All Coders—US Citizens working on U.S. Soil

• Important for HIPAA and Compliance

Dual certified within first year

• Including RCC

3 or more years of radiology coding experience

Coder samples reviewed quarterly

• Benchmark: 95% or higher accuracy

• Most coders are also interventional or diagnostic coding specialists

Custom coder access

Client coding profile

Radiology Services Coding

PBN processes 1 million radiology CPT’s per year

PBN’s radiology clients represent over $35 million in annual revenue

Longevity:• 1 radiology client with PBN since 1992• 4 additional radiology clients with PBN for 10+ years

Radiology Coding Experience

• Transcript to Coderyte• PBN CPC, RCC review

Radiologist Specialist

Coders

• Missing documentation to client weekly

• Physician specific education

Never Downcode

• Correct claims checked against: CCI, Duplicate, and payor-specific edits

• Corrections made prior to initial filing

Claim Filing Pre-Edits

Radiology Coding Lifecycle

Radiology Coding Best Practices

Optimized Billings• Reports that could achieve a higher level of service (or additional billable

codes) with appropriate documentation are returned to the client each week for additional documentation (pre-billing).

Physician Education• Regular documentation education with physicians in order to capture all

services being provided. Common deficiencies include E&M billing, conscious sedation, PQRI.

Auditing• Internal auditing of each coder annually• External auditing of each coder annually

– Audit scope and frequency based on regulatory changes, practice changes, coder experience, previous audit results.

– Results provided to client• All billing staff audited annually at a minimum

Customizable Solutions — Payors

Standard A/R work flow• A/R queues worked aggressively

based on Average Days to Pay (No more than 45 days):

• No response triggers follow up

– Online status check

– Phone call

• Denied claims:

– Appeal / resolve within 30 days of receipt of denial

• Focus on future denial prevention

• Over 120 day A/R below 20% from DOS (PBN Radiology at 18.63%)

Example custom solutions

• All claims called on after 30 days

• Medicaid / Medicare eligibility checks in the first 30 days

• Special invoicing solutions for charges billed to outside parties (i.e. hospitals)

• Custom queue designs

• Pre-appointment insurance verification

• Pre-appointment deductible / coinsurance verification

Customizable Solutions — Patients

PBN standard process• At adjudication to patient

responsibility:

– Day 1 – statement 1– Day 28 – statement 2

(pre-collection letter)– If no response:

– Review for Medicaid / Medicare eligibility / other account problems

– Call patient as needed– Turn over to collections

• 24 hour online patient customer service and payment portal.

• Dedicated customer service department for all incoming calls

Example custom processes

• Auto dialer calls:

– After 1st statement– Pre-collection

• Live calls 30 days after first statement

• Second statement at 35 days

• Pre-collection live calls based on dollar amount (over $500 gets 2 calls, over $100 gets 1 call)

• Customized pre-collection letter

Follow-up Methods:

PBN standard process• Client / specialty focused

• Radiology denial resolution expertise

• Extensive use of internet for verification of eligibility, claim status and appeals around time)

• Calling: Often the easiest way to resolve a claim

• Coder review of all coding related denials

• Electronic error capture from the 4010 acceptance file.

HE 4010 ACCEPTANCE FILE.

Payor relationship management• Regular meetings with major payors

to discuss ongoing problems

• Project submission for bulk appeals caused by payors

• Ongoing attendance at payor sponsored seminars

• Proven success permanently resolving denial problems

Denial Prevention and Resolution

Preventing denials = more money, faster• Denial trend analysis

• Monthly detailed review of systemic denials

• Denial root cause analysis

• Meetings with PBN liaison, IT and A/R staff to determine potential solutions for preventing recurrence of specific denial issues.

• Liaison follow up with client / hospital staff / facility staff as needed.

SUCCESSFULLY PREVENTED RADIOLOGY DENIALS

• Pre-claim filing medical record review for medical necessity for Medicare / Medicaid

• PBN built “LCD” lists for Medicaid and other known payor specific policies.

• Assisting hospitals with building “drop down” ordering indications lists

• System changes to capture hospice indicators and automatically add the appropriate modifier.

• PECOS – identifying referring physicians that are not enrolled in PECOS and working with them and hospital medical office staff to expedite enrollment.

Denial Prevention and Resolution

Preventing denials = more money, faster• Denial trend analysis

• Monthly detailed review of systemic denials

• Denial root cause analysis

• Meetings with PBN liaison, IT and A/R staff to determine potential solutions for preventing recurrence of specific denial issues.

• Liaison follow up with client / hospital staff / facility staff as needed.