When I started my own practice twenty years ago, I tried to learn everything I could about billing and coding. I hired a practice management consultant and worked with her on a weekly basis until I began to understand the basic rules governing reimbursement. Over the years since, I've looked at nearly every explanation of benefit statement that comes into my office, and spoken to carriers about a countless number of denials. The only thing I know for sure is that it's impossible to know all the rules, and just when you think you've got it, the rules change again.
But certain common misconceptions come up repeatedly from members who attend the AAN practice management courses, and the most egregious can land you in a heap of trouble. So, what do you need to know to make sure you bill by the book and thereby avoid an unhappy audit? I asked members of the AAN Medical Economics and Management (MEM) Committee to share their experiences with Neurology Today.
1. JUST BECAUSE IT HAS A CODE DOESN'T MEAN IT'S COVERED
“There are CPT codes for telephone services and for oversight of care planning by physicians and nonphysicians, but most Medicare carriers will not cover the cost of the services,” said Marc Raphaelson, MD, a neurologist and sleep medicine specialist in practice in the Washington, DC, area. If a code lacks relative value units (RVUs), it will not be reimbursed, explained Dr. Raphaelson, who attributes this rule and most of the others to Ellen Riker, a lobbyist who has worked for the AAN and other specialty societies.
2. JUST BECAUSE IT'S COVERED DOESN'T MEAN YOU CAN BILL FOR IT.
“Polysomnography is a covered test for patients with sleep apnea, and we know that sleep apnea is present in about 60 percent or more of patients with stroke,” said Dr. Raphaelson, who also is an AAN representative on the Relative Value Update Committee. But if a patient presents with stroke, the doctor elicits a history of loud snoring, and the polysomnogram demonstrates snoring without significant sleep apnea, most Medicare carriers will not cover the cost of the diagnostic test. “You can't bill the patient unless the patient had previously signed an Advance Beneficiary Notice that the test might not be covered by the Centers for Medicare and Medicaid (CMS),” Dr. Raphaelson explained.
3. JUST BECAUSE YOU CAN BILL FOR IT DOESN'T MEAN YOU'LL GET PAID FOR IT.
“Code 95920 — the hourly code for intraoperative monitoring which is billed along with base codes such as somatosensory evoked potentials (SSEP) or central motor potentials (MEP) during surgical procedures—is routinely done in practice, but may not be paid — or paid for after much difficulty — by some insurers,” said Gloria M. Galloway, MD, director of the Intraoperative Evoked Potential monitoring program at Nationwide Children's Hospital in Columbus, OH. She recalls that after a recent spine correction surgery for neuromuscular kyphoscoliosis on a 15-year-old girl at her hospital, eight units of this code were billed (along with the base SEP and MEP codes) indicating eight hours of monitoring had been done. Several weeks later, the billing department at her hospital informed her that the claim was denied stating there was no indication for the monitoring. “These codes have been billed in this same way for many years in practice at my hospital and in general, as standard practice,” said Dr. Galloway, noting that sometimes, nevertheless, claims for them are denied. Although surgical referral for a monitoring request, the operating room report, the neurophysiologic monitoring report, and surgical history and physical were sent with a resubmitted claim, two weeks later the insurer denied the claim as not routine practice. Only when two articles were sent as evidence of standard of care was the claim paid—at a reduced amount and 120 days later.
4. JUST BECAUSE YOU'VE BEEN PAID FOR IT DOESN'T MEAN YOU CAN KEEP THE MONEY.
“Several of the neurologists in our department approached documentation for billing purposes in rather unique ways,” said a neurologist who did not want to be identified. “One was so far behind on his documentation that when we were audited, there were no notes in the electronic or paper charts,” he recalled. “Thus, based on the sample, and this volume, we had to return all the money we'd been paid, he explained. “Another billed all his encounters at the highest level (triggering the audit), and then wrote his notes at a level of detail that he felt clinically appropriate. Because the notes that were sampled clearly did not support a level 5 billing, the department had to repay Medicare.
5. JUST BECAUSE YOU'VE BEEN PAID ONCE DOESN'T MEAN YOU'LL GET PAID AGAIN.
“Some carriers retract their policies for coverage of codes that have been covered previously,” said Allison Brashear, MD, a member of the Education Committee, MEM guest, and chair of the department of neurology at Wake Forest University Baptist Medical Center. She recalls that one payer recently altered its policy for coverage of botulinum toxin injections for cervical dystonia by adding that there must be changes in the patient's quality of life. “Supplying the diagnosis was not sufficient; in order to have the treatment covered, the notes had to document impairment of activities of daily living, trouble working, etc.,” she explained, adding that this was a new rule that they had not had to address in the past nor with any other payer.
6. JUST BECAUSE IT'S COVERED BY ONE CARRIER DOESN'T MEAN IT WILL BE COVERED BY ANOTHER.
“Just because a code is covered by Medicare, it does not mean it is covered by the patient's insurance provider, or if it is, it may not be covered for the same indications,” said Gregory L. Barkley, MD, an epileptologist at Henry Ford Hospital in Detroit. Although many insurers follow rules established by Medicare, payers have their own proprietary rules for reimbursement and don't necessarily follow the Centers for Medicare And Medicaid Services (CMS) rulings. Similarly, just because it is covered by a national or state insurance company coverage policy, it does not mean it is covered by the policy purchased by your patient's employer. “For example, magnetoencephalography is now covered by Blue Cross Blue Shield of Michigan (BCBSM), but the United Auto Workers Voluntary Employee Beneficiary Association BCBSM policy still classifies it as ‘experimental’”, Dr. Barkley explained. To make matters even more complex, just because a code is covered by the traditional indemnity plan does not mean that it is covered by the preferred provider organization (PPO) or health maintenance organization (HMO) plan from the same company. Many insurers have multiple product lines, each with differing allotted reimbursements, and variations in coverage policies.
7. JUST BECAUSE YOU'VE BEEN PAID IN ONE STATE DOESN'T MEAN YOU'LL GET PAID IN ANOTHER.
The CMS states that in the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD). The CMS Web site, www.cms.gov, offers links to LCDs by state and by carrier. (A link to my state, New York, brings me to a list of LCDs on the carrier's Web site where I can select nerve conduction studies, for example, and the indications, limitations, and the diagnostic codes that support medical necessity.) Local carriers set policies that may vary from carrier to carrier. If you have offices in two different carrier regions, you may be asked to follow two separate LCDs.
8. THERE ARE THOUSANDS OF RULES AND THEY CHANGE EVERY YEAR.
“This is quite true,” said Joel M. Kaufman, MD, executive director and CEO of Lifespan Physicians Professional Service Organization and chair of the Payer Policy Subcommittee of MEM. “A good example is CMS eliminating consult codes as of Jan. 1 of 2010, and now seeing local plans following that lead.” In addition to being aware that the CMS and commercial payers change the rules, it's important to pay attention to state legislative mandates, Dr. Kaufman said. Moreover, rules don't all change at the same time. “Different payers have different cycles, and some change processes throughout the year (all in the name of improving quality, of course),” he explained. He urges neurologists to read (at least glance over) notices and updates from all the major plans that they participate in, and have someone in the office attend a local coding and billing update course at least once a year. “At least every quarter, all the clinicians should sit down with the billing staff and review claims that were resubmitted, rejected, or paid less than expected to see what changes in coding need to be made,” Dr. Kaufman advises.
9. NOT KNOWING EVERY RULE CAN LAND YOU IN THE SLAMMER.
More rules, proposed under the new health care reform law, were released in September and designed to reduce the estimated $55 billion in fraudulent or improper payments made annually by Medicare and Medicaid programs, according to administration officials. No specialty is immune from investigation, including ours, and neurologists have been among those indicted for fraud in the past.
10. YOU'LL NEVER KNOW EVERY RULE.
Because rules are so diverse and extensive, I keep three ring binders for each carrier and update them as rules change. I organize them by procedures/CPT codes, and my staff refers to them to remind me of documentation requirements, limitations on numbers of units that can be billed, and rules regarding medical necessity. •
Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today, as well as the editor-in-chief of the AAN Web site,AAN.com, and chair of the AAN Practice Management and Technology Subcommittee.