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Q&A with Billing and Coding Expert Kirk Mack

Wednesday, October 23, 2019 9:00 AM

BSM Products and Services, Billing, Coding & Compliance

Written by: BSM staff

Kirk Mack
Senior Consultant

This past August, the Rose & Associates division of BSM was thrilled to welcome billing and coding expert Kirk Mack as a senior consultant. Since then, Kirk has swiftly put his 25 years of ophthalmic expertise to good use by consulting in the areas of chart audits and utilization reviews, as well as providing customized training and guidance to providers and their teams. We recently sat down with Kirk to ask him some questions regarding billing and coding trends. Read Kirk’s answers below to gain knowledge from our newest expert in this important arena. 

What makes proper billing and coding so tricky?

There are several reasons this topic can be tricky. The first is the sheer volume of information — that alone can be intimidating. For example, when you look at the size of industry coding manuals (i.e., the CPT book, ICD-10, and HCPCS manual) determining where to start looking can take time. Second, the rules and regulations published by the Centers for Medicare & Medicaid Services (CMS), the federal government, and other third-party payers can be hard to find — and even when you do find them, the information is often confusing. Third, the application of the regulations/rules published by the ruling entities can vary significantly depending on who you ask. That means those working in this arena have to wade through the sources and determine what makes sense, so they may defend or support the rationale used when billing and coding for services.

What specific billing and coding areas can practices improve on?

The proliferation of electronic health records (EHRs) has made me concerned that some practices may rely on their systems too heavily when it comes to coding, specifically with office visits. It is often assumed the computer knows more about documentation and coding than the people in the practice. However, the computer can only code what the user enters. Therefore, if errors, contradictions, omissions, etc. are in the record, the coding is probably wrong. For example, if a practice fills up the patient history with insignificant information, the EHR may give it credit for the volume of documentation rather than the quality, resulting in a possible over-coding scenario. To avoid this, practices should appropriately train employees on the limitations of EHRs as it relates to accurate billing and coding.

Why do practices struggle with using modifier -25 properly?

Modifier -25 is used when a practice is requesting reimbursement for an office visit and a minor procedure on the same day. The modifier plays a large role in those practices that provide minor procedures, and most often, intravitreal injections. The real challenge is in the definition, and the CMS published guidelines of how/when modifier -25 can be used. Unfortunately, it is not black and white. Practices typically want a ‘yes’ or ‘no’ answer, and modifier -25 is used sometimes. If a practice never uses modifier -25 or uses it with 100 percent of its minor procedures, analysis should be done to determine the appropriateness.

What upcoming billing and coding changes should practices be aware of?

2020 lists some significant code changes to cataract surgery (with and without endoscopic cyclophotocoagulation) and extended ophthalmoscopy codes. In addition, CMS has proposed a significant change to the Evaluation and Management (E&M) codes for 2021, which are used periodically for office visits in ophthalmology and optometry. Specifically, the requirements to support the levels of service for new and established patients are proposed to change. Currently, there are five levels of service for E&M codes. The proposal would decrease the levels for new patient office visits from five to four in 2021. It is likely we will see significant discussion around this topic throughout 2020.

What universal tip/advice would you give to ophthalmology practices regarding billing and coding?

Billing and coding is actually the product of chart documentation. Whether paper or electronic, if the documentation is poor or less than compliant, the billing/coding is likely inaccurate. Fortunately, or unfortunately, billing and coding are tied to documentation — so make sure your practice is trained to execute proper documentation practices! In turn, you should see less billing and coding errors down the line.

YOUR TURN: Do you have a question for Kirk, the newest senior consultant for Rose & Associates? If so, leave it in the comment section below.

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