Medical Billing and Coding Healthcare Blog

PGM Billing, one of the nation's leading medical billing companies, is profiled in a recent report by Becker's Hospital Review.

The report identifies companies that provide revenue cycle management solutions specific to the healthcare industry.

PGM's profile reads as follows:

"Physicians Group Management (Lyndhurst, N.J.). PGM, founded in 1981, offers physician billing services, facility billing services and EMR solutions. The company offers billing solutions specifically tailored to a number of different specialties including allergy and immunology, anesthesiology, cardiology, chiropractic, dermatology, emergency medicine, gastroenterology, mental health, nephrology, oncology, orthopedics, pain management, primary care and urology."

As the report notes, "Revenue cycle management is essential to any business's strategy. These processes are only growing in importance in healthcare as every dollar is expected to stretch further than before."

According to the Healthcare Billing & Management Association, "Revenue cycle management (RCM) is the process that manages claims processing, payment and revenue generation. It entails using technology to keep track of the claims process at every point of its life, so the healthcare provider or medical billing company doing the medical billing can follow the process and address any issues, allowing for a steady stream of revenue. The process includes keeping track of claims in the system, making sure payments are collected and addressing denied claims. RCM encompasses everything from determining patient insurance eligibility and collecting co-pays to properly coding claims using CPT and ICD-9 codes."

Of RCM, MedPageToday writes: "RCM is the lifeblood of every practice. Effective patient registration, insurance and benefit verification, charge capture, and claims processing are essential to maintaining viability."

Becker's Hospital Review features up-to-date business and legal news and analysis relating to hospitals and health systems. Content is geared toward high-level hospital leaders (CEOs, CFOs, COOs, CMOs, CIOs, etc.), including hospital and health system news, best practices and legal guidance specifically for these decision-makers.

Insufficient documentation is the cause of the vast majority of improper payments for laparoscopic hernia repairs.

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter, a newsletter from the Centers for Medicare & Medicaid Services developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations, such as the Office of Inspector General.

As the newsletter notes, a Comprehensive Error Rate Testing (CERT) contractor conducted a special study of medical billing claims for laparoscopic hernia repairs submitted from July through September 2014. When CERT reviews a claim, all lines submitted on the claim undergo complex medical review. The long descriptions of Healthcare Common Procedure Coding System (HCPCS) codes for laparoscopic hernia repairs are:

  • 49650 - Laparoscopy, surgical; repair initial inguinal hernia.
  • 49652 - Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible.

The contractor determined that most improper payments were due to insufficient documentation (there were also some claims with incorrect coding errors). Insufficient documentation means that something was missing from the medical records. For example, the medical record was missing one or more of the following:

  • A signed operative report;
  • The correct date of service; or
  • A signature log or attestation for an illegible signature on a specific date of service.

Examples of Improper Payments

Example 1: Insufficient Documentation Due To Missing Signature

A general surgeon billed for HCPCS 49652 for a laparoscopic repair of an umbilical hernia with mesh insertion. The submitted documentation included an unsigned operative report for the correct date of service for the billed procedure. The CERT reviewer requested a signature attestation for the unsigned operative report as well as additional documentation from the billing provider and received a hospital discharge summary dated one week prior to the date of surgery. The discharge summary documented that the beneficiary had been an inpatient investigated for abdominal pain and that umbilical hernia repair was scheduled for the following week. Although the discharge summary provided support for the medical necessity of the procedure, an unsigned operative report is insufficient to support this claim per Medicare guidelines. This claim was scored as an insufficient documentation error and the Medicare Administrative Contractor (MAC) recouped the payment from the provider.

Medicare requires providers of all services to sign their records. Providers should not add late signatures to the medical record, but instead may submit a signature attestation, such as the one available on the CERT Provider website. Providers should also submit an attestation if signature(s) are not legible. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry, must be for a specific date of service, and must contain sufficient information to identify the beneficiary.

Example 2: Insufficient Documentation Due to One Procedure Billed by Two Surgeons

A urologist billed for HCPCS 55866 (laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) and for HCPCS 49650 with modifier -51 (multiple procedure) for an initial laparoscopic repair of an inguinal hernia. Modifier -51 is appropriate to use when multiple surgical procedures are performed at the same session by the same provider. Report the primary procedure (in this case, the prostatectomy) as listed without a modifier; report modifier -51 with the additional procedure.

The submitted documentation did not support that the billing physician performed an inguinal hernia repair on the billed date of service. The urologist's operative note indicated that during the performance of a laparoscopic prostatectomy, after the bladder was immobilized, a very large hernia and hernia sac was visualized and dissected. Once the prostatectomy was completed, a general surgeon came in to perform the inguinal hernia repair.

A review of Medicare billing records showed a paid claim for HCPCS 49651 (laparoscopy surgical repair recurrent hernia) for the general surgeon on the same date of service for the same beneficiary. The general surgeon's operative note documents that the beneficiary was undergoing a robotic prostatectomy by the urologist when the general surgeon was called into the operating room to evaluate a large inguinal hernia. It further documents that, once the prostatectomy was completed by the urologist, the hernia was repaired by the general surgeon. The trocar sites were then closed by the urologist note that the general surgeon's claim was not sampled by CERT). This claim was scored as an insufficient documentation error and the MAC recouped the payment from the urologist for the laparoscopic inguinal hernia repair.

Note: Providers and their billing representatives must use caution when using modifier -51. It is inappropriate to use multiple procedure modifier -51 when there is no second procedure performed by the same surgeon.

Example 3: Incorrect Coding for Laparoscopic Hernia Repair

A general surgeon billed for HCPCS 49652 for a laparoscopic repair of an umbilical hernia with mesh insertion. The submitted operative note supports the incidental discovery of an incarcerated umbilical hernia while performing a laparoscopic appendectomy for gangrenous appendicitis with perforation. The operative report does not document the placement of mesh, but states that the hernia was closed "using the fascial closure device with 3 sutures and 0 Vicryl, this seemed to close nicely." The CERT medical reviewer recoded the claim from HCPCS 49652 to HCPCS 49653 for a laparoscopic repair of an incarcerated umbilical hernia. This claim was scored as an incorrect coding error and the MAC adjusted the payment.

For help with proper coding and billing, check out the practice management tools from PGM Billing, one of the nation's leading providers of medical billing services.

X