
Adjust
j
or not to adjust
j
an entire transaction?
Adjustments reduce the ability to collect
 Adjustments reduce your profit
 Adjustments can create a loss
 Consequently, before
f
keying
i
an adjustment,
j
we should dig deeper and fully understand
the who, what, why, where, and when of the
transaction to be adjusted

1
•
Common denials send the message that
we cannot get paid and we cannot bill
the patient
– Bundling
– Not medically necessary
– Not covered
– No prior authorization
– Timely filing
– Duplicate
So what do we do? Adjust?

Bundling is usually the most common
denial
› E/M
› Minor surgical procedures
› Major surgical procedures
› X-rays
› Labs
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
Surgeries have global periods
 Become familiar with the rules that apply to
global pricing as they apply to all surgical
procedures -- including minor surgeries performed
in the physician's office or in an hospital
department

Charges that occur within a global period of
a procedure will be considered “bundled” or
“included” in the actual surgery
How do I unbundle:
› Know global periods
 Available on your Medicare website
3

Can I unbundle? How do I unbundle?
› Understand National Correct Coding
Initiative (CCI) edits
›
The purpose of the NCCI edits is to prevent improper payment when incorrect code
combinations are reported. The NCCI contains two tables of edits. The Column
One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table
include code pairs that should not be reported together for a number of reasons
explained in the Coding Policy Manual.
 Coding with Modifiers by Deborah Grider
 Published by the American Medical Association
4

Post-op visits are considered included in
the
thatt the
th ffee th
th surgeon was paid
id for
f the
th
actual surgery – or the “global” fee of
the surgery

What if something develops with the
patient that is totally unrelated to their
global surgery?
› We have to be able to communicate this with
the payor
› We communicate with modifiers
› We do not adjust!
Mrs. Sikes has her g
gallbladder removed on
1-05-2011. The global period for this
procedure would end on 4-05-2011.
 The patient returns on 2-22-2010 for their 6
week check-up. Her incision is doing well,
but she complains of strep throat
symptoms. The surgeon documents a
history, exam, and medical decision
making and wants to bill for a E/M level 3.
Can he?

5
The payor would deny this E/M since this
visit is within the surgical global period
 Add a 24 modifier to the E/M and a
diagnosis code of strep throat
 The 24 means that this visit was unrelated
to the surgery (The diagnosis code
change alone will not get the claim
paid)


The key to avoid the denial is to place
the 24 modifier with the E/M before it
goes to the insurance company
› If you receive a denial for this E/M,
adjustments can and do occur

Does your billing system prompt you when
today
today’ss charge to be keyed is within a
global period.? Do we receive a warning
that this may be bundled?
› If so, we need to verify up front - to save us time
and effort on the back end with denials and
back-end work
6
 Does
your billing system prompt you
when today’s charge to be keyed is
within a global period?
 Do you receive a warning that this
may be bundled?
 Verify the nature of the visit prior to
keying the charge
› This saves us time and effort on the back
end with denials and back-end work
The 24 modifier is only for use on E/Ms
7

What happens if the patient has to go
back to surgery by the same physician
within a global period?

Whether additional surgery is planned,
unplanned or unrelated,
unrelated modifiers again
unplanned,
will tell the payor what the
circumstances are
› Don’t adjust because the payor tells you to!
Modifier 58 – staged or planned surgery
by the same physician during a postoperative period
 Modifier 78 – Unplanned return to the
operating room by the same physician for
a related procedure during a post-op
period
 Modifier 79 – Unrelated procedure or
service by the same physician during the
post-op period

8

y the
Research p
patient account to identify
CPT® that your recent denial is bundling
against – may have to go back a full 90 days
in the patient record

Keep in mind - the charge that is causing the
bundling edit will be a charge by the same
physician or same specialty

Sometimes a procedure is done the
same day as an E/M
› The physician can bill for both and get paid
for both, but the documentation needs to
justify both

One rule (of many)
many)- if the patient is on
the appointment book schedule to
come today for the procedure, then an
E/M is not usually billable….unless
9

But if p
patient comes to the clinic with knee
pain and….
 Doctor documents a history and exam, discusses
several treatment options
The patient and doc decide that the patient would
benefit from receiving an injection into the joint
(20610)

Decision is made at the visit, then the
physician should be paid for both the E/M
and the 20610
 A 25 modifier must be appended on the E/M

Here is an example of multiple unrelated
procedures same day
› Patient comes in with knee pain, and
abscess, and a skin lesion
› Codes billed are 20610, 10060, and 17000

Insurance pays 20610
20610, denies the other 2
as “included”
› Don’t adjust them – do your research!
› First, determine the location of all three
10
20610 – performed on the knee
 10060 – I&D abscess on the finger
 17000 – skin lesion on the face
 Three separate areas – all unrelated to
each other
 Use the 59 modifier on the 10060 and the
17000 to tell the payor that these were
separate procedures

Skin lesion removals are commonly done
in multiples during a visit
 The 59 modifier would need to be used
on any of the 2nd or 3rd skin lesions
removed to notify the payor that these
were in separate areas
areas, ii.e.
e hand
hand, foot
foot,
neck

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
Decision for surgery same day as surgery

Surgeon sees a patient today in the ER
who has a compound fracture that will
require immediate surgery – the surgeon
risks what procedure he will do
explains risks,
do,
etc – and the decision for surgery is made
just prior to doing the surgery
Insurance will deny this visit as being
provided during the global period of the
surgery
 Don’t adjust this visit off!

If surgery has a 90 day global period,
attach modifier 57 to the E/M
 If surgery has a 10 day global period,
attached modifier 25 to the E/M

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 Not

y necessary
y denials
medically
The physician may order tests that he feels
are necessary to diagnose the condition
 Rarely will he order something that is not
medically necessary!

i ad
i l ffor CO50 - nott
If we receive
denial
medically necessary, then these usually
occur because we failed to include all of the
necessary diagnoses on the claim

Before you adjust, search the chart
documentation to see if the reason for
the ordered test was documented, but
not coded on the fee ticket
› Check with the physician or nurse if unsure

It should be a rare occasion that a
charge is adjusted off for not being
medically necessary
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
Denials for “service not covered”

This is different from “not medically necessary”
We don’t automatically adjust these off!
Cosmetic procedures are never covered
Weight loss plans are never covered
If we bill these services to the insurance
company, and receive the denial that the
service is not covered, then we must bill the
patient for these services – not adjust them off





Medicare also has non
non-covered
covered services.

Denials PR-49 and PR-96 - These ANSI
denial code that begins with “PR” means
“patient responsibility
› Medicare
M di
is
i telling
t lli
us tto Bill th
the P
Patient!
ti t!

So bill the patient - Do not adjust!
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
No prior authorization
“No
authorization” denials
Surgical procedure
 Visits
 Hospital stay
 X-rays


Your hospital is a resource for info.
› They may have obtained a PA# and then
we can refile our claim with this number in
the appropriate field

Some payors do retro-auths.
› See if they will allow us to provide additional
information – sometimes this might require a
letter from the physician to explain
extenuating circumstances
15
y
 Timely
 Do
g denials
filing
not Adjust – until research is done
› Payors have different timely filing deadlines
 Aetna – 90 days
 BCBS – 180 days
y
 Medicare – one year from DOS
 United Health Care – 90 days

Be familiar with the deadlines of each of
your major payors
New claims for today’s visits are not the
problem
 Corrected claims are usually the culprit
 Denial is received and we make a
change
 CPT®,
CPT® DX,
DX DOS,
DOS ID#
 A new claim is submitted with the correct
information, but it is now beyond the
payors filing deadline

› What do we do?
16





Attach a copy of the denial to the claim
and
thatt th
the claim
d mailil in
i hard
h d copy proving
i
th
l i
was originally filed timely, but denied
Write on the new corrected claim the
previous claim number that was assigned by
the payor
Also indicate on the claim that this is
“Corrected”
Or “Corrected Claim – SYTG47385609”
This will refer the payor to their system’s
previous assigned claim number
Sometimes patient’s do not give us the
correctt insurance
i
information
i f
ti
 We file a claim to BCBS

 BCBS denies for “coverage termed”
We contact patient to find out correct policy
info.
 Now they
y have Aetna, so we correct our
system demographics and refile
 This claim doesn’t hit Aetna’s system until 90
days after the DOS – denied for timely filing
 What can we do now?

17
Payors are aware that this situation does
occur

If we can provide a copy of our
electronic claims acknowledgement
showing where we initially filed to the
wrong payor, BCBS, in a timely manner,
the payor will process our claim
MVAs and WC also contribute to some of
the timely filing denials that we receive
 We may see a patient a few times as a
result of a MVA – and file to their auto
insurance carrier, but then they have
maxed out their benefit
 When filing now to their group insurance,
we should include a copy of the dated
letter from the MVA insurance to prevent
any timely filing deadlines

18
Very rarely should there ever be an
adjustment for Timely Filing
 Our systems drops claims daily: As long
as we can prove that we did file it initially
by using an electronic claims
acknowledgement report – we will be
able to receive payment every time

Duplicate denials
 A charge is keyed twice with same DOS
 A charge is billed as a qty 2 - bilateral
 A charge is processed twice - denied as
duplicate – but we have still not been
paid

› Need to call the payor

Each duplicate denial should be
researched fully
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
Keying error?
› Duplicate hospital visits billed on same DOS – 22
08
› Was this a keying error? Check to see if there
was a visit billed on 2-07 or 2-09

Bilateral ?
› Did we bill two of something and not use RT/LT or
the 50 modifier for bilateral procedure?

Payment already received?
› If so, discard denial
› If not, the payor should be contacted

Conclusion:
› Don’t adjust just because the payor says so
 We are obligated to adjust contractual
obligations such as amounts over the
allowable for the insurance companies that
we have agreements with – Medicare,
Medicaid BCBS,
Medicaid,
BCBS PPOs,
PPOs etc.
etc
 However, when the insurance company
disallows the entire charge for one of the
reasons that we reviewed here today, have a
plan
20
j
g to the root of
› Don’t adjust
without g
getting
the problem – maybe as much as 89 days
ago!
› Understand global days and the correct use
of modifiers to unbundle appropriately
› Understand that by doing an adjustment, our
h i i
ill never be
b paid
id ffor performing
f
i
physicians
will
a service that they provided
› MORE CASH! LESS ADJUSTMENTS!
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