Common Pitfalls in Cardiology Medical Billing

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Common Pitfalls in Cardiology
Medical Billing
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Common Pitfalls in Cardiology Medical Billing
Although treatment has advanced by leaps and
bounds in the last few decades, heart disease
remains the leading cause of death for U.S.
adults. And with more than 20 million U.S. adults
facing coronary artery disease, cardiology
remains one of the busiest and highest-paid
specialties. But cardiology is a complex field
with ever-changing treatments and procedures.
That means keeping track of new cardiology
medical billing guidelines and medical coding
best practices, which can sometimes vary across
payers. Even a solid claim scrubbing process may
not catch every slip-up. Due to high dollar value
claims, cardiology practice wont afford to
receive claim denials. In this article, we listed
common pitfalls in cardiology medical billing,
and avoiding them would ensure the financial
sustainability of your cardiology
practice. Common Pitfalls in Cardiology Medical
Billing 1. Inappropriate Use of
Modifier Modifiers are two-digit codes that show
youve somehow altered the service in the
original five-digit CPT code. Inappropriate use
of modifiers like modifier -22,-25, -51, -52, and
-53 is one of the common pitfalls in cardiology
medical billing. For example, when you submit a
claim to the insurance carrier that is coded with
a 25 modifier, you are telling the carrier to pay
you for both the E/M visit and the minor
procedure. The insurance carriers will review
claims with an E/M and procedure codes for
accuracy. Ensure that when you bill both codes on
the same day, your documentation must support
both codes. Document adequately for the E/M
separate from the procedure. Typically, when
these services have been audited payment was
rescinded due to incorrect coding, incomplete
documentation, and/or lack of medical necessity
to support both codes billed on the same day by
the same physician.
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Common Pitfalls in Cardiology Medical Billing
2. Not Coding for Comorbidities While billing for
cardiology, the billing team often forget to
document one or two diagnoses. Cardiology
patients often face more than one diagnosis, also
called comorbidity. Diagnosis for common heart
diseases includes diabetes, high blood pressure
(hypertension), and COPD. Its important to
document these comorbidities to avoid claim
denial as well as get reimbursed for all
delivered services. When documenting different
diagnoses, check the coding instructions and read
the code descriptions carefully. In some cases,
you may need a combination code. A combination
code helps classify multiple diagnoses, a
diagnosis with a complication, or a diagnosis
with a secondary manifestation. 3. Absence of
Eligibility Check One of the most common pitfalls
in cardiology medical billing is not checking
patients specific coverage guidelines for a
procedure or test. Missing eligibility and
benefits verification can pose problems for the
patient and the practice. Reimbursement could be
at stake, and patients may feel confused or
frustrated when they receive a surprise bill for
care received. Beyond insurance eligibility, its
also important for your team to check coverage
guidelines before a cardiology procedure or test.
Youll need to make sure all prior
authorizations, referrals, or pre-certifications
are in place before the scheduled procedure. Each
insurance carrier has specific guidelines, so
understanding the intricacies of the patients
plan is critical for a smooth claim filing
process.
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Common Pitfalls in Cardiology Medical Billing
4. Absence of Prior Authorizations Over-stretched
office and billing staff might overlook or rush
through checking for prior authorizations,
pre-certs, and referrals. It could prove a costly
mistake for any cardiology practice. Claim
denials received due to the absence of prior
authorizations are considered hard denials
which are difficult to reverse. Once you receive
a claim denial due to the absence of prior
authorization, most payers wont change their
decision. By doing the necessary leg work on the
front end of the revenue cycle you can prevent
such denials at the back end. To avoid such
pitfalls, be sure to gather and verify all
insurance information from the patient during
scheduling. Also, review payer reimbursement
guidelines for tests and procedures that require
prior authorization or pre-cert. Provider portals
or payer websites are a good sources of finding a
list of services/ codes that might require prior
authorization. 5. Incomplete Clinical
Documentation Incomplete clinical documentation
is one of the common pitfalls in cardiology
medical billing. Incomplete documentation will
lead to claim denials and eventually could lead
to an external payer audits. Proper documentation
is critical to justifying medical necessity and
the selection of codes for billing. It tells the
story of a patient visit by recording pertinent
facts, findings, and observations. Payers will
use this documentation to verify coding choices,
site of service, medical necessity,
appropriateness, and accurate reporting of
furnished services. Each office note must tell a
complete story and be able to stand alone. While
documenting ensure to mention why the encounter
is taking place, as the coder will assign a
different code for a routine visit vs. a surgery
clearance vs. an initial visit. If known, it is
important to document whether or not patients are
compliant with their medications.
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Common Pitfalls in Cardiology Medical Billing
To Summarize, Regular staff education, proper
documentation, and adopting good coding practices
will result in faster reimbursement, fewer
external audits, and overall improved compliance.
Regular internal audits will reveal common coding
and documentation errors. It will show up areas
where staff need to be trained. An open
communication channel between physicians and the
billing team is a necessity for successful
revenue cycle management. In this article, we
listed only prime pitfalls in cardiology medical
billing, there are a lot of other billing errors
that lead to denied payments. As multiple parties
are involved in painting an accurate picture of
the patients comprehensive care and acuity
level, the involvement of cardiology billing
experts is essential. Legion Healthcare Solutions
is a leading medical billing company providing
complete billing and coding services. We assist
cardiology practices to avoid billing pitfalls
and secure timely and accurate reimbursements. To
know more about our cardiology medical billing
and coding services, contact us at 727-475-1834
or email us at info_at_legionhealthcaresolutions.com
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