Optum Product Assessment for Client Claims Manager Client Product Assessment Report Professional Editing September 2014 Confidential Copyright (c) 2014 OptumInsight CPT codes, descriptions, and other CPT material copyright (c) 2013 American Medical Association 1 Optum Product Assessment for Client Return on Investment Based on the data received, and using conservative calculation methodologies (which are further delineated in this document), the potential calculated return on investment (ROI) is 5.1:1. For unbilled revenue and expenses relating to resubmission of denied claims, the Commercial dataset identified $377,566, the Medicaid dataset identified $135,764, and the Medicare dataset identified $719,416. This results in a Total Annual Impact of $1,232,746 divided by the annual system cost of $241,583. Details of these findings are outlined in the Annual Cost Justification section of this report. Annual Cost Justification The following table summarizes the annual opportunity costs and the total dollars that Claims Manager could potentially return to your organization. Client Claims Manager Projected ROI Period Findings Annualized Findings $57,589 $115,178 $131,200 $262,400 Category I Non-billed Code Edits $10,972 $21,944 Category II Resubmission/Review Edits $56,899 $113,798 Category I Non-billed Code Edits $48,580 $97,160 $311,133 $622,266 Type of Edit Category I Non-billed Code Edits Commercial Category II Resubmission/Review Edits Medicaid Medicare Category II Resubmission/Review Edits $1,232,746 (Annual Impact) RETURN ON INVESTMENT (ROI) 5.1:1 $241,583 (Annual System Cost) Table Notes: Using conservative calculations, the resubmission costs were calculated using $25 per claim. This estimated cost includes the typical cost of labor to pull the patient’s record, compare the documentation to the codes assigned, make a decision regarding a more appropriate code combination, and finally the costs tied to actual resubmission of the claim to the payer. Note: Estimated typical cost of $25 to resubmit a claim is a value calculated by the American Medical Association Practice Management Center (PMC). Standardizing CPT Codes, Guidelines and Conventions, Administrative Simplification White Paper. May 19, 2009: Page 7. Confidential Copyright (c) 2014 OptumInsight CPT codes, descriptions, and other CPT material copyright (c) 2013 American Medical Association 2 Optum Product Assessment for Client Client First Pass Rate Optimization LCD/NCD 6.4% Clean Lines 96.5% Errored Lines 3.5% General Coding 90.3% Validation 3.3% Based on the sample provided, Category II Claims Manager edits identified errors that would have delayed reimbursement on 29,699 out of 839,260 claim lines (3.5%). Category III 26.4% Clean Lines 89.5% Lines with Edits 10.5% Category IV 35.0% Category II 33.7% Category I 4.9% Based on the sample provided, the four categories of Claims Manager edits identified errors, potential errors, and informational requirements on 88,130 out of 839,260 claim lines (10.5%). Confidential Copyright (c) 2014 OptumInsight CPT codes, descriptions, and other CPT material copyright (c) 2013 American Medical Association 3 Optum Product Assessment for Client Edit Detailed Results All Lines of Business Category I – Non-billed Code Edits Edit Description VEN Venipuncture SUB Occurrences Billed $ Non-billed Occurrences Non-billed $ 1,083 $13,961 977 $2,935 Add-on Procedure without Primary Procedure 910 67,149 910 50,079 mVP Medicare Venipuncture 886 13,724 809 2,439 mMPN Medicare Pneumococcal Vaccines 530 4,727 530 12,081 INJ1 Injection Procedure Not Reported with Reported Supply 348 149,419 199 4,565 mMHB Medicare Hepatitis B Vaccines 244 5,467 244 5,570 mMFL Medicare Influenza Vaccines 135 1,906 135 3,083 mSB Medicare Add-On Procedure without Primary Procedure 130 79,886 130 36,389 sOG Medicare Outside Global Period 6 0 0 0 OGP Outside Global Period 2 174 0 0 mOG Medicare Outside Global Period 1 0 0 0 EST Established Patient Code for New Patient INJ Injected Supplies Totals (17,929,292) (1,375) (142,897) 4,312 $336,413 (157,742) 3,934 $117,141 The VEN edit (Venipuncture) occurs on claims where a code for a lab test that may require a blood specimen was billed but there was no code on the claim for the actual blood draw, for example 36415 Collection of venous blood by venipuncture. CPT code 83036 Hemoglobin; glycosylated (A1C) accounted for 44% of the occurrences. CPT code 85018 Blood count; hemoglobin (Hgb) accounted for 24% of the occurrences. Provider IDs XXXXX and XXXXX accounted for 9% and 8% of the occurrences, respectively. The SUB edit (Add-on Procedure without Primary Procedure) occurs when an Add-on code on the claim line was billed on a claim without the primary service. HCPCS code G0008 Administration of influenza virus vaccine accounted for 30% of the occurrences. This code should be billed with Vaccines/Toxoids codes 90653-90668, 90673, 90685-90688, or Q2034-Q2039 as the primary procedure. CPT code 90672 Influenza virus vaccine, quadrivalent, live, for intranasal use accounted for 28% of the occurrences. This code should be billed with Immunization Administration codes 90460, 90473, or 90474 as the primary procedure. Provider ID XXXXX accounted for 10% of the occurrences. Confidential Copyright (c) 2014 OptumInsight CPT codes, descriptions, and other CPT material copyright (c) 2013 American Medical Association 4 Optum Product Assessment for Client Category II – Resubmission/Review Edits Edit Description Occurrences Billed $ Resubmit $ mPV Medicare Preventive Vaccines 9,601 $249,317 $171,456 NPD Not a Primary Diagnosis Code 7,069 719,947 125,648 LBI LCD Part B Missing or Invalid Diagnosis 1,529 114,702 27,287 sEV Medicaid Multiple E/M Codes 1,010 216,953 17,913 IAG Diagnosis Not Typical with Patient Age 817 163,139 14,504 MOD Modifier Not Appropriate with Procedure 799 415,213 14,177 mEV Medicare Multiple E/M Codes 711 108,947 12,686 mM51 Medicare Modifier 51 Required 697 584,507 12,456 UOV Unbundle Procedure - Modifier Override 641 201,652 11,355 RDL Repeat Radiology Requires Repeat Modifier 440 56,224 7,833 mUO Medicare Unbundle - Modifier Override 438 147,254 7,811 MFD Typical Daily Frequency Exceeded 361 123,310 6,391 HOV History Unbundle Procedure - Modifier Override 341 65,390 6,056 mN51 Medicare Modifier 51 Inappropriate 310 291,842 5,526 mMOD Medicare Modifier Not Typical for Procedure Code 299 75,881 5,349 GSP Post-Op Surgery by Provider 292 386,562 5,167 LPR Repeat Lab Procedure Requires Modifier 212 6,235 3,781 mEH Medicare E/M and Surgery without Modifier History 190 39,282 3,383 sUO Medicaid NCCI Edit - Modifier Required 173 31,113 3,077 GFP Global Follow-Up by Provider 169 20,104 2,986 mSP Medicare Post-Op Surgery by Provider 162 139,898 2,903 The NPD edit (Not a Primary Diagnosis Code) occurs on lines where the Primary ICD-9 code is not allowed for reporting alone or as a primary diagnosis (i.e., sequenced first). ICD-9-CM guidelines indicate to ‘code first underlying disease’ or ‘nature of the condition’ and use the E or V code for detailed analysis. ICD-9 code V45.01 Cardiac pacemaker in situ accounted for 19% of the occurrences. ICD-9 code V45.89 Other postprocedural status accounted for 14% of the occurrences. Overall, V codes accounted for 96% of the occurrences. Provider IDs XXXXX and XXXXX accounted for 6% and 5% of the occurrences, respectively. The MOD edit (Modifier Not Appropriate with Procedure) occurs on claim lines that contain a modifier that is not appropriate for the procedure code. Many of the procedure/modifier combinations may be appropriate but Optum has not identified a national source to develop those combinations. New Patient Office Visit codes 99202-99205 billed with modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period accounted for 15% of the occurrences. CPT code 36415 Collection of venous blood by venipuncture billed with modifier QW CLIA waived test accounted for 9% of the occurrences. No particular provider trending identified. Confidential Copyright (c) 2014 OptumInsight CPT codes, descriptions, and other CPT material copyright (c) 2013 American Medical Association 5
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