Case Study: Enhancing Medical Coding Practices for a Leading Cardiology Practice
This case study emphasizes the importance of precise coding practices and continuous education in optimizing financial outcomes for medical practices.Background
Location: Long Beach, California
Practice Type: Group Practice
Our client, an award-winning cardiology practice, is renowned for its excellence in patient care and cutting-edge cardiovascular treatments. As a trusted group practice with multiple locations, they serve a substantial number of patients each month, providing comprehensive cardiac care including diagnostics, interventions, and follow-ups. Despite their clinical success and high patient satisfaction ratings, the practice faced significant financial and operational challenges due to issues in their cardiology medical coding process. The primary issues stemmed from inaccuracies in coding and the improper use of cardiology codes and modifiers, leading to numerous denied claims and decreased reimbursements.
Challenges Faced
1. Inaccurate Coding Practices
Outdated Codes: The practice’s in-house coders were often using outdated CPT and ICD-10 codes, which did not reflect the most recent updates and revisions. This resulted in frequent denials as insurance companies rejected claims that did not adhere to current cardiology coding standards.
Incorrect Code Selection: There were numerous instances where the wrong codes were selected for procedures, leading to misrepresentations of the services provided. For example, using a general cardiology code instead of a more specific one that accurately described a complex procedure.
2. Improper Use of Modifiers
Modifier Misapplication: Coders frequently misapplied modifiers, such as using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure) incorrectly. This led to rejections, as insurance companies often scrutinize modifier use closely.
Overlooked Modifiers: Essential modifiers that could have justified additional payments were often overlooked. For instance, modifier -59 (distinct procedural service) was not used when appropriate, causing bundled payments for services that should have been billed separately.
3. Lack of Training for Staff
Insufficient Knowledge of Updates: The staff was not adequately trained on the latest coding updates and guidelines specific to cardiology. This knowledge gap resulted in the ongoing use of outdated practices and failure to adapt to new coding requirements.
Lack of Specialty-Specific Training: General coding training did not cover the nuances and complexities of cardiology procedures, leading to a high error rate in coding submissions.
4. Documentation Gaps
Incomplete Documentation: Physicians often provided incomplete documentation, which lacked necessary details to support the codes used. This made it challenging for coders to select the most accurate and appropriate codes, leading to denials.
Ambiguous Descriptions: Ambiguous or unclear descriptions of procedures and patient encounters complicated the coding process, resulting in errors and omissions.
5. Denied Claims
High Denial Rates: A significant portion of submitted claims was being denied, causing cash flow disruptions and increasing administrative overhead. The practice struggled to identify and rectify the underlying issues leading to these denials.
Lengthy Appeals Process: The high volume of denied claims necessitated a time-consuming and labor-intensive appeals process, which diverted resources from other critical operational areas.
Our Approach
1. Comprehensive Audit
We began by conducting a comprehensive audit of the practice’s coding processes. This involved:
Reviewing Denied Claims: We analyzed patterns in denied claims to identify common errors.
Assessing Documentation: Evaluating the quality and completeness of physician documentation.
2. Establishing Clear Coding Protocols
Developing Coding Guidelines: We created a detailed coding manual tailored specifically for cardiology, including common procedures and their appropriate codes and modifiers.
Implementing Best Practices: Establishing protocols for regular updates and continuous compliance with the latest coding standards and payer-specific guidelines.
3. Training Programs
Customized Training Sessions: We organized training sessions for the practice’s staff, focusing on cardiology-specific coding.
Workshops and Webinars: Conducted workshops and webinars to keep the staff updated on new codes and coding changes.
4. Certified Coders Integration
Deploying Certified Coders: Our team of AHIMA™ and AAPC™ (CCC) certified medical coders, specializing in cardiology, worked alongside the practice’s staff to ensure accurate coding.
Real-time Support: Providing real-time coding support and query resolution to the practice.
The Results
Improved Coding Accuracy
Proper Use of Codes and Modifiers: Our intervention led to the correct use of CPT and ICD-10 codes and modifiers, improving their coding accuracy to 97%. For instance, the practice previously misused CPT code 93458 (catheter placement in coronary artery for coronary angiography). By ensuring the appropriate documentation and using the correct code, the accuracy improved significantly.
Modifier Expertise: Correct application of modifiers like -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) reduced claim rejections.
Enhanced Reimbursements
Increased Acceptance Rates: The acceptance rate of claims improved drastically, resulting in higher reimbursements. For example, the use of modifier -59 (distinct procedural service) was refined, preventing bundling issues and ensuring separate reimbursement for distinct services.
Revenue Growth: Overall, the practice saw an astounding revenue increase of 44% within the first six months of our engagement.
Reduced Denied Claims
Decline in Denials: The rate of denied claims dropped by 25% due to more accurate coding and thorough documentation. Once we took over the eligibility verification and authorization process, we ensured clean claim submission with a consistent claim first-pass rate of 97%.
Efficient Appeals Process: With accurate coding, the process of appealing denied claims became more efficient and successful.
Better Documentation
Physician Training: Educating physicians on the importance of detailed documentation improved the clarity and completeness of medical records, facilitating more accurate coding.
Template Utilization: Implementing documentation templates for common cardiology procedures ensured all necessary information was captured consistently.
Leverage Expertise
By partnering with Bristol Healthcare and leveraging its data-driven approach, the cardiology clinic was able to enhance its coding accuracy, leading to a substantial reduction in denied claims and an increase in reimbursements. Our systematic approach, which included thorough audits, clear coding protocols, specialized training programs, and the incorporation of certified coders, effectively tackled the underlying causes of their coding issues. Click the link to learn more about our full-scale cardiology billing services.
Experience the power of specialized cardiology billing services designed to propel your practice to new heights. Call 800-253-7320 to schedule a free consultation today!