Fighting Back When Insurance Companies Bundle Charges

Insurance bundling is the process where a payer will often lump separate charges together to pay your practice less.

For example, lets say you have a patient that comes in for evaluation of high blood pressure and you notice the patient has two suspicious skin lesions - one on their left arm and one on their stomach. You then make the determination to excise one and perform a biopsy on the other.

You code 99214 with modifier -25 (E&M for patient with high blood pressure); 11403 (stomach lesion excision, benign, 3.0 cm); 11100 with modifier -59 (biopsy of arm lesion).

Modifier -25 is to be appended to a CPT code that is a separate and distinct service that is provided during the same visit. If modifier -25 is not added to the evaluation and management code (99214) both lesion codes could be denied, or the 99214 code itself might be denied. Modifier -25 identifies to the payer that the codes are truly separate services that were rendered.

Modifier -59 is to be utilized for a distinct procedural service and alerts the payer that two services that usually would be bundled into the lesion code should be reimbursed separately because the biopsy (11100) was performed separately. The two lesions that were examined were definitely separate, distinct and unrelated to each other.

If the insurance company does not pay for each service and is ignoring the modifiers -25 and -59, ultimately they are bundling.

The best way to fight back against bundling is to track your claims submissions and check them against your explanation of benefits forms to ensure that all services are paid.

The following are indicators your payers may be bundling your services:

An E&M code is indicated but no payment was made because the carrier bundled the charge with that of an unrelated service. When the charge is listed but no payment was made because the payer bundled the charge with an unrelated charge for another diagnosis. When this occurs you will often see the following denial code, "Payment for this service is included in the fee for the procedure." When the modifier is listed but the payer omits the service modifier (such as the -25 or -59) and no payment is made. When the code is totally omitted from the EOB as though the service was never rendered. For instance, you coded an E&M code and a minor outpatient surgery on the same day. The claim was filed using the -25 modifier. When the EOB's are received, the only charge noted is the surgery code. The E&M code is not included.

Certain explanations on your EOB's may also indicate that the payer is bundling some of your charges. Examples are as follows:

Medical visit not allowed for separate reimbursement The procedure code submitted on your claim has been changed to one that better represents the services performed by your physician. Payment for one or more billed procedure codes has been denied because it is considered a component of this billed procedure code. Payment for this service is included in the fee for the procedure. This service is a component of a primary procedure. Payment for the primary procedure includes reimbursement for the related procedure.

Make sure and analyze your EOB's for an extended period of time to identify if any of the issues above exist in your practice. Make a list of the payers that are attempting to bundle and what CPT codes and procedures they are bundling so your staff will be aware of this and keep an eye out for it moving forward.

Once you identify any charges that are being bundled, go ahead and immediately appeal those with the payer. It's imperative that you address it immediately as each payer has a deadline in terms of when a claim can be appealed.

The bottom line is to not accept what the insurance company pays but to ensure that payment has been made in accordance with your contract and that no bundling is occurring.

What to Do When Your Chiropractic Exams Are Downcoded

What to Do When Your Chiropractic Exams Are Downcoded

If you are having trouble with exam downcoding in your chiropractic billing - in other words, you bill for a 99204 but the insurance only pays for a 99203 or you bill for a 99213 and the insurance pays for a 99212 - keep reading because this article can potentially put thousands back in your pockets!

Trends in Downcoding Downcoding is not new, nor is it a passing fad. The practice of an insurance company paying you lower fees and at a lower code that you billed is also not unique to chiropractic.

Basically, from the insurance perspective, here's the inside scoop on how downcoding occurs. (As many of you already know, I fully admit that I used to work as an insurance claims analyst and so I have an intimate knowledge of their methods!)

Everyone is NOT Downcoded Rest assured, insurance companies do not try to downcode every possible E/M or exam code for every provider every claim. However - certain E/M codes are highly audited in the chiropractic profession and subject to near constant downcoding.

Which ones? For chiropractors, the biggie is 99205. In fact, there are many even within the chiropractic profession who will go on record and state that DC's have no business using that code.

Downcoding 101 While exam codes such as 99205 are pretty much automatically flagged in the chiropractic world, most insurance companies employ sophisticated software tracking systems to determine which codes under which circumstances they will target for downcoding.

How does one get on such a hit list? Easy. Your coding trends are significantly outside the "normal" values that your peers submit.

Let's look at it this way: if your peers bill 99203 20% of the time and 99202 80% of the time but you bill the reverse - 99203 @ 80%, the software at your friendly insurance carrier is programmed to "kick you out." Once labeled an "outlier" your claims are tracked and either immediately or periodically subject to downcoding.

In other words, the insurance company will try to bring your claims back to the middle - what they consider "normal" patterns.

The Real Issue With Downcoding No one likes to be an outside, but the real meat behind the issue of downcoding is dollars lost! Every time your claims are downcoded, you are forced to fight to defend your care. Every time you fight, you lose some $$$ just because of staff time spent fighting.

Now, one solution is to not fight back. Bad idea. Call me crazy but I believe that if you truly perform a 99203 then you should be paid for a 99203!

The other solution is to "play it safe" or stay under the radar and downcode yourself. I know many DC's who use this strategy and while it is true that they aren't audited as much, they are also losing thousands of dollars each year by not asking the insurance companies to pay them for what they do.

My Solution My solution is rather simple: know your stuff and be paid for everything you do.

Knowing your stuff is a problem for some DC's not because they are bad chiropractors, but because they know virtually nothing about billing and coding!

The Most Common Error in E/M Coding When I audit one of my client's claims or exam notes to determine if they are compliant and correct, here is one near universal mistake that I repeatedly see DC's making.

Neglecting the Review of Systems is by far the easiest way to perform a sub-par exam that will get downcoded!

ROS, the Key to Highly Paid Exams As you know, each E/M code has criteria - history, exam medical decision making - that you have to meet in order to merit a particular level of exam code.

In other words, you can't bill out a 99205 (the highest level E/M code) while performing a brief exam worthy of a 99202 and expect to be paid fully!

For many DC's the stumbling block that virtually causes their claims to be downcoded is the ROS.

A Complete ROS For a complete Review of Systems, it is necessary that you cover and document ten (10) individual bodily systems in your examination.

Cover less than this and you will not be eligible to report a complete examination and thus, you automatically pull yourself out of certain billing levels.

Nearly all coding books (if you don't yet have one, get one) have a section detailing which E/M codes require complete exams or more detailed documentation to merit the code.

Frequent Downcoding or Audits If you are getting dowcoded or audited frequently, chances are your Review of Systems is lacking.

If you are performing a complete exam but not getting paid for it, thereis a high degree of likelihood that your documentation is the problem.

Either way - you are losing out on money for things you are doing - not good in my book!

The Good News Here's the good news, doc.

Fix your Review of Systems and you are on your way to "earning" the right to code for higher level examinations and also on the right track for reducing your exposure to audits by billing incorrectly!

It's easier than you think and does not require you to spend loads of time in your exam performing every test known to man. You just need to be able to know what the requirements are - and satisfy them.

Now, go back to the office - review your ROS and get paid for EVERYTHING you do!

How Physician Billing Affects a Practice

Medical practice profitability depends largely on the efficiency of their billing processes, as this determines how they get paid for any medical services provided. In order for a medical establishment or physician's office to thrive, their billing procedures must be streamlined and effective.

What Is Medical Billing?

Medical or physician billing is the process of sending invoices or submitting claims to medical insurance companies in order to receive compensation for medical services rendered. These can include diagnostics, tests performed, general office visits, hospital and emergency room visits, examinations, surgery, treatment, or any other service that a doctor or medical professional provides to a patient.

What Do Insurance Companies Expect From Medical Billers?

Medical insurance companies have certain expectations regarding the claims and bill generating process; therefore, it is very important for all healthcare billing services to have a clear understanding of these procedures in order to receive timely and accurate payment.

There is a very standard process used to submit claims for payment to insurance companies. The patient's medical record and background history, the nature and depth of the physical examination, the extent of procedures performed, if any, and the intricacy of the medical decision making process are all evaluated to define the correct degree of service to use when billing the insurance company.

A trained medical coder then converts the degree of service into a standardized procedure code interpreted from the current procedural terminology database. The diagnosis is converted into a code as well, interpreted from another standardized database. The medical coder then compiles both codes into a claim, and the claim is submitted by a medical biller to the insurance company.

Typically, claims are submitted electronically using what is called an Electronic Data Interchange, which often submits the claim directly to the payer. In addition to electronic claims submission, about 30% of medical insurance claims are still submitted manually, using an actual paper form.

Why Is It Important To Bill Properly?

Billing and claim filing for medical services is an extremely complicated process, but it is integral to the success of any medical practice. Billing an insurance company improperly or using the incorrect method by which to file a claim can result in the insurance company delaying payment, or even denying the claim entirely. This will force the biller or medical professional to start all over with the claim filing process. For a physician or medical professional who renders countless medical services every day, this kind of time between providing the services and receiving payment for them is completely unacceptable.

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Medicare Announces Charging for Enrollment

Medicare will start charging fees for some enrollment applications

Wow, I'm not sure why this surprised me so much but when I saw this email I was surprised. Medicare is going to start charging providers who submit enrollment applications? Well it's not all providers, but still it is going to affect many. But the CMS (Centers for Medicare and Medicaid Services) announced that effective Friday, March 25, 2011 Medicare Administrative Contractors will begin collecting application fees for certain provider/supplier enrollment applications. This is for both paper and online, or PECOS, applications.

How much will this application fee be? That is the first question I had. But the answer is not clear. It appears that they are charging $500 for new enrollments for 2010 but since it wasn't effective until March of 2011 I was left a little perplexed. Anyway, it looks like the fee for 2011 is $512 for new enrollments and $200 for revalidations and/or adding practice locations.

Also, the fee is not applicable to all providers. The fees do not apply to physicians, non-physician practitioners, physician organizations, and non-physician organizations. It is only applicable for institutional providers of medical or other items or services or suppliers. It is applicable for the CMS-855A, CMS-855B (not including physician and non-physician practitioner organizations), and CMS-855S applications.

Personally, I think this is going to cause some major confusion. As if it wasn't hard enough for providers to just figure out what forms need to be submitted, now they need to determine if they need to pay. Also, some of the MAC's (Medicare Administrative Contractors) are already difficult to deal with. (Just for the record, some are very pleasant and helpful.) Now they have another way that they can return apps stating that the fee was not included, even if no fee was needed. As we all know, Medicare being a government agency is full of red tape. If the provider makes a mistake they have to fix it, but if the MAC makes a mistake, the provider still has to fix it.

And I find it very ironic that Medicare is now requiring all providers to accept payments through EFT (electronic funds transfer) but they are requiring payment for these apps by paper check. They haven't developed a mechanism yet for receiving payment electronically. Of course they will have exceptions based on hardship but those will be determined on a case by case basis at the discretion of the MAC. I think consistency will be an issue there. There is a published document but it was a little difficult to wade through all 110 pages.

I'm usually a "glass is half full" person and as I read back through this I feel I'm being quite negative. However, after doing thousands of Medicare applications over the past several years, I have seen many problems in the application process. To me, this addition of a fee is just going to complicate things even more. We'll be watching to see how it plays out!

Copyright Michele Redmond 2011

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Stay Away From Denials With This Lowdown on Newborn CCI Bundles

The new Correct Coding Initiative (CCI) 16.1 has an edit that family coders should take note of - more so if the practice tends to newborn patients.

Know the latest CCI 16.1 edit and gear up to observe it with this expert breakdown.

Take a look at Column 1 on these Hospital E/Ms. As per the latest CCI edits, these codes are in column 1 of the mutually exclusive (ME) edits:

99231 (Subsequent hospital care, per day, for the E/M of a patient, which needs at least two of these three key components: a problem focused interval history; a problem focused examination; medical decision making that's straightforward or of low complexity ...) 99232 (... an expanded problem centric interval history; an expanded problem focused examination; and medical decision making of moderate complexity...) 99233 (... a comprehensive interval history; a detailed examination; and medical decision making of high complexity ...).

Column 2 of these edits covers these codes:

99460 (Initial hospital or birthing center care, per day, for E/M of normal newborn infant) 99461 (Initial care, per day, for E/M of normal newborn infant seen in other than hospital or birthing center) 99462 (Subsequent hospital care, per day. for E/M of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same DOS (date of service). If the FP carries out normal newborn services (99460-99462) on the same date and the newborn later becomes ill and gets subsequent hospital care (99231-99233), you should only go for a code from the 99231-99233 code set, according to Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The services are ME as the newborn care codes (99460-99463) are for "normal" newborns (for instance newborns without medical problems); while the subsequent hospital care codes (99231-99233) are for problem-oriented services, according to Moore.

As both sets of services are designated as "per day," medical coders must select between them for a given patient on a given date. "Consistent with the ME nature of these services, Correct Coding Initiative doesn't permit a modifier to override the edits," continues Moore.

Bottom line: You should never report 99460-99262 and 99231-99233 for the same patient on the same date of service.

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Medical Billing and Coding Job Description, Training and Salary

If you've been thinking about taking some medical coding or medical billing classes online or getting medical coding or billing training you want to make sure you understand what this career and the job entails and have a good idea what kind of salary you'll make. Of course you may want to open a work from home business and it's certainly possible but may require a good education and training and an entrepreneurial ability to do so.

Going into a home business is not for everybody and getting on the job experience first is a good idea unless you have extensive education and feel like you completely understand the billing business.

Medical billing means you would be documenting patients' visits to a doctor, clinic or hospital or other type of health facility. Medical billers, assistants or Specialists enter clinic and patient information into expensive billing or practice management software so you can submit medical claims to health insurance companies. You would also be posting payments from insurance carriers and patients and run off management reports. You may also be required to make follow up calls.

Medical billing doesn't have to be done in a doctor's office. You can do billing from home, any office, clinic or hospital, billing service or facility that has the necessary software. Many doctors outsource their billing and may choose a home based business if the service is competitive in terms of cost. Or they may choose a smaller service and not necessarily one of the large billing services. So cost is a factor.

Medical coding is a totally separate function and not a part of the medical billing business. Medical coding cannot be done from home or outsourced to a service. Medical coders usually work right in the doctor's or clinic's office doing the coding before it is sent on to the billing service. Coder's salaries are comparable to medical biller's salaries.

So if you decide to get medical billing training you don't have to worry about coding and vice versa. People usually choose one or the other. Medical billing is more popular and offers more versatility since you can work from home in either your own business or for a doctor or clinic that allows you to do that.

Billing services often have graveyard shifts and may run around the clock. Salaries to start out run at least $10 an hour and up depending on your training, education and or experience, or related experience. You can move up fast as you gain the experience on the job and can command a much higher salary for the experience you're getting both from the clinic, practice or company you're working for when and if you leave for another medical billing job.

You don't need national certification, for example, as a billing specialist but it may help you get your foot in the door faster. There is money available for both your local on-campus and online medical billing training too. Make sure to check out online schools thoroughly to avoid any scams.

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