Cardiothoracic Surgery billing and accounts receivable

Cardiothoracic claims are few, large and heavily scrutinised. Assistant surgeons, co-surgeons and global periods account for most of what is lost.

Where the money leaks in cardiothoracic surgery

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Assistant-at-surgery denied because the payer does not allow one for that procedure
• Co-surgeon modifier used without documentation from both surgeons
• Services inside the 90-day global period billed separately
• Device and implant charges denied for missing invoice or serial documentation
• Prior authorization absent for a procedure the payer treats as scheduled rather than urgent

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working cardiothoracic surgery, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Co-surgeon modifier used without documentation from both surgeons”
• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Co-surgeon modifier used without documentation from both surgeons”
• CO-151 — Too many services billed
  The payer accepts the service but not the quantity or the frequency at which it was billed.
  Recovered by being appealed with clinical documentation. Matched from: “Device and implant charges denied for missing invoice or serial documentation”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Prior authorization absent for a procedure the payer treats as scheduled rather than urgent”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a cardiothoracic surgery AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions