Most transactions between providers and staff still depend on a charge ticket, encounter form, or superbill. That sheaf of triplicate forms communicates the details of the services rendered so that information can then be entered into the actual billing form or screen.

What ends up on the charge ticket is hit or miss, with hieroglyphics and scratch-outs scribbled by busy doctors. And even when the ticket is completed correctly and legibly, one sheet can’t hold all applicable codes or their nuances. Predictably, some services get missed or aren’t properly communicated. Coders or billers may not even realize that crucial information is missing.

Common problems to make coders aware of:

 

• Laceration repairs: Note the laceration location, length, and depth; if any of these items are missing, the service can’t be properly coded.
  
   
• Lesion removal: Note the lesion location, its excised or shaved diameter, and its type.
  
   
• Destruction of lesions: Is the lesion pre-malignant or malignant? How many lesions did you excise, and what method did you use? Watch out especially for code 17003; it applies to each additional lesion after the first one, up to 14. So if you removed three lesions, bill 17003 twice.
  
   
• Incision and drainage: Was it simple or complicated, single or multiple?
  
   
• Debridement: Mention the depth and structures involved.
  
   
• Arthrocentesis: Make the location clear.
  
   
• Therapeutic, prophylactic, diagnostic injections, and infusions: Your coder needs to know if infusions were delivered via IV, IA, IM, or subcutaneously. Was it initial, sequential, additional sequential, or concurrent? Also mention whether it was a push or infusion. If it was an infusion, note the time it took. Don’t forget to explain what substances you used.
  
  Often, coders also make these ICD-9 coding errors. Remind them to:
  
   
• Use the appropriate fourth and fifth digits for diabetes codes.
  
   
• Use the newer 585 series codes for the different stages of chronic kidney disease rather than the former ESRD codes.
  
   
• Record all codes for co-morbid conditions affecting the treatment or management of the presenting problem(s).
  
   
• Include E-codes that describe how and where an injury or accident occurred.
  
  These are just a sampling of circumstances that give rise to more complicated coding in primary care. The list of codes and modifiers required for payment under PQRI is long and will only lengthen.
  
  Dangerous folklore
  
  Like any other industry, healthcare coding propagates its own myths and folklore about how things work. But don’t believe everything you hear, especially if it’s along the lines of, “No one pays for that.”
  
  Ever overhear those comments in your billing office? If so, you’re likely losing money because at some time someone decided that that’s simply the way a specific rule works.
  
  Ask your staff, “Based on what?” Billers will frequently perpetuate rumors or misstatements based on little real experience. People may apply a single experience with a single claim or payer to all payers and claims.
  
  Let’s say you have a combination of CPT codes, a visit, and a small office procedure, and you code it in such a way that the diagnoses are distinct, the modifier is in place, and all else seems correct with the claim — and it is denied. Don’t just read the denial code on the remittance advice or EOB. Call the payer and ask specifically what is wrong with your code combination.
  
  If the denial is backed up by a reasonable payer- or policy-specific explanation (and not something you shouldn’t have coded), make a note that that combination is not payable by that payer for the reason given. If the same thing happens with another payer, record that as well. But don’t simply decide that the combination “doesn’t get paid,” because as soon as you do — and stop billing for it — you won’t bother to submit a claim to a third payer, who is ready to reimburse you for the service.
  
  By becoming more aware of individual third-party reimbursement policies, you’ll master the details that explain which codes or services are payable. Remember, the rules live at the payer level, not at the water cooler.
  
  This article originally appeared in the June 2008 issue of Physicians Practice.
  
   

Bill Dacey