When Norfolk, VA-based Sentara Healthcare’s patient access staff secures authorization for a scheduled service, it is not always the end of the story.

“The hospital runs the risk of the physician office supplying the incorrect procedure code,” says Gail Toney, manager of coding audit and recovery audit contractor (RAC) program.

This could be because the provider used an outdated code that has been updated with a new, more specific ICD-10 code. In other cases, the problem is clinical: After the procedure is underway, someone discovers a different procedure is needed.

“A procedure might start out endoscopic surgery, but might have to convert to open surgery due to disease or anatomy,” Toney explains.

Regardless of the reason, incorrect codes result in denied claims. “If the wrong CPT code is gathered for precertification, you run the risk of not having the appropriate diagnosis code to cover the test,” Toney cautions.

Coding is not the main role of patient access. “But gathering good data up front always leads to less rework on the back end,” Toney notes. Patient access staff should know these basics:

An unlisted procedure code. Most unlisted procedures are not covered, or require additional documentation (like an operative note) for claims processing.

If patient access staff sees an unlisted procedure and it is the only code they have, says Toney, “they can use their questioning attitude to see if there is something more specific that can be done, or document in the comments section why the unlisted procedure is valid as per the physician.”

The range of codes used for different types of procedures. For example, 70000-79999 for radiology services.

Add-on codes. These are eligible for payment only if reported along with the primary procedure. “If this is the only CPT code staff are given, they know they have to reach out for the primary code,” Toney reports.

National Correct Coding Initiative (NCCI) and Local Coverage Determination (LCD) edits. “If staff has access to a scrubber where they are can put the diagnosis code as well as the CPT code, they will know up front if the claim may be denied due to an CCI or LCD edit,” Toney notes.

Incorrect codes end up on claims for all kinds of reasons. Deborah Vancleave, senior vice president of revenue cycle services at MediRevv, says these are the most common issues:

  • The provider selects the incorrect codes. For example, the provider selects an E&M code based on the level of service he intended to provide to the patient. However, that code is not reflected in the service or the documentation.
  • Staff select the wrong codes because they misinterpret clinical documentation, or because the documentation is not specific enough.
  • Order sets are predetermined to include a designated number of services. In reality, a portion of those services were not provided, or another service was provided. “Then, erroneous codes could end up on the claim,” Vancleave adds.

Inaccurate coding causes compliance issues, more denials, lost revenue, and negative patient experiences, says Meghan McKee, MediRevv’s vice president of coding. “Coding training should also be provided to ancillary staff supporting the physician,” McKee says.

It starts with the scheduling system, which needs to reflect the appropriate appointment types. Some hospitals try to limit the number of appointment types, but this can result in someone using incorrect codes. “The better and more precise the information is from the onset, the better,” Vancleave offers.

Accuracy of physician orders sets the stage for correct billing, cleaner claims, and fewer denials. “This also will allow coding to follow suit, and code appropriately,” Vancleave notes. Ideally, automation takes most of the guesswork out of coding. “Patient access representatives are overloaded with information and manual processes that require them to be all things and know all things,” Vancleave observes.

For example, if a scheduler selects a regular mammogram appointment type, but the patient is presenting for a 3D mammogram, it causes an error. “It may or may not be caught further up the revenue cycle chain, possibly leading to incorrect billing and loss of revenue,” Vancleave explains. Patient access also needs the ability to spot which codes or procedures are not covered by the payer. If they cannot, says Vancleave, “that could impede the facility’s ability to collect for noncovered services.”