Coding & Billing: Don't Leave Money on the Table

Financial Management

By: Bob Lathrop, Bob Lathrop, David Jagrosse

Published: 2/11/2020

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The bundling guidance you follow impacts your reimbursement rates.


SEPARATE CHARGES Coding according to the American Medical Association guidelines could let you earn more for performing two shoulder procedures at one time.   |  National Cardiovascular Partners

One of your top priorities as a surgical administrator is to maximize reimbursements for the services performed at your facility. That's no small task when dealing with complex, bundled payment arrangements — a group of procedures covered by a single, comprehensive CPT code. There are two methods to use when coding bundled procedures:

  • National Correct Coding Initiative (NCCI) edit bundling. This is CMS's strict set of bundling guidance, which lets providers know which CPT codes may be bundled when their procedures are performed in the same outpatient surgical setting. On top of federal payers, many commercial payers have adopted this bundling guidance because it's easy to apply and clearly spelled out.
  • AMA bundling guidance. The American Medical Association's guidance is less structured than the NCCI edits, meaning it's more likely for providers to report CPT codes separately to increase reimbursement.

If you don't pay close attention to which method your payers use, you could be coding incorrectly or leaving a significant amount of reimbursement money on the table. Let's look at how these bundling methods differ as well as the best practices your coders and billers should use to get the most out of each.

Payer contracts

Accurate, efficient and profitable bundling is based on the payer contract. Review your contracts with a fine-tooth comb, and make sure coders and billers are acutely aware of which edits your payers follow. Many facilities simply follow NCCI edits for all payers, regardless of what an individual payer's policies state, as a precautionary policy or form of under-coding. After all, if you're following strict, widely accepted NCCI guidelines to the letter, there's little risk of up- or over-coding. While there's nothing wrong with being safe, you could be leaving a lot of money on the table if you follow this one-size-fits-all approach to bundled payments.

For example, consider an arthroscopic rotator cuff repair (CPT 29827) performed with and an arthroscopic limited debridement of superior labral tearing (CPT 29822). If the payer is using the NCCI edits, the debridement of superior labral tearing (CPT 29822) would be considered bundled if it was performed on the ipsilateral or same shoulder as the rotator cuff repair. However, if the payer is following AMA bundling guidelines, CPT 29827 and CPT 29822 can be reported separately. In other words, you'll get reimbursed at a higher rate if you go by the AMA guidelines.

An audit is all about taking corrective action on your policies, not your people.

How much higher? Keeping in the mind that rates for commercial payers vary, the Medicare Adjusted Reimbursement Rate for CPT 29827 is $2,744.32 and $1,256.79 for CPT 29822. If you code according to the NCCI edit guidelines, you'll receive $2,744 for the bundled procedures, about $1,250 less than you'd make by billing them under AMA guidance.

Granted, the majority of payers are starting to follow NCCI edit guidelines — and that's only likely to increase moving forward. But there are still quite a few payers that follow AMA guidelines, and I've seen a lot of facilities lose out on reimbursements by not being aware of this. Don't miss out; check your payer contracts.

Quarterly audits a must

In addition to knowing the ins and outs of your payer contracts, you'll also need to schedule external audits of your coding and billing practices on a quarterly basis. Yes, a lot of facilities do annual audits, but here's a major reason why that time frame isn't ideal: What if the audit uncovers claims that need to be rebilled? If you're doing the audit yearly, you could easily fall outside of the payer's statute of limitations for resubmitting claims. Most times, a payer won't even consider a claim that's eight months old. On the other hand, if you audit quarterly, you'll likely be well within that statute of limitations. Another reason to steer clear of annual audits: It's too much information to take in at one time. Important issues are bound to get glossed over.

The idea of an audit may make some of your staff a bit standoffish and even uncooperative. Remind these folks that auditors aren't there to make coders look bad at their jobs. They're there to make sure your coding and billing procedures are as accurate and beneficial as possible, so the more open and upfront you are with your auditing company, the more efficient the process will be. Remember, an audit isn't personal. It's all about taking corrective action on your policies, not your people. OSM

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