Tips for Verifying Pricing on Facility Claims

Reimbursement for facility claims depends on a number of factors, including contractual rates and correct coding. To gain a more accurate estimate of reimbursement for facility claims, follow these best practices:

Pre-Submission Review

• Verify the member's product (e.g., Medicare Advantage vs. Commercial). Different product lines often have different benefits and reimbursement rules.
• Are your billing NPI and taxonomy accurate and do they match the services you are billing?
• Have you confirmed your vendor or your offsite reviewer has the appropriate contractual rates?

Coding Accuracy – CPT/HCPCS, ICD-10, and Modifiers

• Are all CPT/HCPCS codes appropriate for the services rendered and supported by documentation?
• Are all ICD-10 diagnosis codes specific, accurate, and consistent with the CPT/HCPCS codes?
• Are all necessary modifiers (e.g., 25, 59) correctly appended and justified?
• Have NCCI (National Correct Coding Initiative) edits been considered?

Contractual Rate and Billing Alignment

• Verify rate sheets / compensation pages in your contracts and compare them to how you billed, i.e., revenue codes, HCPCS/CPT codes, and determine if your billing matches what you are configured for in our system.
• Verify if there were recent updates to your rates. Out-of-date rate information can be a common source of discrepancies.

Look for more tips on verifying facility pricing in January Provider News.