Coding and Support

Coding and Support

Numerous resources are available at Cochlear™ Americas to help you keep current with the latest coding rules and updates applicable to our implantable hearing technology.

Accurate reporting of services and procedures performed during the pre-operative, operative, and post-operative care of a cochlear implant or Cochlear™ Baha® patient is a critical component in securing a positive coverage decision from a payer. Accurate reporting of services and procedures will also avoid improper payments that may result from inaccurate coding. Most payers follow the coding nomenclature established by the American Medical Association (AMA), CMS, and various specialty societies. This is the key to protecting providers from complicated coding edits, non-complaint coding, and unnecessary claim denials.

Unfortunately, not all payers adopt the same coding mechanisms established by CMS and the AMA (state Medicaid plans). Therefore, Cochlear Americas' Reimbursement team has numerous resources to help you keep current with these coding requirements for our technology.

Why is coding important?

Proper coding reports and policies within a medical practice protect the practice from:

• Lost revenue.
• Fraud or abuse allegations.
• Accounting errors.
• Theft.
• Payback requests from payers.
• Denials.
• Over-coding/under-coding.

Proper coding, reports and policies ensure:

• Audit readiness.
• Maximized accounting.

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The rules are clearly spelled out and, as long as the codes applied to a particular treatment comply, they are unchallengeable. Beyond that, there are subtleties involved in coding which, properly applied, can contribute significantly to revenue.

Knowledge of coding refinements and applicable changes allows providers to code with confidence without fear of challenge and with the ability to defend their charges if required.

What is the difference between coding and documentation?

Coding is how you identify the treatment provided to patients to third-party payers that will reimburse you accordingly. Documentation is how you apply the codes to support your claim for the treatment you provided. Knowing the correct codes and their refinements will enable you to define the services you provide precisely. Documentation relies on these codes to tell a complete and accurate treatment "story" or narrative. both are important.

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Why is "Medical Necessity" important in the coding process?

"Medical Necessity" may determine whether or not you will receive payment. If you do not demonstrate medical necessity with your coding and documentation, you risk:

• Delays.
• Denials.
• Paybacks.
• Audits from the health plan.

It is not too hard to demonstrate medical necessity if you simply provide the information (codes and documentation) that health plans expect to see.

The information health plans want includes:

• The patient's history.
• A complete exam that overlooks no detail of the basic complaint.
• A sound diagnosis that considers not only the patient's basic complaint but also potentially related conditions.
• A treatment plan that is linked to the findings of the exam.
• A defined course of treatment with goals and timelines.
• By observing all of these requirements, the provider's chances of satisfying all payer requirements increases.

How will I improve collections and reimbursement?

• Proper coding.
• Documentation.
• Continuing coding education.

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Cochlear Americas can work with you to help you understand how to code completely and fairly for the implantable hearing services you provide to your patients. The best way to improve collections is to provide payers with proper coding and documentation so that your claims are clean and will not delay your payment. If you are challenged in any way, your best defense is your precise coding and documentation. Continuous coding education will help you or your coder comply with the law and maximize reimbursement opportunities.

Accurate coding is one antidote to the declining health of provider reimbursement rates. "I've worked with practices that are losing 15 percent, easily, to undercoding," says Todd Welter, President of R.T. Welter & Associates, a Denver-based consulting firm.*

Is 15 percent worth the trouble of coding conscientiously?

Yes! Particularly when you consider that the median total medical revenue per FTE physician is $492,648 - that means nearly $74,000 is potentially lost to undercoding.*

On the flip side, practices must ensure that they do not overcode. Begin optimizing proper coding:

• Use modifiers correctly.
• Choose the correct patient category.
• Understand and apply appropriate levels of evaluation and management (E&M) service.
• Properly link ICD-9 and CPT codes.
• Know where to get good help.

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Support Services

Cochlear Americas helps to reduce or eliminate barriers to our implantable hearing solutions by collaboratively partnering with clinicians, facilities, and private/commercial health plans. We offer comprehensive, unparalleled, expert professional services to secure and maintain coverage and appropriate payment by:

• Providing physician, audiologists, and facility customers with reimbursement analysis and coding education.
• Helping obtain and maintain coverage policies and appropriate payment for cochlear(tm) products by serving as a local liaison to payers (CMS, state Medicaid plans, and commercial health plans).
• Educating key payer decision-makers and influencers about Cochlear's implantable hearing technology.
• Providing reimbursement support services to assist physician offices, audiology clinics, ambulatory surgical centers, and hospitals in securing positive coverage and authorization decisions for cochlear Americas' implantable hearing solutions.
• Working towards enhancing state and Federal coverage guidelines and policies.
• Providing the necessary evidence-based documentation in support of case-by-case prior authorization for individual patients in need.
• Helping our provider customers to manage the preauthorization and appeals process for services that have been denied.
• Developing strategies to secure and maintain coverage, coding, and payment for emerging and existing implantable hearing solutions.
• Monitoring and evaluating new and existing national and large local payers' medical coverage policies.
• Shaping policies and driving evidence-development activities that support coverage and payment.
• Informing and educating clinical study sites on coding, coverage, and payment mechanisms for clinical studies.
• Working collaboratively with audiology and physician specialty societies on coverage advocacy efforts.

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Additionally, free online seminars on implantable hearing coding are available. These seminars provide information on:

• Basic coding.
• Cochlear implant edits.
• Modifiers.
• HCPCS coding.
• New coding changes.

Through the online seminars you can:

• Ask specific coding questions in real time.
• Learn implantable hearing solutions' coding with case examples.
• Clarify correct coding of related to bilateral implantation.
• Clarify coding related to CCI edits.
• Identify appropriate coding for audiology and speech pathology services.
• Clarify appropriate use of modifiers.

Cochlear Americas offers a staff of regionally-based Reimbursement managers who understand coding, coverage, and payment methodologies from both the national and local market perspective. As a service to our customers, we provide coding, coverage, and reimbursement assistance for Cochlear Americas' implantable hearing solutions.

Our Reimbursement team offers regional and individual Reimbursement Workshops or visits to provide education to our customers on:

• Coding.
• Payer contracting negotiation tips.
• Practice/clinic/service line management.
• Medical management of predeterminations/denials.
• Payer advocacy.
• Clinical trial reimbursement.

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Otologic Management Services (OMS)

OMS, a division of Cochlear Americas, is a no-charge service assisting patients and providers obtain necessary insurance coverage and facilitating the appeal process when coverage is denied. These services are relative to private/commercial health plans.

Candidates, recipients, or providers can call OMS directly to request assistance with:

• Predetermination of benefits.
• Preauthorization/Pre-certification.
• Appeals of denials.
• Reimbursement questions.

How do patients or providers access OMS?

• Candidates, recipients, or providers can call OMS directly and request assistance.
• Provider reviews and signs a letter of agreement.
• Provider completes a clinic information form.
• Patient must complete a patient information form and sign a release.
• All completed information should be submitted to OMS via fax along with medical documentation (audiograms, medical history, etc.). OMS will provide a checklist of information required.

* Physician's Practice: Discover the Power of Positive Coding, Five Ways to Code Better by Pamela Moore (March/April 2002)

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