Though considerable tensions remain over narrow (and narrowing) provider networks and coverage and claims disputes, I see a continuing
shift toward greater cooperation. With all of the financial pressures on both sides of the chasm, building bridges seems more fruitful than lobbing mortar shells.
After claims are closed, most hospitals and health systems, many with six figures’ worth of claims annually, will not review accounts that have been paid or adjusted off. Certainly, they will look at outright denials, especially if there is a pattern. But closed claims mostly have been the Dead Letter Offices of the healthcare system. And yet, there may be gold in them. In fact, it is likely.
The proper use of seventh-character extensions, which designate episodes of care and are required for injuries, poisonings and external causes, are explored.
While smoking cessation is a medically necessary and payable service, it is often administered and not billed or billed but not fully supported in the documentation. There must be information capturing the patient’s opinions related to behavior change as well as providing input on a plan to change that behavior.
While the services for transitional care management and chronic care management are very different and have very different requirements, they have one glaring similarity: They are both often-missed revenue opportunities.
Coding for diabetes used to present challenges because unclear documentation or poorly stated manifestation relationships prevented capturing the type of diabetes and its complications. ICD-10 has further delineated diabetes into five code categories and even greater specificity is necessary to code accurately.
Salud Revenue Partners collaborated with senior healthcare leaders on a series of four articles exploring revenue cycle challenges affecting community and safety net providers. The series was published by Becker’s Hospital Review, a major trade journal, and tells how many community providers, including safety net hospitals, haven’t adequately addressed fundamental challenges in the revenue cycle created by health payment reforms, vast changes in the insurance markets and the rise of healthcare consumerism.
Coauthors of articles in this series include Alan H. Channing, Principal, Channing Consulting Group , former President and CEO, Sinai Health System, Chicago; Jesse Ford, CEO, Salud Revenue Partners; Michael Karpf, MD, Executive Vice President for Health Affairs, UK HealthCare, Lexington, Ky.; Dennis Price, CFO, The Polyclinic, Seattle; José R. Sánchez, CEO, Norwegian American Hospital, Chicago; and Jennifer Swindle, Vice President of Coding Solutions, Salud Revenue Partners.
Defining medical necessity for evaluation and management services is difficult. Clinicians and coders should be careful to include only those things that are necessary for patient treatments to determine the appropriate levels of E&M services.
Modifier 59 is used when procedures normally bundled together should be reported as distinct and separate procedures. The determining factor for using X modifiers is if a service that is usually part of a bundle should not be in a particular instance, for a particular patient, on a particular day.
A high-risk colonoscopy is covered every 24 months and a low-risk colonoscopy is covered once every 10 years, so using the right code for each is important. Without a diagnosis to support high-risk patients, the service will not be paid.