When was the last time you updated your encounter form?

Hopefully, the answer is this year or this quarter. Procedure and diagnosis guidelines change every year. These codes represent opportunities to bill correctly and avoid loss of revenue. Often, EMR and practice management companies emphasize on levels of Evaluation and Management codes (E&M). The E&M codes represent a minority of revenue and risk for the practice. The majority lies in the types of procedures that the practice performs. Coding also represents compliance risk. Consider the following case study.

A practice performed Percutaneous Endoscopic Gastrostomy (PEG), a procedure that involves inserting a feeding tube into the stomach by one physician usually with the help of another physician who inserts an endoscope through the mouth. The practice traditionally billed 43750, a CPT code to represent PEG without endoscopic guidance. That code was deleted in 2008. The practice assumed that the code 49440 (placement of tube) could be used. Upon review, the practice could not use that code because they did not perform the procedure using fluoroscopy. However, there was no equivalent code to bill for PEG without fluoroscopy as per the new guidelines. Our recommendation was for both physicians to use the code 43246 with a 62 modifier (an indicator for two surgeons).

The above story has multiple dimensions. Coding and billing correctly protects the practice from risk of insurance audit. It allows them to get paid correctly. It also highlights how guidelines change and it's critical for a practice to be on top of guidelines on a monthly basis.

Coding also represents denials. Practices are sometimes stuck in Groundhog Day - they keep on performing the same procedure, making the same coding mistake and getting denied every single time. No one takes the time to review why the denials occur, no one calls insurance companies to question their judgment. We see this behavior in so many practices. Often times the answer lies in simple corrections to codes or using correct modifiers (that help further describe the code without changing its definition). Sending correct claims simplifies the job for the systems at insurance companies. Typically, a claim passes through a system that adjudicates it and checks if it has everything in a way that it requires. If it does, then payments are made. If it doesn't then payments are withheld. Centers for Medicare and Medicaid Services (CMS) has created Local Coverage Determination guidelines (formerly LMRP guidelines) to ensure correct coding on behalf of practices. Most of the private insurance companies follow these LCD guidelines. However, they are one too many and it's often difficult for practices to keep up with these changing guidelines.