As of October 1st, CMS has reinstated many of the procedure-to-procedure edits, which are more commonly known as the National Correct Coding Initiative Edits (NCCI edits). This rule was actually deleted earlier this year, however, it is effective again for PT, OT and speech outpatient therapy services. We are seeing denials for NCCI edit-related issues come in at a rapid pace from many insurance companies especially when it comes to the use of 97530. Your practice is likely facing this same issue.
What can you do to minimize these denials, ensure you are catching them on EOBs, and appealing them successfully?
1) Make sure your EMR is set up properly: Your EMR can be your best defense when it comes to adding the 59 modifier to appropriate codes that are separate and distinct. Check within your company, clinic, and carrier settings to ensure they are set up with the proper modifier functions.
2) Make sure your documentation is correct: If you are performing truly separate and distinct services, a therapist's documentation needs to reflect this. Even with the 59 modifier attached to the codes, insurance companies are still denying or requiring additional documentation. At LRS, we provide strategic coding audits to evaluate a therapist's documentation to ensure that they are meeting the standards that insurance companies require regarding reimbursement as well as compliance and regulatory requirements.
3) Make sure you are analyzing every single EOB: More times than not, insurance companies adjust bundled codes and do not deny them. If your billing team is not looking strategically at EOBs, they are likely allowing this code to be adjusted off instead of marking it as denied. This can be causing your practice a significant amount of money.
4) Make sure your appeals process is up to speed: Set up a fluid and traceable communication process between your billing department and your therapists. Communicating in real time will allow your billing department to be agile and will lead to comprehensive reimbursement.
5) Make sure you are regularly checking reimbursement rates at the code level: This will help you flag any potential issues and investigate lags before they are problems.
Do you think you are missing the payments earned for the care that you deliver? Could a quick spot audit help? Could your appeals process use some standardization? Contact LRS today to see how we may be able to help you improve!