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  coding strategy

Drinking Through A Fire Hose

Prepare your practice for upcoming coding changes

JOHN RUMPAKIS, O.D., M.B.A.

Does anyone else feel like things are changing so fast and that there is so much information to process that it is like drinking through a fire hose? I know I do. Keeping up with all of the changes within medical coding and compliance can be mind numbing, particularly if you don’t have a game plan in place.

To help your focus, here are a few of the big changes that will shape your business in the future and an action plan to keep your practice prepared.

Need-to-know information

Here are a few major changes to be aware of:

1 President Obama signed into law on Dec. 26, 2013 the Pathway for Sustainable Growth Rate Reform Act of 2013. The new law provides for a stable payment environment for Medicare claims with dates of service on or after January 1 through March 31, 2014.

2 The federal government recently launched the Open Payments website, which is the first public repository of national data describing financial relationships between industry and healthcare providers. Commonly referred to as the Sunshine Act, the site lists payments for research, consulting and promotional work and other transfers of value of $10 or more, such as gifts, travel and meals, made by manufacturers and group purchasing organizations to physicians and teaching hospitals. Bottom line: your patients know what you get paid by industry.

3 For the first time in 35 years, CMS released physician payment data to the public. Accessible on the CMS website (bit.ly/codingCMS) and other public websites (www.findthebest.com), the public can now see what their doctors are getting paid by CMS and whether their billing patterns are within or outside of profession-specific norms.

4 Effective January 5, 2015, modifier 59 is getting a complete revamp for 2015. Modifier 59, the most widely used HCPCS modifier, is defined for use in a variety of circumstances, and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. The introduction of subset modifiers is designed to reduce improper use of modifier 59 and help to improve claims processing for providers. This will impact O.D.s by potentially affecting how their use of special ophthalmic testing is conducted on the same date of service.

5 Insurers pay only for services deemed to be medically necessary, based on the patient’s chief complaint or additional conditions identified by the physician that require work-up or focused attention. Services provided out of “convenience” for the patient are not considered medically necessary if the patient did not have any specific complaints relating to the service.

6 Though the exposure created by over-coding an encounter is more obvious, many within our profession don’t recognize the risk they take by under-coding an encounter. Deliberate under-coding is, in reality, “making a false statement” about the services provided, and is ultimately a “misrepresentation” of the facts. Under-coding also fits within the definition of “abuse,” as defined by CMS as “misusing codes on a claim.”

7 The momentum toward reimbursement for quality-based outcomes continues. Increased technology and the convergence of many programs will continue to drive this reimbursement paradigm of the future.

Action plan

In light of these changes, here are a few tips to help you properly manage your coding and compliance protocols.

• Know your carriers. Be sure to have a good grasp on your provider contracts and request updates annually.

• Manage your medical record. Keep in mind that the only thing that can be used against you in an audit is your medical record, and the only thing that you can use in your defense is your medical record. And most importantly, the only thing you have complete 100% individual control of is, of course, your medical record. Properly establish and document your chief complaint and medical necessity for appropriate coverage of services, procedures and tests you perform.

• Manage information properly. Keep up to date with your resources, such as the CPT, HCPCS, and ICD rules, either in print or using an online resource, such as ReimbursementPLUS (www.ReimbursementPLUS.com).

• Get used to ­­— and comfortable with — the economic shift. Policies are shifting a greater portion of costs to patients, and you have to be as comfortable collecting from the patient as you are collecting from a carrier.

Information management

The amount of information is daunting to be sure, but if you prioritize and properly manage the information, you should be able to incorporate these changes into your practice. OM

DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.