The RCxRules Blog

Keeping Pace: Surgical Specialty Requirements

coding for specialty billing requirements

On top of the usual billing and coding challenges faced by all providers, specialty practices across the country have additional requirements to confront. Practices focused on orthopedics, ophthalmology, gastroenterology, ENT, OB/GYN, urology, and general surgery, for example, must account for various surgical requirements to ensure accurate and timely reimbursement.

Billing for surgeries presents various challenges. Billing and coding professionals must maintain and review clinical documentation while adhering to strict compliance. There are vast numbers of surgical CPT codes that represent numerous procedures, services, and locations of care.

Fortunately, there is a way to simplify and automate this complex process. To guarantee accurate reimbursement in the most efficient way, specialty practice billing for surgeries should leverage the RCxRules Revenue Cycle Engine and employ the best practice rules detailed below:

Global Period Rule

Keeping a record of global periods for various procedures can be confusing, and mistakes can lead to costly denials. The RCxRules Revenue Cycle Engine recognizes the global period for every minor and major surgical procedure code and helps to prevent denials.

If a procedure code that is included in the global surgical reimbursement period is mistakenly billed, this rule will identify it and send a task for review.

Missed Surgery Rule

This unique rule seems simple but can catch extremely costly mistakes. Every time the post-op follow-up visit CPT code is billed, the engine looks back through the previous global period to make sure the original surgery was also billed. If not, it creates a task for review so the missed surgical CPT code can be captured.

Duplicate Charge Checking Rule

This rule tackles one of the top denials—duplicate charges. Duplicate charges sneak into the revenue cycle system in myriad ways. A provider may edit information in the clinical system that triggers a new patient charge, for example.

The duplicate charge checking rule reviews the patient history for instances of the same procedure on the same date of service. The rules engine looks for the patient’s unique identifier, the rendering provider, the date of service, and the CPT code. If these four items match across two separate claims, the rule will send a task for review.

Frequency Rule

Many procedures and visits have frequency limitations. The rules engine monitors these procedures and reviews patient history for corresponding codes. If a frequency limit is exceeded, a task will be created for review.

To learn more about how RCxRules can help specialty practices simplify their billing and coding to allow for more accurate and timely reimbursement, set up a 1:1 meeting today.


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