in either an NCD or an LCD. These services are not precluded or qualified through policy but may be subject to coding edits for frequency, volume, or code pairs.
Third-party insurance payers such as Aetna, Blue Cross and Blue Shield, CIGNA, and UnitedHealthcare maintain individual libraries of medical coverage policies. These policies contain the payer’s coverage rationale, interpretation of current medical evidence and literature as well as billing and coding instructions.
Payers often include various evaluations such as clinical practice guidelines, Medicare coverage determinations, medical assessments (from governmental agencies, other health insurers, and independent non-profit organizations), and sometimes use cost-effectiveness research of similar procedures or devices.
Proper Documentation
Proper documentation is critical to justifying medical necessity and the selection of codes for billing. It tells the story of a patient visit by recording pertinent facts, findings, and observations. Payers will use this documentation to verify coding choices, site of service, medical necessity, appropriateness, and accurate reporting of furnished services.
Each office note must tell a complete story and be able to stand alone. For example, auditors interested in services provided in July. 18, 2019 will only review that note; they will not look at notes from other visits unless referenced in the note from July. 18, 2019.
One of the items that the Office of Inspector General (OIG) is looking into is multiple office notes that seem to be “cloned” or “identical.” There are many pitfalls that you can fall into using the “copy and paste” option on your electronic health record (EHR). While this feature is helpful, it could become a problem during an audit if it’s not properly checked during each visit.
One of the billing issues identified by the government as problematic has to do with coding for the location where services have been provided. POS codes must be assigned based on the setting in which the beneficiary receives the face-to-face service.
Because most services include a face-to-face component, this rule applies to the overwhelming majority of services. Where there is no face-to-face requirement, such as where an interpretation of a diagnostic test is performed remotely, you should use the POS code for the setting in which the beneficiary received the test (also referred to as the technical component (TC)) of the test.
Coding becomes much more complex when services are provided in the hospital because a determination will still need to be made as to whether the patient is being treated as an inpatient or outpatient.
When reporting POS, CMS instructs providers to pay more attention to the patient’s general inpatient or outpatient hospital status, rather than the precise inpatient or outpatient code.
That said if you know that a determination has been made regarding inpatient or outpatient status, which is what should be reported.
Highest Degree of Specificity
To explain the importance of the highest degree of specificity would be diabetes. Diabetes including any of its chronic manifestations carries 3 times the risk weight than that of an unspecified diabetes code. Physicians should completely chart all relevant comorbid and chronic diseases so that risk-adjusted outcomes accurately reflect the quality of care delivered.
Also, cardiologists need to remember some of the basics of coding and documentation. When appropriate, document the diagnosis rather than the symptom such as angina compared to chest pain.
Also, chart to the highest degree of specificity such as systolic or diastolic CHF compared to CHF unspecified. They are different diagnoses and the different codes may impact how care is reimbursed or graded. In other words, this impacts revenue and risk adjustment.
More complete and accurate documentation will leave less room for translation and coding errors such as mismatched diagnosis and procedure codes.
Stay Updated
Always keep the most current ICD-10 CM and PCS, CPT, and HCPCS code books in the office. There are frequent changes and guidelines posted by CMS and various coding clinics. The AHA (American Heart Association) offers quarterly newsletters. Refer to the CMS website for updates and subscribe to any publications offered by CMS, OIG, and state and local agencies that regulate billing practices.
Always look up codes in the alphabetical and tabular indexes. At times code may appear to be the correct one in the alphabetic index, but once looking further at the tabular index you may find notes and disqualifiers such as “code first” or “excludes”.
Frequent Audit
Regular internal or external audits are encouraged to track common coding and documentation errors and to identify needs for further education of staff. An open line of communication should exist between physicians, nurses, CDI, coders, and billers. This will provide opportunities for questions regarding diagnosis, procedures, supplies used, etc to properly reflect the acuity and care of the patient.
As in all areas of healthcare, multiple parties are involved in painting an accurate picture of the patient’s overall care and level of acuity. Frequent audits will ensure correct reimbursement and documentation. Maintaining current education, documenting properly, and utilizing good coding practices will result in a faster return in the revenue cycle, decrease external audits, and overall improved compliance.
Keeping abreast of the ever-changing regulations, current and emerging payment models, digitalized healthcare technologies, and much more can weigh down on the cardiology department. If you are amidst these challenges, we understand your struggle to stay on top of account receivables (AR) while focusing on healthcare delivery. This is why you should outsource cardiology medical billing to a dedicated billing company like ours.
Medical Billers and Coders (MBC) is a seasoned cardiology medical billing company specialized in diverse cardiology billing functions. Whether it inaccurate billing or varying compliances, we don’t let these concerns impact your collections.
We have a team of certified billing specialists experienced in subsets of cardiology practice and coding systems such as CPT, HCPCS, and ICD-9CPM. To know more about our Cardiology Billing and Coding services you can call us at 888-357-3226 or write to us at info@medicalbillersandcoders.com
FAQs
1. Why is proper documentation critical in cardiology billing?
Proper documentation is essential for justifying medical necessity, selecting accurate codes, and ensuring reimbursement. It provides a clear record of patient visits, which is crucial during audits and for verifying the appropriateness of services rendered.
2. How does understanding coverage impact cardiology billing?
Each payer has specific rules and coverage policies that determine what therapies and services will be paid for. Providers must check with insurers for requirements like prior authorization to ensure the service is covered and properly reimbursed.
3. What is the importance of coding to the highest degree of specificity in cardiology?
Coding to the highest degree of specificity, such as differentiating between systolic and diastolic CHF, impacts reimbursement and risk adjustment. Accurate coding reflects the quality of care delivered and ensures correct reimbursement.
4. How often should cardiology practices perform audits?
Frequent audits, both internal and external, are vital to identify coding errors and areas needing improvement. Regular audits help maintain accurate documentation, reduce billing errors, and ensure timely reimbursement.
5. How can outsourcing cardiology billing help practices overcome reimbursement challenges?
Outsourcing cardiology billing to specialized experts ensures accurate coding, compliance with regulations, and reduces the administrative burden. It allows practices to focus on patient care while improving revenue cycle efficiency and reimbursement rates.
