Vascular Surgery billing and accounts receivable

Vascular work concentrates money in a small number of large claims, and the two things that decide payment are the imaging that justified the intervention and the modifiers on the intervention itself.

Where the money leaks in vascular 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.

• Endovascular procedures denied for medical necessity criteria in the coverage policy
• Component coding used where a bundled code exists, or the reverse
• Vein procedures denied as cosmetic without documented conservative therapy
• Multiple-procedure reductions applied incorrectly across a single operative session
• Imaging supervision and interpretation billed by the wrong entity

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 vascular 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: “Endovascular procedures denied for medical necessity criteria in the coverage policy”
• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Endovascular procedures denied for medical necessity criteria in the coverage policy”
• 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: “Component coding used where a bundled code exists, or the reverse”

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

Questions