General Surgery billing and accounts receivable

General surgery is a modifier specialty. Global periods, staged procedures, unrelated visits and multiple procedures decide most of what pays and most of what does not.

Where the money leaks in general 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.

• Modifier 25 denied on an E/M billed the same day as a minor procedure
• Post-operative visits inside the global period billed as new services
• Modifier 59 used where the payer requires a more specific X modifier
• Multiple-procedure reduction applied to the wrong line, reducing the higher-valued one
• Assistant surgeon billed where the procedure carries no assistant allowance

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 general 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-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: “Modifier 25 denied on an E/M billed the same day as a minor procedure”
• CO-4 — Modifier and code disagree
  The code and the modifier disagree, or a modifier the payer required was not there.
  Recovered by being corrected and resubmitted. Matched from: “Modifier 59 used where the payer requires a more specific X modifier”

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 general surgery AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions