Pulmonology and Critical Care billing and accounts receivable

Pulmonology splits between office testing with its own component rules and critical care billed by time, and the two are audited for completely different things.

Where the money leaks in pulmonology and critical care

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.

• Pulmonary function tests billed with technical and professional components reversed
• Critical care time billed without the time and the content of that time documented
• Sleep study interpretation billed without the qualifying supervision or credentials
• Ventilator management billed alongside an E/M the payer treats as bundled
• Oxygen and equipment orders denied for missing qualifying test results

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 pulmonology and critical care, 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-B7 — Provider not eligible that day
  A credentialing or enrollment problem rather than a claim problem: nothing this provider bills to this payer will pay until it is fixed, and it is rarely one claim.
  Recovered by being fixed in credentialing, not on the claim. Matched from: “Sleep study interpretation billed without the qualifying supervision or credentials”
• CO-45 — Charge exceeds the fee schedule
  A contractual write-off rather than a denial. It only becomes a problem when the allowed amount is wrong.
  Recovered by being checked against the contract before any work is done. Matched from: “Ventilator management billed alongside an E/M the payer treats as bundled”

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 pulmonology and critical care AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions