Transcatheter Aortic Valve Replacement (TAVR) (also called Transcatheter Aortic Valve Implantation (TAVI) is a procedure which involves replacement of a thickened and narrowed aortic valve of the heart through the blood vessels. Located between the left lower heart chamber (left ventricle) and the body’s main artery (aorta), the aortic valve regulates the blood flow from the heart to the body. If the aortic valve doesn’t open correctly, blood flow from the heart to the body gets reduced. Billing and coding for this cardiac condition can be challenging. Outsourcing these tasks to a reputable cardiology medical coding company is a great option for cardiologists to document TAVR as well as other treatment options and get reimbursed on-time.
TAVR Procedure – How Is It Performed and What Does it Involve?
TAVR is generally an option for people who have aortic stenosis (that causes signs and symptoms), have an intermediate or high risk of complications from surgical aortic valve replacement, have an existing biological tissue valve (but it isn’t working well anymore) and who can’t undergo open-heart surgery. Potential risks of TAVR may include – blood vessel complications, problems with the replacement valve (such as the valve slipping out of place or leaking), severe bleeding and infections, stroke, heart rhythm problems (arrhythmias) or even death. There are two different approaches – Transfemoral approach and Transapical approach for TAVR procedure. Transfemoral approach does not require a surgical incision in the chest and therefore involves entering through the femoral artery (large artery in the groin). Transapical approach, on the other hand, is a minimally-surgical procedure wherein small incisions are made in the chest area. The incisions are made through a large artery in the chest or through the tip of the left ventricle (the apex). Physicians in certain cases may use other approaches to access the heart. Imaging techniques may be used to guide the catheter through the blood vessel, to the heart and into the aortic valve. Upon positioning the new valve, a balloon is inflated on to the catheter’s flip (to expand the replacement valve in to the correct position) and the catheter is removed. The procedure can cause infections (from bacteria in the mouth) and therefore it is extremely important to maintain adequate dental and personal hygiene.
Medicare Coverage for TAVR
Transcatheter Aortic Valve Replacement (TAVR) is covered for the treatment of symptomatic aortic valve stenosis. CMS offers coverage for TAVR under Coverage with Evidence Development. In 2012, CMS released a National Coverage Determination (NCD) that provides details of the qualifications of the physicians who perform TAVR and the patients who benefit from the procedure. Below listed are the top coverage criterions specified in the National Coverage Determination (NCD) –
The procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval (PMA) for that system’s FDA-approved indication.
All TAVR cases must be enrolled in the national transcatheter valve therapy (TVT) registry.
The patient who is planning to undergo a TAVR must be under the care of a multi-disciplinary team of cardiologists both preoperatively and postoperatively.
Both a cardiac surgeon and an interventional cardiologist must independently examine the patient face-to-face and evaluate the patient’s suitability for surgical aortic valve replacement.
IVR cardiologists and cardiac surgeons must jointly participate in the intra-operative technical aspects of TAVR.
Hospitals must perform at least 50 TAVRs and more than 300 percutaneous coronary interventions per year
Applicable Medical Codes for TAVR
Billing and coding for cardiac procedures involves the use of procedure codes and diagnosis codes on the medical claims submitted to health insurers for reimbursement. Relying on the services of a professional and reputable medical coding company that is well-versed in the changing coding guidelines for the cardiology specialty can help in on-time reimbursement.
33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach
33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach
33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (e.g., median sternotomy, mediastinotomy)
33367 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (e.g., femoral vessels) (List separately in addition to code for primary procedure)
33368 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (e.g., femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure)
33369 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (e.g., aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure)
Z00.6 Encounter for examination for normal comparison and control in clinical research program
ICD – 10 Procedure Codes
02RF38Z Replacement of aortic valve with zooplastic tissue, percutaneous approach
02RF38H Replacement of aortic valve with zooplastic tissue, transapical, percutaneous approach
In general, transcatheter aortic valve replacement (TAVR) may provide relief to the symptoms of aortic valve stenosis. However, adopting healthy lifestyle habits like – regular exercise, quitting the habit of smoking, making healthy diet choices, controlling stress and maintaining a healthy body weight can help prevent the reoccurrence of cardiac disorders in the long run. As mentioned above, cardiology medical billing and coding can be challenging. IVR cardiologists, cardiac surgeons and other specialists performing a TAVR procedure can consider the support of a reputable physician billing company to report their services accurately on the medical claims.
A leading medical billing and coding company in the U.S., Outsource Strategies International is proud to announce that our articles – “Here Comes the Sun: Know the Difference Between Heat Stroke and Heat Exhaustion” and “Summer Fun: Be Aware of Sunburns – ICD-10” have been published in the May / June 2022 issue of BC Advantage Magazine.
Heat illnesses range from mild to severe. The sun’s UV rays are strongest during summer months and over exposure to these rays can cause sun burn and other heat-related illnesses such as – heat rash, heat cramps, heat exhaustion or heat stroke. Heat-related illnesses are preventable, with proper prevention tips.
OSI’s article on sunburn is authored by Amber Darst, the company’s Solutions Manager in the Practice and Revenue Cycle Management Department. The article on the differences between heat stroke and heat exhaustion is authored by Meghann Drella, Senior Solutions Manager in the Healthcare Division of the same department.
Our article on sunburn, discusses the types of sunburn degrees, ICD-10 and CPT codes for sunburns, necessary steps to prevent excessive UV exposure, and some first aid tips. The other article discusses the signs, symptoms, diagnosis, treatment options of heat exhaustion and heat stroke. This article also lists the ICD-10 codes to report these heat-related illnesses.
BC Advantage Magazine is a highly acclaimed, CEU-approved national online healthcare publication and the largest independent resource provider in the industry for medical coders and billers, healthcare auditors, practice managers, compliance officers, and clinical documentation experts. It features articles written by industry professionals on a wide range of subjects such as billing/coding, legal issues, marketing, business building, career advantage, coders 20/20, news, reviews and more.
“As a company that has been providing medical billing, coding and other support functions such as insurance verifications and authorizations for medical offices in the USA for more than 17 years, we are proud of our accomplishments. Getting featured in BC Advantage Magazine validates our company’s culture of hard work and customer service,” says Rajeev Rajagopal, President of Managed Outsource Solutions.
OSI has years of experience in providing medical billing and coding services for all medical specialties, including dermatology. We serve a vast clientele – individual physicians, physician groups, free standing diagnostic facilities, multi-specialty groups, clinics, long-term care facilities, acute care facilities, and hospitals. Our coding and billing experts have a clear understanding of the changing coding standards and reimbursement policies of all major government and private insurance companies. Our experience and expertise in the industry have been continuously recognized and featured by BC Advantage Magazine.
Umbilical hernias are common and occur in 10 to 20 percent of all children in the US. It is a medical condition that occurs at the umbilicus when a loop of the intestine pushes through the umbilical ring.
Healthcare providers diagnose umbilical hernia during the physical examination of the abdomen. They are harmless, but if left untreated they can grow and become painful over time. Umbilical hernia can be treated and repaired through surgery. Accurate documentation using ICD-10 and CPT codes is essential for effective revenue cycle management. A medical coding company can ensure that the treatment rendered is appropriately coded so that your medical claims are reimbursed in a time-bound manner.
ICD 10 Codes to Report Umbilical Hernia
K42: Umbilical hernia
K42.0: Umbilical hernia with obstruction, without gangrene
K42.1: Umbilical hernia with gangrene
K42.9: Umbilical hernia without obstruction or gangrene
CPT Codes to Report Umbilical Hernia
Open hernia repair
49491: Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; reducible
49492: Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated or strangulated.
49495: Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible
49496: Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy, incarcerated or strangulated
49500: Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible
49501: Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy, incarcerated or strangulated
49505: Repair initial inguinal hernia, age 5 years or older; reducible
49507: Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated
49520: Repair recurrent inguinal hernia, any age; reducible
49652: Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible
49653: Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when important); incarcerated or strangulated
Additional codes related to hernia repair
15734: Muscle, myocutaneous, or fasciocutaneous flap; trunk
20680: Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate)
+49568: Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair)
On-time reimbursement from insurers for any medical specialties mainly requires the services of skilled medical coders and billing specialists. They must be knowledgeable in the medical coding terminology that includes the names of conditions and illnesses, treatments and medications or procedures and vocabulary related to medical codes. An experienced medical billing and coding company in the U.S., our team is up to date with the changing coding standards. They are familiar with the coding and billing terminologies and vocabulary, diseases and their diagnosis, and treatment options.
Check out some medical coding vocabulary & key terms:
Current Procedural Terminology (CPT) is a medical code set to report medical, surgical, and diagnostic procedures and services. These codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review.
The CPT code set is divided into three Categories. Category I codes that describe medical procedures, technologies and services have descriptors that correspond to a procedure or service. Category II includes supplemental codes for performance management, and Category III is temporary alphanumeric codes for new and developing technology, procedures and services.
ICD or International Classification of Disease codes help classify diseases, injuries, and causes of death. These codes ensure proper treatment and correct charges for any medical services provided.
The ICD code set is maintained by the World Health Organization (WHO) and distributed in countries across the globe. In the U.S., ICD codes are overseen by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS).The latest version of the ICD, ICD-11 came into effect on 1st January 2022.
When the healthcare provider submits claims to an insurance company for reimbursement, each service is described by a CPT code, which is matched to an ICD code. If the two codes don’t align each other, the company may deny payment.
Maintained by CMS, Healthcare Common Procedure Coding System (HCPCS) is a collection of standardized codes that represent medical procedures, supplies, products and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers.
HCPCS is divided into two subsystems, Level I and Level II. Level I HCPCS includes Current Procedural Terminology codes (CPT) for hospital providers, which consists of five numeric digits. Level II HCPCS codes include a letter followed by four numeric digits. These codes are used to report non-physician services like ambulance rides, wheelchairs, walkers, durable medical equipment, and other medical services. HCPCS codes include A-codes, C-codes, G-codes, J-codes, and Q-codes.
Evaluation and Management Codes
Evaluation and Management, or E&M codes are used to describe the assessment of a patient’s health and the management of their care. Reviewed on a periodic basis by the AMA, Evaluation and management codes are a part of the CPT-4 system. E&M codes range from 99201 – 99499.
Modifiers are two-character codes that are added to a CPT® or HCPCS Level II code to report any necessary changes in the definition of the procedure. CPT codes have numeric modifiers, while HCPCS codes have alphanumeric modifiers. Modifiers are added at the end of a code with a hyphen. It provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.
Upcoding is coding or reporting for a higher-level service or procedure than what is actually done, to increase the reimbursement rate. At the same time, downcoding is using a code that is of less dollar value than the actual procedure performed.
When used right, Z codes can improve claims accuracy and specificity, and help to establish medical necessity for treatment. These codes, found in Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) of the ICD-10-CM code book, can be used in any healthcare setting. Z-codes describe circumstances outside of injury or disease that cause a patient to visit a health professional.
The Z codes (Z00-Z99) provide descriptions for a situation wherein the symptoms a patient displays do not point to a specific disorder but still warrant treatment.
When an insurer denies payment for any treatment provided, providers can appeal by objecting to the decision made and requesting to re-consider the claim.
Billing specialists at reliable medical coding companies can ensure that your practice has only fewer accounts receivable and unresolved dental claims.
In medical billing, accounts receivable refers to the outstanding reimbursement owed to providers for issued treatments and services, whether the financial responsibility falls to the patient or their insurance company.
AR management is a collection of processes such as identifying denied/unpaid claims, re-filing the corrected claims, minimizing AR days, and eliminating aged AR.
Advance Beneficiary Notice (ABN)
ABN isa notice given by a doctor or a supplier to Original Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case. It is used to get reimbursement for the services provided to the beneficiary of the Original Medicare Plan.
Explanation of Benefits (EOB)
An Explanation of Benefit (EOB) refers to a statement generated by a health insurance provider describing what costs they will cover for the medical care received by the patient. The EOB is generated when the provider submits a claim for the services rendered.
Medical coding and billing specialists play a key role in evaluating medical records and Charge Tickets to ensure completeness, accuracy, and compliance with the right ICD and CPT codes as well as correct modifiers. They should have good knowledge in medical terminologies, anatomy and physiology details, and state and federal Medicare reimbursement guidelines. Professional medical billing and coding companies providing medical coding services will make sure to provide their staff regular training in all regards.
Earning sufficient revenue to cover overhead expenses and provide quality care is a major challenge for healthcare practices and hospitals. In addition to numerous declining reimbursements, government regulations, and third-party requirements, medical billing denials are the main concern for sustaining a successful medical business. Denials and delayed or incorrect reimbursements from payers are the results of inefficient coding and billing. Getting professional support is a viable solution. There are different types of denials and partnering with an experienced physician billing company can help prevent them.
Change Healthcare: Most Medical Billing Denials are Preventable
Findings of the Change Healthcare 2020 Revenue Cycle Denials Index show that about 85% of denials are preventable, but nearly a quarter (24%) of these cannot be recovered. The analysis revealed worrying statistics:
The average denials rate is up 23% since 2016, topping 11.1% of claims denied upon initial submission through the third quarter of 2020
Since the onset of COVID-19, denials have risen 11% nationally.
The highest denial rates are in regions with the highest first-wave of COVID-19 outbreaks
Half of the denials are caused by front-end revenue cycle issues (Registration/Eligibility, Authorization, Service Not Covered).
The top denials cause remained constant since 2016: Registration/ Eligibility, approaching 27% of denials.
Common Causes of Medical Billing Denials
Claim denials come under two categories: hard and soft. A hard denial is when the insurance refuses to pay the claim because the service is not covered. Even appeals may fail to reverse or correct a hard denial, leading to lost revenue. Soft denial is when an insurance company reviews a claim and rejects payment due to an issue like missing data or lack of documentation. Soft denials are temporary and have the potential to be revered if the provider makes the necessary corrections on the claim or provides the required information. Physician billing companies are well aware of the reasons for claims denials and help practices implement proactive strategies to prevent them.
Missing or invalid claims information: A denial can be triggered when a claim form is incomplete. Missing or wrong data on a claim could be everything from social security numbers to plan codes, modifiers, addresses, and other demographic and technical errors. The Change Healthcare 2020 study found that missing or invalid claim data accounted for 17.2% of medical billing denials and 26.6% are caused by patient registration/eligibility issues. Insurance verification plays a key role in preventing eligibility denials in medical billing.
Medical coding errors: Coding issues in the bill will result in a payment denial. Errors include: missing codes, wrong codes, using the wrong coding system for the insurer, standard of care does not align with the included diagnosis codes, or undercoding and overcoding which occurs when the claim contains higher-level CPT or HCPCS codes than what is supported by medical necessity, medical facts, or the provider’s documentation.
Duplicate claim or service: This type of denial occurs when claims are resubmitted for a single encounter on the same date by the same health care provider for the same beneficiary for the same service. Duplicates account for up to 32% of Medicare Part B claim denials.
Lack of coordination of patient benefits: Some patients may have multiple payers. Claims must be submitted to the primary insurance first, and depending on the need, the balance is submitted to the patient’s secondary and tertiary insurances. Reasons why coordination of benefit denial occurs include:
Estimate of benefits is missing
Another insurance is considered primary
The member has not updated additional insurance information
Coordination of benefits is necessary to determine which payer is the primary, secondary, and tertiary insurance to ensure that the correct payer’s pay and duplication of payments is prevented.
Service not covered: This type of denial occurs due to neglecting to perform insurance verification to determine if the procedures and services being provided are covered under the patient’s current benefit plan. Service Not Covered accounts for 57.7% of claims denials, according to the Change Healthcare 2020 Revenue Cycle Denials Index.
Medical necessity: A top denial reason (accounting for 6% according to Change Healthcare), medical necessity denials are hard denials. The reasons for this type of denial are:
Inpatient criteria have not been met
Inappropriate use of the emergency room
Length of stay
Inappropriate level of care
Medical necessity denials need an appeal to request reconsideration
Service already adjudicated: This type of denial occurs when a service is already included in another claim/payment which was already settled.
Authorization/Pre-Certification: Payers have specificprior authorization requirements and when these are not met, claims are denied. Moreover, these rules tend to change frequently and unexpectedly and practices would have to resubmit forms for denied claims in accordance with the payer’s updated specifications.
Time limit for filing has expired: Insurance companies have strict time limits for claim submission, including a deadline to submit reworked claims and reviews to check codes and coverage. Inpatient medical coding errors accounted for 81% of complex claim denials in the fourth quarter of 2015, and correcting them can cause delays that go past the submission deadline (https://itechdata.ai/).
Strategies to Prevent Claim Denials
Though most medical billing denials are preventable, the problem continues unabated. Medical Economics reported on a study that identified the factors responsible for the rise in claim denials as “a lack of denials resources, such as expertise to support appeals and data for root cause analysis, as well as staff attrition and training, growing denials backlog, and legacy technology”.
Implementing a denials-prevention strategy that includes the following can help reduce the risk of claim denials:
Know the types of denials your practice is receiving
Track denials – identify the source and root cause of denials
Monitor clean claims ratio
Prioritize medical billing and coding oversight
Determine what remedial measures to take and where they will have the greatest impact
Utilize advanced analytics and artificial intelligence
Last but not least, choose the right partner – a reliable physician billing service provider that will provide dedicated support to manage your revenue cycle. An expert will work with you to identify problematic trends in denials and reduce your denials by implementing best practices for medical billing, coding, and insurance verification and authorization.
The revenue cycle management (RCM) process comprises many complex components – from patient scheduling and registration and insurance verification to medical billing and coding and claim submission. Dealing with these tasks along with patient care delivery is not easy for medical practices and many are choosing to outsource RCM tasks. An experienced medical billing and coding company can help practices navigate their way through the challenges of complex billing and coding requirements, payer rules and evolving regulatory requirements. Partnering with a professional, HIPAA compliant medical billing and coding company can help physicians and their staff to focus on care and improving the patient experience. Today, outsourcing medical billing is proving the best option for physician offices, family practices, clinics, and hospitals to manage their billing and coding tasks.
Medical billing outsourcing provides diverse benefits for practices such as –
Providers and front office staff get more time to focus on patients
Increased cash flow
Reduced risk of billing and coding errors
Appropriate and timely reimbursement
Increase patient satisfaction
According to a Grand View Research report, the global medical billing outsourcing market size which was valued at USD 10.2 billion in 2020 is expected to expand at a compound annual growth rate (CAGR) of 12.66% from 2021 to 2028. Key factors driving the market include the increasing usage of billing and medical coding procedures in revenue cycle management and frequent revisions in the classification systems for medical coding. The front-end component of RCM consists of patient scheduling and registration, insurance eligibility verification and pre-authorization services. Back-end RCM components comprise medical coding and billing which covers charge posting, claim review and submission, payment posting, AR (accounts receivable) management and collections.
Key factors to look into for a medical billing company
Consider experience in your speciality
Consider the company’s experience, especially in medical billing for your speciality. Different specialities come with their own unique billing and coding challenges. Make sure the team can meet the claim submission requirements of your speciality. Check customer testimonials on the company’s website.
Availability of expert resources
Make sure that the company’s team includes billing and coding specialists who are AHIMA or AAPC certified. They need to be familiar with the coding and billing rules, terminologies and all conditions, diagnosis and treatment procedures related to your speciality.
Billing and coding training
Make sure the company provides regular training for their staff. The team must have good knowledge about current ICD, CPT, HCPCS and CDT coding and be up-to-date on industry guidelines and regulations.
Look for comprehensive medical billing services
Choose a medical billing company that will handle all aspects of revenue cycle management — from patient appointment scheduling to claims submission, collections, and AR follow-up. Also, find out how quickly they will begin processing claims.
Patient data security is a major concern for any healthcare practice. And so, make sure that the company you are partnering with is HIPAA compliant. This is important to ensure the confidentiality of sensitive patient data and prevent personal health information (PHI) from getting into the wrong hands. Enquire about the company’s data security policies and the processes they use to make sure your information is protected.
Assess cost before signing up
Make sure you know how the billing company charges for its services. Evaluate their budget and ensure there are no hidden fees before you sign up.
Check how insurance verification is performed
The company should have an experienced team of dedicated insurance verification specialists with excellent skills in verifying patient eligibility for all specialities. The team must be able to confirm insurance eligibility ahead of the patient visit.
Denial management support
Denied claims are a key concern for hospitals, health systems and physician practices. The medical billing company you partner with must provide proper claims denials management and prevention strategies to reduce denials and increase the success rate of claims appeals.
Technology is another important factor to consider when choosing a medical billing service provider. The company must be able to work with your software or use its own software to manage the billing process.
Managing billing, coding, claims submission, AR management and other related tasks in-house can be time-consuming, difficult and costly. Experienced medical billing companies can help practices manage these tasks efficiently, reduce denials and maximize revenue.