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Cod/Den/Appeals

Reimbursement: Coding, Denials, & Appeals

QuestionAnswer
Rules 1-4 of Reimbursement 1. Just b/c it has a code, doesn't mean it's covered. 2. Just b/c it's covered, doesn't mean you can bill for it 3. Just b/c you can bill for it, doesn't mean you'll get paid for it 4. Just b/c you've been paid for it, doesn't mean you can keep the mon
Rules 5-8 of Reimbursement 5. Just b/c you've been paid once, doesn't mean you'll get paid again 6. Just b/c you got paid in 1 state doesn't mean you'll get paid in another 7. You'll NEVER know all the rules 8. Not knowing the rules can land you in the slammer
Rules 9-10 of Reimbursement 9. There's always someone who doesn't get the message 10. There's always someone else who gets the message & doesn't care
Billing for PT services requires an understanding of General billing req'ts Different types of insurance Different types of reimbursement Coding (ICD-9 & CPT-4) Understanding the denial/appeal process
General Billing Requirements Must comply with regulations Must comply with Insurance Plan (it's a contract) May often have to submit records (must show ICD-9/CPT codes & supporting info, procedures must be based on PoC from eval, must be medically necessary & evidence-based)
General Billing Requirements Physician prescription required regardless of direct access status Provider must be licensed Service provided are according to jurisdiction's practice act
Compliance with Regulations includes Supervision rules & regulations CMS/Medicare rules & regulations APTA- HOD policies & position statements; Code of Ethics State Practice Acts rules & regulations
Compliance with the plan includes: Covered Services Prior approval if required Not specifically excluded
Compliance with the plan includes: Medical Necessity Known to be effective in improving health outcomes (based on evidence, professional standards, & expert opinion) Most appropriate intervention considering potential benefits & harms Not maintenance (i.e. ambulation vs. gait training)
Compliance with the plan includes: Reasonable AND necessary Appropriate for the dx Appropriate frequency & duration Expectation of significant functional improvement
Indemnity Plans Also called "traditional insurance" Used before managed care plans came about Pt free to select HC provider Pt files paperwork after visit to insurance Insurance company sends payment to pt Pt either already paid for HC service or then pays HC provid
Managed Care Plans HMOs, PPOs, POSs, Medicare, Medicaid Limit pt's choice of providers that are "in network" of MCO Payments made directly to provider from MCO usu based on pre-arranged discounted amount
CPT-4 Codes Current Procedural Terminology Level I of III of CMS's HC Coding Procedure Classification System Developed by AMA in 1966 Listing of descriptive terms & ID'ing codes for billing/reporting medical services & procedures to 3rd party payers
CPT Codes & PT Most begin in 97000 series APTA very involved in CPT review process Billing with code doesn't guarantee reimbursement Some codes aren't covered by certain insurances Nat'l standards for electronic transactions of HC info set by HIPAA laws & state
History of PT involvement in CPT coding development Prior to 1990's non-physician providers had no input in CPT coding development APTA became very involved in 1990 In 1992, MC implemented new payment system using RBRVS
History & RBRVS Developed based on theory that cost paid for service should be based on cost to deliver that service
Costs divided into 3 categories Work expense of value (mental effort/judgment; physical effort & technical expertise; stress associated with risk to pt) Practice expense Malpractice expense "Office visits" changed to more specific E&M codes (Eval & Mgmt)
HIPAA Requirements on Electronic HC Transactions (what transactions must include) Transaction & code sets National Provider Identifier (NPI) National Employer Identifier Security Privacy CPT (codes & modifiers) & HCPCS for (PT/other services) ICD-9 codes for dx
CPT & PT Restrictions 8-minute rules Timed codes Group Code One-on-one codes PT eval & re-eval code restrictions
Counting Minutes for "Timed Codes" 1 unit = 8-22 2 units = 23-37 3 units = 38-52 4 units = 53-67 5 units = 68-82 6 units = 83-97 7 units = 98-112 8 units = 113-127
ICD-9 Codes International Classification of Disease Billing purpose- PT must include impairment based ICD-9 code as well as medical ICD-9 code (if they differ)
ICD-10 Codes October 2013 (maybe) 68,000 compared to 13,000 3-7 digits- digit 1 alpha, digit 2 numeric, digits 3-7 alpha or numeric
Reasons for Claim Denials Lack of medical necessity 2 "mutually exclusive" procedures/interventions may charge together Lack of evidence for procedure/intervention Duplicate claim Payers may not recognize all the CPT/ICD-9 codes available to PTs
Reasons for Claim Denials Claim filed to wrong primary vs secondary insurance provider Necessary info omitted from claim
Strategies for Successful Claims Submission Request insurance info & benefits before initial tx Collect needed demographic info for claim form Collect all 2ndary insurance info Ask insurance payer if there are any CPT/ICD-9 code restrictions by PTs
Strategies for Successful Claims Submission Find out it pt already used allotted benefits with another PT Inform pt of restrictions in insurance & notify them they'll be financially responsible for charges restricted yet rendered &/or denied by insurance
Strategies for Successful Claims Submission Complete every portion of claim form that is pertinent Use past claims trends to track problems Keep copies of claim forms that have been submitted
Appeals Process Review explanation of benefits & ensure info that was submitted matches your claim (data entry errors) Multiple levels of this process (1st usu review by non-medical personnel; 2nd & 3rd usually reviewed by medical personnel)
6 Tips to Help with Denials 1. Get organized 2. Know your right 3. Act promptly 4. Start talking 5. Start writing 6. Be + & don't antagonize
Created by: 1190550002