Sanity saver: Maintain a master grid of payer rules by CPT

If you're like most of our physician practice clients, you likely participate in the networks of at least a dozen managed care companies. This means that you not only have to manage different fee schedules for each, but keep track of each payer's unique set of rules, as well. Between managing your accounts receivable and adjusting to frequent payer policy changes, the complexity never seems to end. So how do you manage all of these plans without losing your sanity? By capturing the rules in a master grid and updating it frequently, that's how.

Despite being chock-full of valuable information, building this grid isn't complicated. We've even provided a simple template to get you started. Before you begin populating the grid, create a list of your most frequently performed procedures and services. The 80/20 rule always applies, whereby 80 percent of your revenues (or volume, depending on which one you want to measure) is captured in 20 percent of what you do. These are the codes you're going to want to list in the first column of your spreadsheet.

Next, add your payers to your worksheet. Each payer may span several columns, depending on what critical information you want to keep track of for each payer under each code. But by listing out criteria that is relevant and important to your practice, you will be able to see all of your payers at a glance for any given procedure or service code.

Here's a great example. Effective January 1, 2011, replacement CPT codes became effective for vaccine administration services. Previously, vaccine administration was paid based on initial injection (or nasal/oral administration) and additional injection (or nasal/oral administration) per visit. The replacement codes identify vaccines by component, requiring practices to bill based on the number of components contained in each vaccine. In the case of, say, Pentacel, that vaccine has five components, and therefore requires one 90460 code and four 90461 codes.

A month later, we can see that each payer has chosen to interpret and pay these codes in a different way. Some want each code billed multiple times, while some want one code with the number of components listed as units. Some payers will recognize only one of each code per visit and bundle the rest. Most pediatric practices participate with a minimum of 12 insurance companies, so tracking these variations has become complex indeed.

Rather than trying to untangle the rules each time you receive a denial or see something other than what you expected on an EOB, I recommend you take the time to build a master grid. This tool will not only help you submit correct claims in the first place, but will make it faster and easier to research those that come back with problems. Not only will you save time and money, but you'll likely save your sanity too.

Editor's note: Madden is founder and CEO of The Verden Group, a New York-based consulting and business intelligence firm that specializes in practice management, physician education and healthcare policy.

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