Document details of the clinician-patient interaction
At the time of the encounter, you are responsible for documenting your contact with the patient in enough detail to support billing a CPT evaluation and management (E/M) code at the level selected and/or any procedures or other services performed. The TABLE provides an overview of the requirements for each level of office service.
If both an E/M and a procedure are performed on the same date of service, the E/M must be documented to show it was separate from the procedure and that the work was significantly more than would be required to accomplish the procedure. Documentation of the procedure should include the indication, steps performed, findings, the patient’s condition afterward, and instructions for aftercare or follow-up.
If you use an electronic health record for reporting, you may be the one responsible for selecting both the CPT code for services performed and an ICD-10-CM code(s) to establish the medical need for them. Select the most accurate CPT codes, and clearly link them to a supporting diagnosis for each service that will be billed. If more than one diagnosis is applicable, the first one linked to any given service should represent the most important justification, as not all payers will accept more than one diagnosis code on the claim per service billed.
If the billing staff is assigned the task of selecting the CPT and/or ICD-10-CM diagnostic codes based on your documentation, they should be well versed in the services, procedures, and diagnoses reported for their ObGyn practice.
The actual code selection may end up being a joint venture between the clinician and the staff to ensure that accurate information will be entered on the claim. Good and frequent clinician-staff communication on billing of services can transform average reimbursement into maximized reimbursement.
Be aware of bundles
Sometimes more than one service or procedure is listed on a claim on the same date of service. However, it is important to identify all potential bundles before billing to ensure correct payment. For instance, payers like to bundle an E/M service and a procedure, or you may be in the global period (defined below) of a surgery but need to report an unrelated service.
You and your staff must work together to ensure the claim is submitted with the correct modifiers; on the other hand, you may decide that a better method of coding is in order. Some payers, for example, will not reimburse both an insertion and a removal of an intrauterine device (IUD) on the same date of service. If that does happen, a modifier on the removal code might save the day, rather than billing 2 codes.
Continue to: Manage the modifiers