Comanaged claims. Where to start? The work has been done and the claim has been sent, but the payment eludes the practice. How can this be?
There are several factors that could contribute to a denied comanaged claim, whether that’s for comanaged cataract or YAG procedures. Keep in mind that billing rules and regulations can vary by state, payer, and even plan. So, if the techniques mentioned below (that are most commonly accepted for Medicare) don’t work, it may be a great option to call your payer and see what they want.
Maximize Your Comanaged Claims— Expert Tips to Avoid Denials and Optimize Reimbursements
First, always obtain a transfer of care document for each patient and each eye. This document helps ensure that the surgeon’s and OD’s claims match where they need to. The transfer of care should provide all of the information needed to care for the patient and submit the claim.
When submitting the claim, be sure to have the surgeon’s office submit their claim first with the correct modifier, otherwise, the number sentence you provide the payer by way of the CPT and modifier may not translate to the payer and they may deny it. Also, make sure the following items match on the claim:
- DX
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- CPT
- DOS (Should be the surgery date)
The surgeon’s information should go in box 17 and box 19 should read, “Assumed (insert applicable date in xx/xx/xxxx format) Relinquished (insert applicable date in xx/xx/xxxx format) Total Days”.
As an example: “Assumed 12/02/2022 Relinquished 03/01/2023 89 days”.
Since box 19 already indicates the number of days the patient was in post-operative care, box 24. G. (days or units) typically needs to reflect “1”, although some payers may ask for the number of days to be in this box as well. That said, it is important to be cognizant of the particular requirements of each payer.
Use modifiers to denote what took place. The relevant modifiers are listed below:
54 – The surgeon should append this to indicate they only performed the surgery.
55 – The OD should append this to indicate they only performed the post-operative care.
RT/LT – Indicates which eye
79 – Used when the second eye is performed during the global period of the first; Keep in mind that in global period claims, the payment modifiers (54 (surgeon)/55 (OD)) precede both the pricing modifier (79) and anatomical modifier (RT/LT).
24 – Used when a service is performed during the post-op global period but is unrelated to the post-operative care
Finally, a strong partnership between the surgeon’s facility and the provider’s practice is key to ensuring comanaged claims get paid correctly. Set up a process that works and wash, rinse, repeat!
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