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Keep charge ticket coding and superbill format up to date

A column about keeping your practice in good health

By — Posted April 25, 2005.

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Watching a managed care company deny payments, downcode charges or bundle codes is bad enough for a physician just trying to keep up with overhead costs. But some physician charges are destined for denial before they even leave the office. The reason? Incorrect charge tickets.

While it seems elementary to keep the charge ticket or superbill updated, the task can easily be overlooked in the daily pressures of practice and the crises that always take priority.

Physicians have plenty to worry about, but consultants said the superbill should always be something to remember, whether you update it yourself or remind a member of your staff to do it. Without updated codes and a ticket that's formatted to help you find the correct diagnosis quickly, you're essentially taking revenue out of your pocket, health care consultants said.

"It's very often overlooked," said Jane Tuttle, compliance/HIPAA manager for Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center in Boston. "It's absolutely critical it gets reviewed annually. It can save you a lot of time on the back end."

The back end, of course, is the time spent fighting managed care companies for the reimbursement you deserve. But without correct codes, each dispute could be a long battle.

Consultants say it's imperative to review CPT and ICD-9 codes as they are updated annually to ensure the ticket includes any changes or additions that may have occurred. CPT is a registered trademark of the AMA, which develops and publishes the current procedural terminology codes.

Errors on the ticket should be corrected, new codes added, and old codes removed to make the superbill as precise and concise as possible. The ticket also should include its date of last revision, to prevent you from using old tickets and to remind you when it's time to update it again, consultants said.

"I've seen some tickets that can be at least a year old with a tremendous amount of outdated codes," said Reed Tinsley, a Houston-based health care consultant. "When you see your [explanation of benefit] reviews and you see the denied charges, it's not easy to trace it back to the ticket."

Formatting vital

But updating the codes is only half the work necessary to make the ticket a useful tool. Formatting the superbill in a way that categorizes services and makes it easy for physicians to select the proper diagnosis is key to avoiding denials and capturing all the possible revenue from a patient encounter.

Gail Pickens, director of operations at Women's Health Care Center of Houston, a three-physician ob-gyn practice, said when she started working at the practice last year, the charge ticket had not been reviewed, aside from updated codes, for several years.

"There were procedures on there that they weren't doing and important things that were not on there," Pickens said. "They got used to just writing them in. I'm trying desperately to get people to stop writing."

Every ticket should include an "other" category just in case an unusual case comes up, but tickets that don't include regular codes or diagnoses will create more work for staff.

Tinsley said a practice should include both the pertinent CPT and ICD-9 codes on the charge ticket for easy reference, because if something has to be filled in by hand, it means someone else in the office will have to look up the code. This not only is inefficient, but it provides another opportunity for error, Tinsley said.

"The other worst-case scenario is a situation where you get an audit because you're not reporting all your codes," Tinsley said.

Tinsley described one physician who only used two established patient office visit codes, which raised a red flag with insurers and resulted in a Medicare audit.

To avoid the possibility of downcoding or of becoming too reliant on one or two charges, consultants suggest including as many possible service and diagnosis codes as you could feasibly use. Although this can mean 100 or more codes, it also will allow you to properly identify your services.

It might not be limited to just those codes, either.

"When you look at your charge ticket, it's not only CPT and diagnosis codes, but also what other services does this office do that should be included," said Jill Young, a health care consultant based in East Lansing, Mich. "Do you have a lot of check-off boxes for tests?"

Because tests and procedures at San Antonio's Diabetes and Glandular Disease Clinic change rapidly, the charge ticket is reviewed quarterly, said Ann Shorter, assistant administrator for the eight-physician group.

"Recently, we went from letter-size paper to legal-size paper to be able to fit everything," Shorter said. "We're folding it right now rather than making it double-sided."

While general information is pretty standard on a charge ticket, each one has its own style that suits the doctors using it.

Some doctors may prefer single-sided to double-sided tickets, while others may be particular about how the service codes are grouped. Whatever changes you decide to make on your ticket, though, keep at least one thing in mind.

"Don't make the print so tiny you can't read it," Tuttle said.

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External links

AMA on current procedural terminology (link)

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