Medicare Coding & Billing: Not Just a Job…an Adventure!

If you're looking for adventure in exotic and unexplored new territory, fraught with unexpected pitfalls, hazardous traps, ever-changing challenges to your skill and alertness, and the perpetual risk of seizure and imprisonment, it's not necessary to become a soldier of fortune. Just step up boldly and embrace the job of coding and billing Medicare claims for an O&P business. It's a tough job-but in this case, virtually everybody's got to do it. Since survival can depend on the success of claims management, we contacted experts to identify the most significant and the most common problems filers face-and collected some advice on how to anticipate and dodge the worst of the dangers. Make Policy Changes and Education Top Priorities Tony Plattner, CO, FAAOP, CEO of Plattner Orthopedic, Peoria, Illinois, notes that the biggest challenge for his billing department is trying to keep up with the frequent Centers for Medicare & Medicaid Services (CMS) policy changes and reimbursement rates. Despite the difficulty, he reports that about 90 percent of his Medicare claims are going through as "clean"-being accepted and reimbursed without further follow-up. "The reason they've been improved, I believe, is due to some internal changes that we've made in order to adapt to Medicare policy changes. Medicare wants everything electronically, so we now electronically bill," Plattner says. Reimbursements are also improved by the electronic fund transfers from Medicare that go directly into his company account. "That cuts down significantly on the amount of time that the claim is out being reviewed, and also expedites the receipt of our payment. That has been a huge improvement for us," he points out, noting that the internal structural changes that were necessary have been well worth the pains of the adaptation process. Documentation is always a major concern, says Plattner, and documentation takes time. "We have one person who devotes about 75 percent of her time to billing Medicare. A secondary person also helps with the structure of the claim and compiles the essential information before it goes to the biller-appropriate prescriptions, justifications for the L-Coding, letters of medical necessity from the physician, signed delivery receipts or tickets, etc. "We try to stay very astute on that, so that we don't submit a claim until we have all our documentation in order. Because if you have one minor piece missing, it can create a major problem." Plattner also credits education with the success of his recent Medicare reimbursements. "At least once a year, we send our billing people to seminars. The AOPA [American Orthotic & Prosthetic Association] billing and coding seminars are vitally important, and I also utilize private organizations. This helps [our billing personnel] to understand the intricacies of not only Medicare billing, but also the insurance companies' billing and how to successfully handle their claims." And there's always that underlying fear of an audit, he concludes. "If you don't do it correctly, according to the rules, with thorough documentation, it's going to come back and haunt you someday." An audit can-and usually does-happen without warning, and what happens when you don't have the required documentation in your files? You lose. (Editor's note: See " Truth and Consequences: Honest Billing Mistakes are Still Mistakes ,") Be Aware of Common Errors An outreach specialist for NHIC Corp., Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A, shared some of the most common errors seen on incoming claims from O&P providers. <img src="https://opedge.com/Content/OldArticles/images/2007-10_01/1-2.gif" alt="Claim submission errors (CSEs) are errors made on a claim that would cause the claim to be rejected upon submission to the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC). The top ten American National Standards Institute (ANSI) Claim Submission Errors for January through March 2007 are provided in this table. Information courtesy of NHIC Corp., Hingham, Massachusetts, DME MAC (Jurisdiction A)." /> Claim submission errors (CSEs) are errors made on a claim that would cause the claim to be rejected upon submission to the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC). The top ten American National Standards Institute (ANSI) Claim Submission Errors for January through March 2007 are provided in this table. Information courtesy of NHIC Corp., Hingham, Massachusetts, DME MAC (Jurisdiction A). Jurisdiction A's top ten claims submission errors list for the first quarter of 2007 is led by the use of an invalid procedure code or modifier. The number of errors of this type nearly doubles that of the next on the list-an invalid question number entered for the certificate of medical necessity (CMN) being sent. Our specialist notes what the lists confirm: "Usually the top errors, particularly for O&P, are the modifiers. Not including a RT' or LT' for right or left, that's a big one. And if it's a lower-limb prosthesis, they need to include a functional level modifier, which is also a common omission. "Incorrect coding is a big issue, and many of the common mistakes are made across the board, by all suppliers-like not having correct provider or identifier numbers. Sometimes it's as simple as a mistake in entering the number-a keying error. "Whichever number was submitted-if it's invalid or a digit was mis-keyed-those incorrect numbers cause a lot of rejections," she adds. "It's a good policy to take extra time to review your claims before submission to ensure that all the required information is there, and that everything is complete and correct-especially those digits." <img src="https://opedge.com/Content/OldArticles/images/2007-10_01/1-3.gif" alt="This table reflects those claims that were accepted by the system and processed but were later denied with a return/reject action code. These returns/rejections could have been prevented, according to our specialist, with proper completion of claim information. This table represents the top errors for claims processed from January through March 2007. Information courtesy of NHIC Corp., Hingham, Massachusetts, DME MAC (Jurisdiction A)." /> This table reflects those claims that were accepted by the system and processed but were later denied with a return/reject action code. These returns/rejections could have been prevented, according to our specialist, with proper completion of claim information. This table represents the top errors for claims processed from January through March 2007. Information courtesy of NHIC Corp., Hingham, Massachusetts, DME MAC (Jurisdiction A). The Devil's in the Details Gina Flori, sales coordinator for Acc-Q-Data, Boca Raton, Florida, a specialist in O&P, stresses the importance of being detail-conscious when you prepare a claim. Although electronic claims are required from businesses with more than ten employees, the electronic process can be difficult, too, Flori points out. "Often the electronic claims don't allow enough space in their 80-character note segment field to include all the details and list everything needed when billing repairs or replacements, or submitting additional information required for processing. Yet they won't accept a hard-copy submission." However, she adds, it is possible to coordinate ahead of time with the particular service center when more than 80 characters are necessary and arrange to send the additional documentation via fax at the same time the claim is transmitted. She agrees that tracking the numerous and frequent changes in CMS codes and policies is a full-time job and can be overwhelming to businesses with limited staff. That is why Acc-Q-Data offers claims and billing service that includes such monitoring. "You really have to read every little thing they're putting out there," Flori says. "If it's a bulletin, an update, a summer advisory, fall advisory, I go through it all. Just when you think you have it down and have the most current information, it changes again. We have someone here whose job it is to stay on top of any coding and guideline changes, and teams who answer, follow up, and post for assigned accounts." Another problem Flori sees is the tendency of people to use familiar, but outdated, materials. "Some diagnoses now need to be taken to the fifth digit, where previously that was not necessary. You must use the most current diagnosis book and have the most current diagnosis codes in your system." Early mistakes are sometimes impossible to correct later, Flori notes. "If no pre-certification is done, and the claim is billed, it's too late to go back. You can't change the date of service; you can't redeliver the item." Correct coding is vital, including modifiers, and mistakes can be costly. "If a C-Leg® patient is marked at a K-2 level, and it's paired with a Flex-Foot® that's only covered for K-3 and above, you just lost $4,000 on that foot because the rest of the claim is coded K-2, and you can't change that one code to K-3," Flori explains. Elizabeth Carlstrom, president of O&P Business Solutions, Round Rock, Texas, points out the similarity of CMS to the Internal Revenue Service (IRS). With multiple contacts in several jurisdictions, you're likely to hear contradictory information, depending on whom you talk to, and when. This only adds to the confusion of an already complex process. "I think there's a real problem internally with Medicare in training its staff and getting everybody on the same page. People quote their ombudsmen, but since ombudsmen tell people different things, I have found there are many gray areas." (Editor's note: See " Ombudsmen: Where Are They Now? ", for an important update on this resource.) Recent changes are making a big difference in the way claims must be filed, says Carlstrom. "What was acceptable even three years ago is not acceptable nor processable anymore. It's tougher today." Carlstrom offers the following advice, which is common sense but often overlooked. Do it right the first time. That way you don't have to go back and clean up a mess later, wasting time and energy. Choose responsible staff members to handle billing, and arm them with detailed knowledge. Don't stint on sending your staff to training seminars-AOPA's annual Coding & Billing seminar, O&P Business Solutions' annual Claims & Billing Symposiums, and state Medicaid office classes. Even Blue Cross/Blue Shield, Aetna, and others typically offer a provider workshop, sometimes at no cost. "It's important for business owners to invest in their staff," Carlstrom stresses. Verify insurance. Be thorough. Determine whether the deductible has been met, and if not, be sure to collect it from the patient before you deliver the device. Since patients often do not understand their financial responsibility for any out-of-pocket expenses they may incur, it's your responsibility to educate them. Beware the dangers of electronic claims filing. Although electronic filing seems easier and requires less paperwork, if you fall under the ten employees or less umbrella, Carlstrom advises you to file claims manually. Avoid the trap of generic prescriptions. If the doctor sends a prescription with minimal information, providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are required by the new quality standards to communicate with their referring sources, advising the physician in writing of the provider's recommendations about the prescription. "Your cover letter with a detailed prescription, complete with all codes and quantities for fabrication, should use terminology such as, If you concur, please sign and date the attached detailed prescription and return it to our office. Once we receive it from you, we will proceed accordingly,'?" Carlstrom says. "When the doctor returns it, you now have a complete, signed, and dated detailed prescription, where the doctor has signed off on each Healthcare Common Procedure Coding System (HCPCS) code you plan to deliver and bill for. Your detailed prescription, delivery acknowledgment receipt, and claim form should be consistent." Choose O&P-specific patient-management and billing software. Use software such as OPIE and Futura, which simplify the process and keep things accurate, says Carlstrom. "Once the practitioner does a coding worksheet, just enter those codes, quantities, and modifiers. OPIE and Futura software then print a detailed prescription, line for line, and OPIE even adds a justification to each code. Excellent documentation." Be aware of medical policies. Each jurisdiction may present medical policies differently on its website, and they may be difficult to find, but you must be aware of them and follow them to ensure reimbursement, says Carlstrom. Local coverage determination (LCD) describes the medical policy for different types of devices. "People not only don't know where to find this information, they don't even know they need to find it. A lot of people just assume that all they need to know is in the Medicare manual," she says. "That's not so. If you want to know how many clear-fit sockets you can do, for example, that's in the medical policy." Be code conscious and stay current with HCPCS code and fee schedule changes. "Download the annual Excel spreadsheet and keep it handy. Be aware," she cautions, "that the termination date and code description are at the far right end of the spreadsheet. They are easy to overlook." Don't skip a single detail. "Make sure that everything is in your patient's medical records before you even file a claim," she advises. The Medicare manual says explicitly now that you need to have supporting documentation, detailed prescriptions, etc., in your patient's medical record prior to submitting a claim. But people work backward. That's a big problem." Take your accountability seriously. "The new quality standards for DMEPOS providers clarify their policy about the billing errors and your responsibility and accountability as a supplier. So it's important that people read and digest those quality standards and make sure that there's accountability in everything you do, including complete supporting documentation." Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer. Truth and Consequences: Honest Billing Mistakes Are Still Mistakes Take it from one who knows. A former O&P practitioner, who prefers not to be identified, shared his own experience-one he assures us is not an isolated case. As the result of a coding error that passed undetected from Superbill through billing department, and was reimbursed without comment by Medicare, "Mr. Older N. Wiser" found his central facility raided and his files and computers confiscated by FBI agents with guns drawn. And after 2½ years of legal battling, he wound up spending ten months in a federal prison and an additional five months under house arrest, which was followed, years later, by a civil lawsuit for an additional $100,000 in damages. "Yes, it could happen to you," says Wiser. Since an honest oversight is something you can't prove, the rule pertaining to accountability applies. If it's wrong, you as business owner are responsible and must face the consequences. "I'm the captain of the ship," Wiser says, "and I have to go down with it, regardless of who's doing what and who's not doing what. Now, I believe in Ronald Reagan's statement: 'Trust, but verify.'?" Wiser's cautionary tale includes a checklist of pointers for those who wish to avoid incarceration and federal lawsuits: Lock up all your medical records and files, and require people to sign in and sign out to access them. An unscrupulous somebody could abuse and misinterpret a lot of information in those records and make a lot of trouble for you. Don't put your medical records and financial records together in the same file. Store billing information separately, not in the patient's medical chart. Don't just send your office staff to administrative training-go yourself. In fact, go first and then go along with your staff at intervals throughout the year so that you can be kept abreast of what's going on at all times. Employees are just employees. No one takes care of your business like you do, nor does anyone keep track of all those frequent changes. Stay on top of things. Don't just depend on your staff. Don't let anyone sign your name for anything. Don't ever use a rubber stamp signature pad to let people sign things. There's just too much temptation out there. Sign off on everything yourself. Don't depend on Superbills. Review and revise them, and make sure that the codes you're using actually describe the codes you're delivering. In Wiser's case, he misread a code; thus the Superbill he authored and used over many years included a base code that included a foot in addition to a code for the foot he thought he was using. He basically ordered a leg with two feet-and no one caught the mistake...until the FBI arrived. Don't dispense anything without the patient and/or a witness's signature. If you hand out a dozen socks that day, get a signature on a description of what you just dispensed. Patients have short memories. "I don't remember getting those socks. He didn't give me anything!" That can come back to you. Don't allow someone to make your bank deposits without a weekly audit. Everyone has their own check system in their office, but when you're giving someone access, just remember that there are unscrupulous people who could do a lot of harm on their way to the bank. It isn't always your accountant making that trip. Don't just let your technician sign off on lab work. The technicians are the ones that put things together. They're the ones that pull components from inventory and put them on a unit. They're the ones making the repairs and using components. Verify all your work that is delivered or repaired by requiring not only the signature of the technician that did the work, but also the signature of someone on your supervisory staff. Someone must be answerable for errors. Don't look to AOPA, ABC, or the Academy to help you out or come to your defense. It's not their job. If you are made aware of anything that you know is in error, get a lawyer quickly. Nip it in the bud. No matter whose fault it is, tell the truth. And if you point a finger at someone, don't forget who the finger is attached to. "I had been in the business for 35 years when all this happened," warns Wiser. "I never had any problems or complaints, ever-nothing but a traffic ticket-so it hit us hard. We were so naïve. We thought that if you told the truth, things would work out.... My lawyer advised us, 'This isn't about justice, and it isn't about truth. It's about money.' A relatively insignificant amount, which I would cheerfully have paid, admitting my oversight. But that wasn't enough." -Judith Philipps Otto Ombudsmen: Where Are They Now? Like the cowboy heroes that have ridden off into the sunset without fanfare and barely a casual goodbye, Medicare ombudsmen are now lost to O&P providers-and surprisingly few of the resources we consulted were aware of the change. But when every ombudsman's phone number (Internet-listed or on personal Rolodexes) took us to a recording that said "This number is no longer in service," we made the deduction pretty quickly. After pursuing leads, some of which led to dead-ends, we located an outreach and education (O&E) specialist at NHIC Corp., Durable Medical Equipment Medicare Administrative Contractor (DME MAC), Jurisdiction A, who shared some vital information about recent changes in the Medicare system, as well as some essential references and links you might want to use in updating your Rolodex or its electronic equivalent. Durable Medical Equipment Resource Center (DMERC) Regions A through D are now known as jurisdictions assigned to DME MACs. There have been some minor changes in the geographical composition of each jurisdiction. Check the map to see who belongs to which jurisdiction at www.cms.hhs.gov/MedicareContractingReform/Downloads/DME_MAC_Contractors.pdf "None of them are called ombudsmen anymore-that name has totally gone away," says our specialist. Instead, they are now known as provider outreach specialists or education specialists, or provider relations specialists, depending on the term each jurisdiction prefers. "We no longer handle individual claims issues," she explains. "We handle education either on a one-on-one basis or via seminars, trade shows, or other events to get the information out." Why the change? "The ombudsman title encompassed more responsibilities of an individual 'liaison' type of position with more focus on individual suppliers and claims issues," our specialist says. "Upon the implementation of the DME MAC contracts in 2006, the position was absorbed within the customer service area, via the triage structure, and outreach and education was to focus on strictly educational efforts, not individual problem solving. Thus the title changes. The customer service triage structure was introduced to the Part B world some time ago; however, it was not implemented for the DME MAC [formerly DMERC] until each one became a DME MAC, which began in July 2006. "The triage structure does include that of a provider relations research specialist (PRRS), who is to handle complex provider issues that can't be handled through the Level I and Level II representatives, similar to what an ombudsman use to handle. The difference is that suppliers cannot contact the PRRS directly as, per CMS contractor directive, customer service is to be contacted first and foremost, with emphasis on self-service technology, such as the interactive voice response (IVR) system. "The triage structure is to serve as the means for inquiries to be handled by the appropriate level of service to include referral to the PRRS. If necessary, referrals for education can then be made to the O&E team. We understand that this may be difficult for the supplier community to adjust to and may not be very favorable to them. However, in this day and age, self-service technology is all around us, and CMS must comply as well, in order to preserve resources and funding." So, whom does a provider contact if he has a claims question and needs help? Start with the customer service department, advises the specialist. The new triage/tier approach to customer service offers different levels to process questions more efficiently: Level 1 Representatives: Basic questions include eligibility; claim status; and authority to refer to Level 2. Level 2 Representatives: More complex inquiries; more experience and training; policies, medical review; handle re-openings; handle call-backs. PRRS: Most complex inquiries to research; have a 45-day turnaround to allow additional research time; access to the same information as an outreach specialist; will refer issues to the O&E team as appropriate. Reach your jurisdiction's customer service department at these numbers: Jurisdiction A: 866.419.9458 Jurisdiction B: 877.299.7900 Jurisdiction C: 866.270.4909 Jurisdiction D: 866.243.7272 For additional details about the triage structure, visit www.medicarehic.com/dem_pub_downloads.html Receive current updates automatically by visiting www.medicarehic.com/dme/ and subscribing to a listserv specifically for O&P suppliers. Where can the provider go for help with coding questions? For coding assistance, counsels, or contact, either call the statistical analysis DMERC (SADMERC) at 877.735.1326, or visit the Durable Medical Equipment Coding System website: www3.palmettogba.com/dmecs/jsp/index.jsp "The site is very user-friendly," the specialist notes. "Just enter the item that you're looking for, and it will pull up the code. This system is a couple of years old and has been a lot of help to a lot of suppliers. I used it a lot myself, actually, to identify the right codes and eliminate the need for a phone call." -Judith Philipps Otto

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