Best Practices for Molecular Billing Documentation

One of the main catalysts for denied medical billing claims is incomplete or inaccurate documentation, and complex claims often demand more complex documentation. Consider molecular diagnostic testing claims. These claims are rejected at a higher rate than others, largely because of nuanced documentation requirements. Even when providers think their claims are accurate and complete, payors frequently find mistakes to halt claims before reimbursement approval.

The broad scope of molecular billing

Does the patient’s insurance cover familial DNA testing? How do you code an employer-mandated drug test? What’s the modifier for multiple tests of the same type? In the world of lab testing, numerous variables are involved, making molecular diagnostics claims anything but simple.

Between the lab test(s), the Current Procedural Terminology (CPT) code and any modifiers, the patient, and the insurance — as well as the chain of custody with contracting third-party labs — molecular diagnostics claims are prone to mistakes. Typically, something as simple as a wrong code, incorrect documentation, or missing information will bounce a claim back to the provider.

Often, providers are stuck in the middle of an unforgiving tug of war. They rely on lab tests to diagnose patients or determine the next step in treatment, but they’re left waiting on reimbursements due to denied claims. In the middle, cash flow suffers.

Best practices for molecular billing

Providers have the responsibility to do everything they can in filing complete, accurate, timely claims — and to jump on denials as soon as they bounce back. Here’s a look at some documentation best practices to ease the stress associated with molecular billing:

• Code all procedures accurately. Ensure codes are accurate, complete, and relevant to the diagnosis. Check with both labs and payors to determine appropriate coding protocol and educate revenue cycle managers and on-staff medical coders on how to classify and code common procedures accordingly.
• Verify patient information upfront. Accurate patient information spans their identifying information, insurance coverage, medical history, and other relevant data. Ideally, this process will also help confirm payor responsibility and provide insight into the lab test’s medical necessity or relevance.
• Understand coverage and policy. Insurance stipulations can be a claims killer. Knowing what’s covered vs. noncovered by the payor can prevent billing mistakes while also creating cost transparency for patients.
• Review and verify, before and after. Establish a process for vetting and reviewing information as it’s entered, as well as before the claim goes out. In the case of denials, seek clarity on the cause of denial and develop a process for reverifying or updating information.

There is no silver bullet for filing a perfect claim every time. The sheer variability of molecular diagnostic testing makes prescriptive claims virtually impossible. Instead, build strong frameworks around billing for these claims — starting with documentation. Although this will require an upfront investment of time, it’s quickly justified in the reimbursements to follow thanks to fewer denials.

Complex doesn’t mean impossible

You’ve checked and double-checked a claim, verified everything, and still it was denied. The frustration is palpable! Remember, claim denials for molecular testing are common. Don’t get upset. Instead, seek to understand. Where does the fault lie?

• If it’s internal, continue to build your framework of checks and balances for claim integrity. If this doesn’t work, consider outsourcing RCM to a partner who can reduce denial rates and improve transparency in molecular billing documentation.
• If it’s with a third-party lab, seek to open a line of communication with them to clarify expectations for data integrity. Is there a problem you can address with better standards and practices?
• If it’s with your patient, stress the importance of information accuracy and completeness. Work with them to proactively resolve incorrect or missing information.

Providers shouldn’t view this as babysitting or herding cats. Instead, consider it an opportunity to create more control over your billing documentation and claims submittal processes. It also will naturally keep your processes aligned with evolving best practices, reimbursement guidelines, policy updates, and regulatory changes impacting the billing process. When providers own more of the process, they can exercise more control over RCM and their cash flow.

Establish standards for excellence

It’s not enough to check and double-check billing documentation for molecular diagnostic tests. Providers need clear procedures for verifying and validating information along with irrefutable documentation relevant to the patient, procedure, and claim.

Find your expert guide to best practices for molecular billing at BrightDriveHCS.com.