EXECUTIVE SUMMARY

Coding expertise in an ASC can help the facility maintain compliance with payers’ rules and ensure proper staff education.

  • Learn the difference between surveillance and screening in colonoscopies.
  • Periodic audits of coding ensure that coders are following all guidelines.
  • ASCs should educate physicians about how to ensure coding is accurate and results in optimal reimbursement.

ASCs need coding expertise to support the entire revenue cycle management team from scheduling to collection.

Whether an ASC employers its own coders or contracts with an outside company, it is important to follow guidelines, educate staff, and provide oversight. ASCs also should stay up to date on coding changes, according to Juanita Mendoza, CPC, CASCC, coding services manager for Sovereign Healthcare.

“One of the things that always has been a hot topic is the difference between surveillance and screening,” she says. “Previously, there wasn’t any guidance on how to code a colonoscopy screening vs. surveillance. In our facilities, our coding is outsourced, but when we contract with them they have a facility coding information form that tells them what guidelines we want them to follow. I sent this information about surveillance colonoscopy to them, and I do periodic audits of their coding to be sure they follow this guidance.”

Mendoza offers some advice to ASC leaders who are looking to ensure their facilities code accurately and receive optimal procedural reimbursement:

Educate physicians and staff. When there is new guidance or a coding change, Mendoza gives coding staff a short PowerPoint presentation, hitting key points. “Then, I give them a handout with documentation examples, and I expound on it with them,” she explains.

Educating physicians requires more explanation to help them understand why a word used a certain way could result in coding denials. “I don’t believe that surgeons are aware of how their documentation is interpreted by a coder,” Mendoza says. “This circles back to surveillance and screening. A screening is an exam that is done in a seemingly healthy patient to look for a disease. If the disease is found, then the patient can get treatment.”

The key to screening is that the patient seemingly is well and shows no signs or symptoms of disease. If a patient has received a diagnosis screening, then there is a diagnosis code. This code is based on what the doctor wrote as the underlying issue or reason for the procedure.

“For example, with a screening colonoscopy, a doctor might note that the patient has rectal bleeding,” Mendoza offers. “The fact that he or she included rectal bleeding is a sign/symptom. Now, it’s no longer a screening because the patient had a sign/symptom of rectal bleeding.”

But suppose the rectal bleeding was due to hemorrhoids or something else that is unrelated to the colonoscopy. In this case, the colonoscopy should be coded as a screening. The only reason it was not coded correctly is because of how the physician documented the case.

“Communicating this information to physicians is very important,” Mendoza says. “If the bleeding is not pertinent to this episode of care, then don’t document it.”

If a surgeon sees a patient who reports rectal bleeding, the physician might feel compelled to be thorough and include that in the documentation. But doing so has repercussions. Mendoza suggests a better solution would be for the physician to tell the patient, “I understand that, but you are here for your screening. If you continue to have rectal bleeding, then we’ll see you in the office and take a look at that time.”

“I’m not saying the doctor shouldn’t document it, but as far as this encounter goes, the patient is here for a screening. The clinic notes are up to the doctor, but the documentation needs to be clear that the reason for encounter is screening,” Mendoza explains. “Sometimes, the doctor will say, ‘screening and incidental rectal bleeding.’ The fact that the doctor calls it ‘incidental’ shows that it is not relevant to this episode of care.”

Audit periodically and provide spot checks. Best practices in oversight include periodic audits for coding compliance. “Third-party audits are a great way to go,” Mendoza says. “Audits are not just for compliance purposes; they’re also a learning tool. As an auditor, when I say something is wrong, I have to provide an official guidance.”

Official guidance is not the auditor’s opinion. It is based on, and cites, official sources. Some periodic audits are scheduled quarterly for compliance. Others can be spot checks, held whenever there is new education or new guidance, Mendoza says.

“We need to make sure the new guidance is being applied,” she adds.

Compare pathological reports to diagnosis codes. This advice works very well with colonoscopies, but also might be relevant to other procedures. For instance, a colonoscopy might reveal polyps. Some polyps, called adenomatous, potentially could transform into a malignancy. These are coded differently than polyps that will not transform into malignancy, Mendoza notes.

“A patient who has a history of adenomatous polyps is considered at high risk of colon cancer. This determines the intervals at which they are able to go in for surveillance,” she explains.

A high-risk patient might need a colonoscopy screening every two years. A patient with no risk might be suitable for a colonoscopy every 10 years.

Here’s how coding can affect the patient’s care: Suppose the patient undergoes a colonoscopy. The physician discovers adenomatous polyps. The physician will tell the patient to return in a couple of years for another colonoscopy. But somehow, the physician’s documentation does not include the word “adenomatous.” In two years, the patient returns for a colonoscopy, undergoes the procedure, and the insurance company denies the claim because the coding did not indicate a need for a colonoscopy in less than 10 years.

Since colonoscopies and other major screenings are considered preventive services that payers are federally mandated to cover at no out-of-pocket costs to patients, there is a big financial cost to a patient whose colonoscopy is not covered because of the way it was coded.

“If coders are not checking the pathology report, then they don’t know there was a mistake,” Mendoza says. “This is a challenge for ASCs because the physician has the patient’s entire medical history in their report. All the ASC has is the documentation related to that particular encounter.”

The solution is to check the pathological reports before assigning a diagnosis code for a polyp, Mendoza adds.

Track denial trends. “We track denials because these create a problem with patient responsibility,” Mendoza says.

For example, a patient may believe a service is preventive and will be covered 100%. However, if the documentation does not support this notion, then the procedure will not be processed as a preventive service.

“We’ll have problems on the back end with the patient,” Mendoza notes. “Sometimes, the claim is denied because the diagnosis code doesn’t match up with the procedure code.”

Anytime a denial is related to coding, Mendoza’s team reviews the issue and tries to correct the problem. One time, the coding sent to the insurer was correct, but the claims still were not processed correctly, she says. The trend appeared to be a system problem because a review of the coding showed it to be correct. Still, the claims were not processed correctly, Mendoza recalls. When told of the error, the insurance company asked the organization to send all of its incorrect claims in bulk to be corrected. “They, hopefully, will make adjustments in their system so it would not continue to be a problem,” Mendoza says.

Correct problems. “Number one, documentation has to support the service,” Mendoza says. “If something wasn’t a diagnostic procedure, and the doctor mentioned it in error, then the coder has to generate a physician query, asking, ‘Documentation says this. However, is it this or that?’”

Another way to correct a coding issue is to direct the physician to dictate an addendum, correction, or additional note that clarifies the situation, Mendoza offers.

“The documentation has to support the service code and has to be clarified,” she explains. “It can be fixed with additional documentation, or billers can turn around and submit a corrected claim.”