Take these five key steps to limit reimbursement headaches

SCOTTSDALE, ARIZ. – Headache specialists can take five key steps related to coding and billing that can protect their financial investment in their practice, said Stacy Girard, M.B.A., a certified professional coder and revenue analyst at Mayo Clinic Arizona in Phoenix.

Those steps include reviewing annual changes in Current Procedural Terminology (CPT) codes, understanding code descriptions and how to use modifiers, consistently tracking reimbursement denials and intervening if they trend out of control, reviewing medical and reimbursement policies at least once 1 year, and determining their financial liability when services are not covered, Ms. Girard said at a symposium sponsored by the American Headache Society.

The CPT codes for neurologic procedures will not change in the upcoming year, Ms. Girard said. In headache and migraine treatment, some of the most common codes include 64405, for unilateral occipital nerve block; 64450, for unilateral block of another peripheral nerve; 64612, for unilateral facial nerve chemodenervation; and 64615, for bilateral chemodenervation of the facial nerve, trigeminal nerve, cervical spinal nerve, and accessory nerves, she added. Code 64615 was introduced in January 2013 and has “greatly simplified billing for a number of procedures for chronic migraine,” she said.

Payers routinely deny reimbursement claims, Ms. Girard noted. To avoid a reimbursement denial, clinicians and coders must use modifiers correctly when appending claims, she said. For example, they should use modifier 25 only if the same physician performed a completely separate evaluation and management (E/M) service for a patient on the same day of a procedure. And CPT code 64615 already signifies bilateral chemodenervation, so coders should not add modifier 50 to indicate that the service was bilateral, she added.

“You cannot expect what you don’t inspect,” said Ms. Girard. “You cannot expect to be paid for everything if you are not on the back end, inspecting your denials.” She creates a chart to track reimbursement denials by type and month, and reports the results to her practice, highlighting areas “that are really getting out of control,” she said.

Several denial reason codes worth tracking include CO50, CO55, and CO56, for treatments that are deemed “not a medical necessity,” “experimental/investigational,” or “not proven to be effective,” and CO151, in which the payer decides that there is insufficient support for the number or frequency of services provided, Ms. Girard said. “Take action on denials,” she emphasized. “Work with your payers and make a connection with them. We meet with our payers on a regular basis and show them what’s routinely being denied. Maybe you need to understand where they are coming from, and maybe you need to say to them that I really don’t agree with this, and here’s why.”

To minimize denials, practices also need to understand reimbursement policies and who is responsible for paying for services, she said. Information on coverage determinations can be found on payer websites under “medical policies,” or “reimbursement policies,” she noted. Medical policies list the payer’s criteria for covering specific services and diagnosis codes, while reimbursement policies specify how the payer handles issues such as bundling rules, global surgery, and multiple procedures for a single patient.

Practices can further limit their financial liability by obtaining signed advanced beneficiary notices (ABNs) from Medicare patients, Ms. Girard said. Without a signed ABN, patients cannot be billed for services that Medicare does not cover, leaving the practice holding the bill, she said. “Are you going to give away your services for free, or is it something the patient is going to pay for because they’ve signed an ABN?”

Ms. Girard declared no conflicts of interest.

SCOTTSDALE, ARIZ. – Headache specialists can take five key steps related to coding and billing that can protect their financial investment in their practice, said Stacy Girard, M.B.A., a certified professional coder and revenue analyst at Mayo Clinic Arizona in Phoenix.

Those steps include reviewing annual changes in Current Procedural Terminology (CPT) codes, understanding code descriptions and how to use modifiers, consistently tracking reimbursement denials and intervening if they trend out of control, reviewing medical and reimbursement policies at least once 1 year, and determining their financial liability when services are not covered, Ms. Girard said at a symposium sponsored by the American Headache Society.

The CPT codes for neurologic procedures will not change in the upcoming year, Ms. Girard said. In headache and migraine treatment, some of the most common codes include 64405, for unilateral occipital nerve block; 64450, for unilateral block of another peripheral nerve; 64612, for unilateral facial nerve chemodenervation; and 64615, for bilateral chemodenervation of the facial nerve, trigeminal nerve, cervical spinal nerve, and accessory nerves, she added. Code 64615 was introduced in January 2013 and has “greatly simplified billing for a number of procedures for chronic migraine,” she said.

Payers routinely deny reimbursement claims, Ms. Girard noted. To avoid a reimbursement denial, clinicians and coders must use modifiers correctly when appending claims, she said. For example, they should use modifier 25 only if the same physician performed a completely separate evaluation and management (E/M) service for a patient on the same day of a procedure. And CPT code 64615 already signifies bilateral chemodenervation, so coders should not add modifier 50 to indicate that the service was bilateral, she added.

“You cannot expect what you don’t inspect,” said Ms. Girard. “You cannot expect to be paid for everything if you are not on the back end, inspecting your denials.” She creates a chart to track reimbursement denials by type and month, and reports the results to her practice, highlighting areas “that are really getting out of control,” she said.

Several denial reason codes worth tracking include CO50, CO55, and CO56, for treatments that are deemed “not a medical necessity,” “experimental/investigational,” or “not proven to be effective,” and CO151, in which the payer decides that there is insufficient support for the number or frequency of services provided, Ms. Girard said. “Take action on denials,” she emphasized. “Work with your payers and make a connection with them. We meet with our payers on a regular basis and show them what’s routinely being denied. Maybe you need to understand where they are coming from, and maybe you need to say to them that I really don’t agree with this, and here’s why.”

To minimize denials, practices also need to understand reimbursement policies and who is responsible for paying for services, she said. Information on coverage determinations can be found on payer websites under “medical policies,” or “reimbursement policies,” she noted. Medical policies list the payer’s criteria for covering specific services and diagnosis codes, while reimbursement policies specify how the payer handles issues such as bundling rules, global surgery, and multiple procedures for a single patient.

Practices can further limit their financial liability by obtaining signed advanced beneficiary notices (ABNs) from Medicare patients, Ms. Girard said. Without a signed ABN, patients cannot be billed for services that Medicare does not cover, leaving the practice holding the bill, she said. “Are you going to give away your services for free, or is it something the patient is going to pay for because they’ve signed an ABN?”

Ms. Girard declared no conflicts of interest.

SCOTTSDALE, ARIZ. – Headache specialists can take five key steps related to coding and billing that can protect their financial investment in their practice, said Stacy Girard, M.B.A., a certified professional coder and revenue analyst at Mayo Clinic Arizona in Phoenix.

Those steps include reviewing annual changes in Current Procedural Terminology (CPT) codes, understanding code descriptions and how to use modifiers, consistently tracking reimbursement denials and intervening if they trend out of control, reviewing medical and reimbursement policies at least once 1 year, and determining their financial liability when services are not covered, Ms. Girard said at a symposium sponsored by the American Headache Society.

The CPT codes for neurologic procedures will not change in the upcoming year, Ms. Girard said. In headache and migraine treatment, some of the most common codes include 64405, for unilateral occipital nerve block; 64450, for unilateral block of another peripheral nerve; 64612, for unilateral facial nerve chemodenervation; and 64615, for bilateral chemodenervation of the facial nerve, trigeminal nerve, cervical spinal nerve, and accessory nerves, she added. Code 64615 was introduced in January 2013 and has “greatly simplified billing for a number of procedures for chronic migraine,” she said.

Payers routinely deny reimbursement claims, Ms. Girard noted. To avoid a reimbursement denial, clinicians and coders must use modifiers correctly when appending claims, she said. For example, they should use modifier 25 only if the same physician performed a completely separate evaluation and management (E/M) service for a patient on the same day of a procedure. And CPT code 64615 already signifies bilateral chemodenervation, so coders should not add modifier 50 to indicate that the service was bilateral, she added.

“You cannot expect what you don’t inspect,” said Ms. Girard. “You cannot expect to be paid for everything if you are not on the back end, inspecting your denials.” She creates a chart to track reimbursement denials by type and month, and reports the results to her practice, highlighting areas “that are really getting out of control,” she said.

Several denial reason codes worth tracking include CO50, CO55, and CO56, for treatments that are deemed “not a medical necessity,” “experimental/investigational,” or “not proven to be effective,” and CO151, in which the payer decides that there is insufficient support for the number or frequency of services provided, Ms. Girard said. “Take action on denials,” she emphasized. “Work with your payers and make a connection with them. We meet with our payers on a regular basis and show them what’s routinely being denied. Maybe you need to understand where they are coming from, and maybe you need to say to them that I really don’t agree with this, and here’s why.”

To minimize denials, practices also need to understand reimbursement policies and who is responsible for paying for services, she said. Information on coverage determinations can be found on payer websites under “medical policies,” or “reimbursement policies,” she noted. Medical policies list the payer’s criteria for covering specific services and diagnosis codes, while reimbursement policies specify how the payer handles issues such as bundling rules, global surgery, and multiple procedures for a single patient.

Practices can further limit their financial liability by obtaining signed advanced beneficiary notices (ABNs) from Medicare patients, Ms. Girard said. Without a signed ABN, patients cannot be billed for services that Medicare does not cover, leaving the practice holding the bill, she said. “Are you going to give away your services for free, or is it something the patient is going to pay for because they’ve signed an ABN?”

Ms. Girard declared no conflicts of interest.