Assess Your Coding. Improve Your Bottom Line.

Coding compliance is perhaps the biggest challenge facing ASCs today. Not only are coding and billing guidelines both complicated and continually evolving; the situation is exacerbated by the fact that you’re currently forced to operate under two different payment methodologies (APCs for Medicare and Medicare HMO programs and APGs for third party payers). Now consider that erroneous procedure coding can do more than cause your ASC to miss out on revenue you’re due. The prospect of fines and the forced reimbursement of overpayments is a harsh reality for even the most diligent of ASCs.

GENASCIS™ has partnered with healthcare regulatory compliance experts MedLearn® to offer ASCs a groundbreaking tool in the struggle for coding compliance. CODECYPHER™ is a powerful Coding Compliance Engine that combines the proprietary technology of GENASCIS with MedLearn’s auditing experience to unlock the mysteries of coding and reporting services performed by ASCs. With CODECYPHER, you can review a customized coding analysis that highlights compliance issues, risks and opportunities, as well as receive case specific decision support on mitigating that risk and taking advantage of those opportunities.

Hospitals nationwide are already dealing with Medicare RAC audits. Can ASCs be far behind? It’s time to heed the advice of the Office of Inspector General (OIG) and implement your own internal compliance program, of which CODECYPHER can play a central role.

Where There’s Smoke, There’s A Modifier.

Leveraging MedLearn’s extensive knowledgebase and audit data, GENASCIS has been able to pinpoint the incorrect usage of modifiers (as well as certain CPT codes) as the most common and egregious causes of both overpayments and underpayments for outpatient surgical procedures. Specifically, modifier 59 has been identified as the modifier that is most often reported incorrectly. Modifier 59’s primary purpose is to indicate that two or more procedures were performed at different anatomic sites, different lesions or different patient encounters.

Based on this insight, CODECYPHER analyzes an ASC's claims for the following issues:

1. Procedure combinations with potential modifier 59 misuse – In this coding analysis, CODECYPHER identifies code pairs that may be at risk for reporting modifier 59 inappropriately by flagging the code pairs for which modifier 59 was reported. Once identified, an ASC can verify if the documentation truly supports the use of the modifier 59.
2. Procedure combinations billed with National Correct Coding Initiative (NCCI) Mutually Exclusive codes – Mutually Exclusive code pairs are identified in the NCCI edits as codes that should never be reported together based on the medical impossibility/improbability they could be performed in same patient encounter. This coding analysis identifies their presence, as well as certain code pairs in which the modifier 59 may be used to bypass the edit.
3. Opportunities to increase revenue by billing modifier 59 – While misuse of modifier 59 can expose your ASCs to fines and repayment, the correct use can ensure your ASC receives appropriate reimbursement for multiple procedures performed in the same patient encounter. This coding analysis flags code pairs where a modifier 59 was not assigned, as well as providing the original bill date to determine if re-billing is possible.
4. Procedure with inappropriate modifiers for ASCs – Under the Outpatient Prospective Payment System (OPPS), there is a comprehensive list of approved modifiers available for use in the ASC setting. This coding analysis identifies modifiers appended to the CPT procedure code that are not present on the approved list. Note: This list of approved modifiers applies exclusively to APCs, not APGs.

CODECYPHER is currently available to users of SourceMedical's Vision, AdvantX and SurgiSource
systems only.

Audit Reveals ASCs Misuse Modifier Codes More Than Half The Time.

CODECYPHER was used to examine six participating beta test ASCs, comprising a total of more than 65,000 accounts; the web-based technology red-flagged 38% of those cases (24,700). To validate CODECYPHER’s efficacy, MedLearn conducted a full manual audit of a randomly selected sampling (122) of the flagged accounts and found that within that audit sample, a stunning 51% of the claims contained misused modifier codes, as well as other coding errors. Conclusion: of the 24,700 cases, nearly 12,600 had misused modifier codes.

	# of Encounters Reviewed	Diagnosis Code Accuracy Rate	Procedure Code Accuracy Rate	Modifier Code Accuracy Rate
Sample ASC #1	22	100%	50.77%	0%
Sample ASC #2	15	72.34%	61.02%	55.26%
Sample ASC #3	25	91.80%	98.11%	86.57%
Sample ASC #4	12	90.63%	62.26%	36%
Sample ASC #5	25	97.14%	93.67%	66.67%
Sample ASC #6	23	82.86%	82%	50%
Total	122
Average		89.13%	74.64%	49.10%
These statistics validate that incorrect use of modifier codes account for the largest percentage of ASC coding errors.

 

Are your claims submitted to CMS or payers using CMS methodologies as error-laden in terms of misused modifiers and other coding mistakes? Can you afford not to know? There is no need to put your facility at risk for payer audits, payment give-backs, and penalties associated with incorrect coding.

 

• Proactively audit your ASC’s coding compliance to prevent costly overpayments and underpayments
• Trend your reporting accuracy including physician performance breakdowns with ongoing coding audits and the concurrent monitoring of coding and billing data
• Determine actual dollar amounts at risk as a result of coding compliance issues identified
• Receive actionable decision support once coding compliance issues are identified
• Access “big picture” analysis of coding compliance via our Modifier Compliance Dashboard
• Profit from the synthesis of MedLearn’s auditing knowledgebase and GENASCIS’ technology acumen
• Review global reports generated for multiple ASCs or micro-focused reports on specific business units within an ASC
• Establish the basis for internal compliance audits prior to governmental intervention

• Customized coding analysis identifying:
  - Procedure combinations with potential modifier 59 misuse
  - Procedure combinations billed with NCCI Mutually Exclusive codes
  - Opportunities to increase revenue by billing modifier 59
  - Procedure with inappropriate modifiers for ASCs
• Analyze compliance metrics by payer, physician, procedure and more
• Decision trees articulating how to correct the potential issues identified in each report are available in Compliance Tools
• Access to the OPPS List of Approved Modifiers
• A Modifier Compliance Dashboard graphically depicts:
  - Trending Case Volume by Compliance Type
  - Trending At Risk Dollars by Compliance Type
  - Physician Breakdown per Compliance Type
  - Top 10 Procedure Combinations by 59 Misused Case Volume
• Reports are based on two-plus years of actual data from your ASC
• Prioritize cases by At Risk Payment Amount
• Filter analysis results by time period, facilities or business units
• Documentation is updated quarterly to coincide with NCCI quarterly updates
• A glossary of terms is incorporated into the product