From the Division of Pediatric Surgery, Department of Surgery, Children's Medical Center Dallas/University of Texas Southwestern Medical Center, Dallas, TX (Ryan, Mutore, Gillory, Chung, Pandya).
the Department of Clinical Revenue, University of Texas Southwestern Medical Center, Dallas, TX (DeLeon).
J Am Coll Surg. 2023 Apr 1;236(4):630-635. doi: 10.1097/XCS.0000000000000559. Epub 2023 Jan 12.
Despite minimal coding and billing training, surgeons are frequently tasked with both in clinical practice. This often results in denials for reimbursement based on incorrect or insufficient documentation, and reduced collections for work performed. We sought to evaluate how to correct these deficits while improving reimbursement for the most frequently rejected procedures at a high-volume academic center.
Hospital billing data were analyzed for a 4-year period (2018 to 2021) to determine the CPT code denials with the largest overall cost. The denials were then stratified according to payor, reason for denial, and preventability. Assigned ICD-10 codes were categorized based on specificity as related to the procedure. The distribution of denials according to ICD-10 specificity was evaluated using the chi-square test.
A total of 8,833 denials representing $11,009,108 in billing were noted during the study period. The CPT code 44970 (laparoscopic appendectomy) was the code associated with the largest financial impact, representing 12.8% of the total denied amount ($1.41M). Of the 823 denials for CPT 44970, 93.3% were associated with nonspecific ICD-10 codes, whereas only 42.0% had been associated with procedure-specific ICD-10 codes. Of the patients with nonspecific codes, 80.7% of denials were due to criteria that could be remedied with supplemental information or timely filing, representing $1,059,968 in collections.
This is the first study to systematically evaluate a pathway for using denial data to improve collections for work performed at a high-volume academic pediatric surgery practice. Using this methodology, targets for improvement in coding and/or documentation can be identified to improve the financial performance of a surgical department. This study also provides evidence that association with nonspecific diagnostic codes is correlated with initial denial of payment by insurance companies.
尽管外科医生在临床实践中只接受过很少的编码和计费培训，但他们经常需要同时进行这两项工作。这通常会导致由于文档不正确或不充分而导致报销被拒绝，并且完成的工作收入减少。我们试图评估如何纠正这些缺陷，同时提高高容量学术中心最常被拒绝的程序的报销率。
对 4 年期间（2018 年至 2021 年）的医院计费数据进行分析，以确定 CPT 代码拒绝中总成本最高的代码。然后根据付款人、拒绝原因和可预防程度对这些拒绝进行分层。根据与程序的相关性将分配的 ICD-10 代码进行分类。使用卡方检验评估根据 ICD-10 特异性分布的拒绝情况。
在研究期间共记录了 8833 笔拒绝付款，总计 11009108 美元的计费。CPT 代码 44970（腹腔镜阑尾切除术）与最大的财务影响相关，占总拒绝金额的 12.8%（141 万美元）。在 823 笔 CPT 44970 的拒绝中，93.3%与非特异性 ICD-10 代码相关，而只有 42.0%与特定程序的 ICD-10 代码相关。在具有非特异性代码的患者中，80.7%的拒绝是由于可以通过补充信息或及时提交来解决的标准，代表可收回 1059968 美元。
这是第一项系统评估使用拒绝数据来提高高容量儿科手术实践完成工作的收款的方法的研究。使用这种方法，可以确定改进编码和/或文档的目标，以提高外科部门的财务绩效。本研究还提供了证据，表明与非特异性诊断代码的关联与保险公司最初拒绝付款有关。
