Orthopaedic and spinal surgery
Joint replacements, arthroscopy, trauma and spinal procedures generate detailed theatre accounts.
Billing points we watch
- Multiple procedures in one session need the right codes and modifiers
- Joint replacement and spinal surgery usually need pre-authorisation, and scheme protocols can apply
- Implants and prostheses are usually billed by the hospital or supplier, so your account must match what was authorised
- Trauma cases may be emergencies, which affects PMB treatment
- Assistant accounts depend on accurate procedure codes from theatre
General surgery
A mix of emergency and elective work, open and laparoscopic, in hospital and in rooms.
Billing points we watch
- Emergency admissions can qualify as PMBs, and should be coded and followed up that way
- Laparoscopic and open approaches use different codes
- Histology can confirm or change the diagnosis code
- Several procedures in one session need correct modifiers
- In-rooms procedures may be paid from different benefits than hospital work
Gynaecology and obstetrics
Maternity care, gynaecological surgery and in-rooms procedures each have their own scheme rules.
Billing points we watch
- Many schemes ask members to register a pregnancy with their maternity programme
- Antenatal visits, delivery and postnatal care are billed differently, and benefits can be limited
- Caesarean and other surgical deliveries usually need authorisation
- Assistant and anaesthetic accounts follow the same case
- In-rooms procedures and scans should be checked against the patient’s benefits
Ophthalmology
High volumes of in-rooms examinations and tests, plus day-case surgery.
Billing points we watch
- Cataract surgery may be subject to scheme networks or designated service providers
- Lenses and consumables may be billed by the facility or a supplier
- Procedures on one or both eyes need the correct codes and modifiers
- In-rooms tests are paid from day-to-day benefits on many options
- Authorisation is often needed for surgery and some treatments
Ear, nose and throat (ENT)
In-rooms scopes and tests, and frequent short theatre procedures, often for children.
Billing points we watch
- Procedures such as tonsillectomy and grommets usually need authorisation
- Bilateral and combined procedures need the right modifiers
- In-rooms endoscopy and hearing tests are paid from different benefits
- Paediatric patients are dependants, so dependant codes must be right
- Theatre accounts link with anaesthetic accounts
Urology
In-rooms procedures, endoscopic surgery and cancer-related care.
Billing points we watch
- In-rooms procedures such as cystoscopy may include consumables that need correct billing
- Endoscopic and open procedures use different codes
- Cancer-related treatment may fall under PMBs or oncology programmes
- Authorisation is usually needed for theatre work
- Diagnosis codes should be updated when results confirm a diagnosis
Cardiology
Consultations and in-rooms tests, plus procedures in the catheterisation laboratory.
Billing points we watch
- In-rooms tests such as ECGs and echocardiograms have their own codes
- Cath lab procedures usually need authorisation, and devices are often billed separately
- Many cardiac conditions are PMBs, including chronic conditions on the CDL list
- Emergency admissions need prompt authorisation follow-up
- Repeat tests may be limited by scheme rules
Anaesthesia
Anaesthetists bill their own account for each case, under their own practice number.
Billing points we watch
- Accounts are generally built from the procedure and the anaesthetic time, using scheme rules
- Accurate start and end times and procedure codes from theatre are essential
- Modifiers may apply for patient and procedure factors
- The account must match the surgeon’s authorisation
- Patients receive a separate account, so a clear explanation reduces queries
Radiology
High-volume imaging, where details and referrals have to be right first time.
Billing points we watch
- CT, MRI and some other scans usually need pre-authorisation
- The referring doctor’s details and diagnosis support the claim
- Contrast and consumables need correct billing
- Scheme limits on scans can apply, so benefits should be checked
- Volume means small errors repeat quickly, so checks matter
Also: cardiothoracic surgery, gastroenterology, neurology and neurosurgery, plastic and reconstructive surgery and other specialties. See the billing guide and the glossary.
