Avoid making these three mistakes under APGs
Avoid making these three mistakes under APGs
By Susan Durham
Regional Manager of Network Development
Blue Cross of Washington and Alaska
Seattle
Question: What are the three most common mistakes providers make when billing under ambulatory patient groups (APGs), and how can they be prevented?
Answer: The most common errors involve missing or incorrect coding information on APG-related claims submitted for payment. The lack of correct coding data can lead to an improper payment but also can result in an outright denial of the claim. Most errors stem from a lack of effective claims editing at the hospital or insufficient APG billing experience.
The three most common mistakes we find include the following:
• Missing CPT-4 codes on the UB-92 form.
Hospitals often submit a revenue code on the UB-92 form without an appropriate CPT-4 code. They should submit a correct CPT code on the claim each time because it usually is the only way to properly assign an APG to each procedure. A revenue code does not reveal enough information to the payer about what occurred during the procedure to allow for a proper APG assignment.
Providers are failing to include the codes on their claims because many facilities still rely on their charge description masters for billing under APGs. Historically, hospitals have not billed for items such as surgical supplies using a related CPT-4. The supply charges typically get dumped into a hospital-specific revenue code and billed directly from the Chargemaster.
A troublesome but effective way to correct the problem is to enter a complete set of CPT-4 codes for every ambulatory service into the Chargemaster. This means reviewing every revenue code and entering a corresponding CPT-4 for each service within that revenue code.
• Use of incorrect CPT-4s.
Errors that occur involving the submission of incorrect codes can be similarly linked to the Chargemaster. But they often occur because providers don’t have effective claims edit systems in place to handle APG-related claims. They may be billing electronically but don’t necessarily edit their codes properly for APGs.
Many facilities are still coding for APGs manually even while they’re processing claims for other payment contracts electronically. And many of the vendors of automated billings systems don’t as yet provide the APG grouper. The grouper software usually comes with an internal coding edit that reviews each code prior to grouping under the APG.
One effective way for hospitals to ensure coding accuracy is to assign a staff person whose primary responsibility is to oversee all APG-related claims. This person would be charged with reviewing claims to ensure data quality.
Hospitals are making progress in improving their accuracy rate, and Blue Cross has invested considerable effort in working directly with facilities in the educational process. However, the process will take time. (A set of updated 1997 CPT-4 and ICD-9-CM diagnoses and procedure codes for APGs are now available free of charge. See the editor’s note for ordering information.)
• Confusion over reporting units.
A third type of error involves units of time or encounters. Facilities are defining these units in ways that are inconsistent with the payer’s definitions of what constitutes the same unit.
For example, let’s say a patient comes in twice a week for physical therapy involving orthotic training (CPT-4 97500). The code specifies 30 minutes of time initially for each visit. Each additional 15 minutes gets assigned a separate code (CPT-4 97501). But what if at some point the physician orders one visit to last only 15 minutes instead of 30 and the following visit to last only another 15 minutes? Should you roll both encounters into one under CPT-4 97500?
The definition of what constitutes a unit is important because it influences the number of times a corresponding APG rate gets multiplied by its relative weight to produce a payment. If the provider casually lumps units of time together and reports the wrong CPT code, the error can result in an under- or overpayment. Therefore, if you bill one unit of billable time for every 15 minutes, then everybody has to define the unit in the same manner. Reach an agreement with the payer and adhere to it consistently.
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