About Maria Todd

Several years ago, I had an anterior cruciate ligament (ACL) reconstruction by allograft.  My surgeon said the case took 5 hours because of my weight at the time.  The guides to drill the pilot holes did not work. When he billed for the case, his reimbursement was only $1500, not because of anything other than a biller (from a “professional” billing service, mind you) who billed the case as a standard procedure without submitting for extended service or complications.

When I found out what had happened, I volunteered to write an appeal letter for him, which in any other situation would have increased my copay, but it didn’t because I was already at 100% benefit (it had been a bad year, medically). One skillfully written letter and 15 minutes drafting time resulted in a $3500 additional payment.  It also resulted in additional payment to the assistant surgeon of about $350.  Since the assistant surgeon was also from the same practice, the net positive revenue to the practice was an additional $3850.   Now I don’t know about you, but I will write letters like that all day long for that kind of result.  Better yet, why not code it correctly the first time and avoid the margin erosion from having to submit the appeal(s) in the first place?

Use these eight factors to distinguish, extensive and complicated procedures
Coding decisions often come down to the discretion of the surgeon and the coder. They carry heavy liability for up-coding and compliance tied to the Federal False Claims Act if done to perpetrate fraud or abuse and therefore should not be made with proper judicious discretion.  Still, there are eight little tests that you can apply to determine if your procedure is a candidate for extended or complicated procedures.  Also, make sure you record in the chart that you did the tests to show your thought process in the event of an audit, (kind of like algebra when you had to show your work, not just the answer to the problem.)

1.    Excessive bleeding.  An accurate and descriptive operative report should always note blood loss and if it happened why it happened. Excessive bleeding and management of hemostasis that is unexpected or unanticipated may qualify as extended or complicated.
2.    Length of the procedure.  The surgeon should always record in the operative note if the procedure took extra time to perform, and if so, how much time overall was spent.
3.    Nature of the wound closure.  The surgeon needs to specify how he/she closed the wound. If the surgeon’s wound closure involved multiple layers of subcutaneous tissue may qualify for extended and local soft tissue flaps may quality as complicated.
4.    Number of separate incisions. The operative note will usually specify the number of incisions. If the procedure usually only involves a single incision but additional incisions were required, the procedure may qualify as extended or complicated.
5.    Presence of blood vessels. If a blood vessel required extensive or complex handling, retraction or dissection or anastomosis during the surgery, such as pilonidal cyst wrapped around an artery.
6.    Presence of nerves. Nerves in the operative site have to be handled with special forceps that are protected in order to retract the nerve out of the operative field. This often qualifies as a complication. If a mass must be dissected from a nerve sheath, that may also qualify as a complicated procedure.
7.    Presence of tendons.  If a tendon creates extra work in the operative field as above in the example of the blood vessel or nerve, it may qualify as extended or complicated.
8.    Size of any cyst, polyp or biopsy site. If the size of the mass requires additional suturing or other treatment, it may qualify as extended or complicated.

Managed Care Contract Support for Proper Coding
Often I hear from providers who are frustrated because despite the best practices in coding and claims submission, they cannot get the payer to honor the modifiers and pay claims they way that the provider expects to be paid.  I often have to review the contract first before I can comment and when I do, I find a gaping loophole in their contract that supports the payers determination and not the providers "expectation".  One cannot have expectations without support for those expectations and understaindgs written into the contract.

Correct coding will help track payer profitability because you can sort your data on the modifiers. It is also imperative that you ensure that your contracts provide for standard interpretation and bundling logic and not some proprietary standard that does not take into account modifiers to code for complicated or extended procedures. Verify this at the time you negotiate your contracts. Othewise the properly coded procedure will be paid the standard amount because there is no mutual understanding reduced to writing in the contract.  This little failure in your contract can mean the difference between payment and no payment for the additional amounts otherwise due you.

Ensure that your contract language resembles the language below in Exhibit 1

Exhibit 1

For Coding and Bundling interpretations, plan shall acknowledge and adhere to Official Coding Guidelines and official coding advice as approved by the four cooperating parties (American Hospital Association, American Health Information Management Association, Center for Medicare and Medicaid Services, and National Center for Health Statistics) responsible for administering the ICD-9-CM coding system. Coding Clinic for ICD-9-CM is the official publication for the ICD-9-CM coding guidelines and advice as designated by the four cooperating parties. Any deviation from the above shall be included as an attachment to the agreement. At such time that ICD-10 is implemented in the United States, this policy shall be assumed to be updated concurrently.

Where to get help
I am happy to assist physicians that need to perform a one-time clean up on denials, appeals and resubmissions of claims that should have been paid under extended or complicated service modifiers, on a percentage of recovery.  I am also available to consult on managed care contract negotiations that will help you realize higher revenues for the services you provide.  Just AskMariaTodd™!  We have coders, contract analysts, former managed care medical directors, and even attorneys down the hall to assist you.

About the Author:

Maria K Todd, MHA, PhD is known around the world for her expertise and generosity in sharing ideas, techniques and practical tools with her colleagues in the industry. She is a leading health care industry consultant and described by clients and peers as a visionary and thought leader. Statistically, she is the leading trainer in managed care contracting worldwide.  Since 1989, she has lectured professionally through colleges, universities, seminar companies, publishers and non-profit professional associations as well as on-site private training classes for hospitals, medical groups, offshore revenue cycle business process organizations and pharmaceutical and medical device manufacturers. In total she has delivered more than 2600 managed care training classes and seminars to over 53,000 attendees and participants.  Every month the number grows higher and higher!

Conflict Disclosure: The author is a professional consultant and derives a substantial percentage of her income reviewing managed care agreements and advising hospitals, physicians and others on matters regarding managed care and contracted reimbursement. The author previously worked for a Health Plan in provider relations as a contract negotiator. The author has no other conflicts to declare. This disclosure accurate as of November 5, 2008.

Notice: Please remember that the opinions, and information contained in this document is that of the individual author.  These materials (1) do not constitute legal advice; (2) do not form the basis for the creation of any relationship; and (3) should not be relied upon without seeking specific legal advice with respect to the particular facts and current state of the law applicable to any situation requiring legal advice. These materials may only be reproduced with the prior written consent of Maria Todd.  These materials are provided with the understanding that the author is not rendering legal, accounting, or other professional advice or opinions on specific facts or matters, and, accordingly, such entities assume no liability whatsoever in connection with their use.

You can learn more about managed care contracting in Maria's latest book,The Managed Care Contracting Handbook, 2nd Edition (2009)

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