athenahealth’s April Rule of the Month
Welcome to the April Rule of the Month. This month we introduce a rule which addresses the medical necessity of assistant surgeons.
Every surgical practice deals with the issue of assistant surgeon requirements; is an assistant surgeon considered medically necessary for the procedure and therefore reimbursable? The Center for Medicaid and Medicare Services (CMS) National Physician Fee Schedule categorizes the need for an assistant surgeon based on the procedure being performed. Complex or lengthy surgeries may warrant an assistant surgeon and therefore the charge for an assistant surgeon may be paid or may require supporting documentation to be paid. If the procedure does not warrant an assistant surgeon the charge will most likely be denied.
The issue:
Medical billing for assistant surgeons is not an easy task. Even with the CMS guidelines in place, some payers have their own rules for assistant surgeon billing. United Healthcare and Aetna, for example, do not follow all of the CMS guidelines. This makes Assistant Surgeon billing a complex job.
The solution:
athenahealth recognizes the need to help clients decide when it is appropriate to charge for assistant surgeons. The athenahealth Rules Engine compares the CMS fee schedule with the procedure entered on the claim to determine if the assistant surgeon is considered medically necessary by CMS and payer rules. The Rules Engine will even alert clients if additional documentation is needed to support and advocate for the assistant surgeon charge. This happens prior to claim submission in an effort to help athenahealth clients improve the speed of adjudication and reimbursement.
How it works:
The athenahealth Rules Engine offers claim advice containing the facts needed by the practice to decide how to code based on the medical record. The practice is able to look at the procedure and determine the proper next steps such as if:
- Any documentation needs to be attached
- The charge should be entered as $0 (for tracking in the system)
- The charge should be deleted
The athenahealth Rules Engine also offers claim advice regarding assistant surgeon modifiers to help our clients.
The assistant surgeon claim advice rule is another example of how athenahealth works to help our clients. The benefit of an advice rule is that the Rules Engine provides you with the vital information and advice for the claim (based on industry standards) but ultimately lets you make the judgment call. As you can see, in a hectic surgical practice this claim advice is very helpful. Stay tuned for next month’s athenaPulse Rule of the Month.