Resident expert answers potpourri of members’ coding questions

May 30, 2012

Edited by Chuck Brownlow, O.D., Medical Records consultant

It’s been an interesting month at the askthecodingexperts@aoa.org desk. Lots of great questions, including some that appeared to be facing many offices at the same time. I’ve taken the liberty of extracting some of my suggestions/responses and have “cleaned them up” for the column this month.

Q: I’m frustrated with some of the provider agreements I’ve signed over the years and would like to make decisions as to which plans to renew, which to re-negotiate, and which to “wean”from the plans we participate in. What opportunities do I have for doing this and how do I make those decisions?

A: You have one big opportunity to impact the fees an insurer pays you and that is your decision whether to accept the contract in the first place. It’s important to carefully consider all facets of the agreement at that time. Items to consider are the fees they offer compared to your usual fees and the costs of providing care in your own practice, whether the agreement permits you to provide your patients care for all covered services within your scope of practice, whether you have openings in your schedule that might be filled if you accept the agreement, etc.

This first opportunity is followed, usually annually, by opportunities to accept or reject the agreement at renewal time. In my opinion, you should go through the same process at renewal time that you did with the original agreement. Your practice changes from year to year, and so do your professional and personal goals. A plan that may have fit your practice and your patients one year may no longer fit a year or two later.

All health care providers should be carefully scrutinizing key elements of every agreement annually and negotiating any condition in the agreement that doesn’t match the internal “requirements” established by the provider. This process requires thought and preparation, of course.

Keep in mind that health plans are businesses, and good businesses purchase materials and/or services as cheaply as possible while doing all they can to ensure the quality of the materials and services they provide to their “customers.” As businesses, they are unlikely to increase payments to a provider unless the provider informs them payments are no longer adequate.

Start this process now by following these steps:

  • Meet with your accountant and other advisers to develop parameters for acceptable provider agreements for your practice. Make decisions on fees, scope of practice, etc., that can be used to match provider agreements against the needs of your practice and your patients. These decisions will be unique to your practice. You must create them.
  • Pull out all current agreements. If you can’t find one or more of them, contact the insurer and ask for a copy of the current contract as well as the next renewal contract if it is available.
  • Compare the parameters you’ve developed to the components of each provider agreement.
  • If the components of the contract match the parameters you’ve established, you will probably renew the contract.
  • If one or more of the components falls short of your parameters, prepare to negotiate with the insurer.
  • Inform the insurer you wish to negotiate those components prior to accepting or rejecting the contract or renewal.
  • If an insurer refuses to negotiate and provides you with a “take it or leave it” choice, discuss the options with your advisers and make a decision.

Q: Many of my colleagues have begun using electronic health records. I’m getting a little nervous. Should I be climbing aboard this train or holding off for better products down the road?

A: This is a great time to be comparing EHR software. You can get good online demos, ask lots of questions, and begin sorting out the ones that seem to best fit the way you practice and the specific needs you have relative to practice management, patient records, claims submission, etc. Most important, don’t be in a hurry. Hasty EHR choices have cost some of our colleagues financially and personally, with loss of key staff people, etc. The Health Information Technology for Economic and Clinical Health (HITECH) Act incentive payments are nice, but you will be better off in the long run if you make a thoughtful choice first, even if it takes a little longer.

Q: We’re confused. Can fundus photos and retinal imaging be billed together at the same visit?

A: Three answers for this one:

1. Yes, 92250 and 92133 or 92134 can be billed together on the same day, according to Medicare’s Correct Coding Initiative, assuming you add the 59 modifier to the one with the lower relative value, the imaging.

2. No, some payers will not pay for both services when billed on the same day, modifier or no modifier. In such cases, they normally pay the service with the higher relative value (in this example, 92250) and reject the other code.

3. When in doubt, have a heart-to-heart discussion with your patient. Explain the importance of doing both tests at this particular visit. Acknowledge the difficulties of knowing and abiding by all the rules for all insurers, including which services they cover and under which conditions. Have the patient sign an Advance Beneficiary Notice before doing the services, with the patient thus agreeing to pay if the insurer does not. Submit the claim and send the bill to the patient if the insurer does not pay.

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