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.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   5 Things to Consider When Selecting the Right Medical Billing Service   Medical Billing And Coding Job Description And Salary - What Do Medical Billers Do?   TV Medical Leads   Health Insurance Leads Information   

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

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   TV Medical Leads   CMS Announces "Meaningful Use" Rules   How Under-Coding Affects the Financial Well-Being of Your Medical Practice   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   

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.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   TV Medical Leads   How Under-Coding Affects the Financial Well-Being of Your Medical Practice   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   Important Difference in UK Vs US Health Insurance Models   

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.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   Important Difference in UK Vs US Health Insurance Models   CMS Announces "Meaningful Use" Rules   

E and O Insurance

What is E&O Insurance and why would you need it for your Medical Billing Service? Very good question! E&O Insurance, or errors and omissions insurance would cover your business for any claims made against you that arise as a question of your performance as a billing service. So, if you have a provider that decides to sue you for money that they feel that they lost as a direct result of you either doing something wrong, or not doing something that you were supposed to do, the E&O Insurance would cover you.

You may be thinking, as we did in the beginning, "Oh, I'm just getting started. I don't even have any clients yet. I'm going to do a good job, this won't even ever apply to me." Well, people don't ever plan on getting in an auto accident either but they sure are happy they had collision insurance when they did. People never plan on anything happening on their property, but when their tree falls on someone else's house, they are pretty happy to know they have homeowner's insurance. Just like all of the other insurances we have, E&O, or property liability insurance is only used when something bad happens. That's why we decided to add this section to the contract book!

You can never foresee all the things that can go wrong, and hopefully they never will go wrong. We can honestly say that we hope that you never need the E&O insurance and wonder if you really did need it in the first place. However, for those occasions that do arise where the E&O insurance comes in to save your business, we will be happy that we encouraged you to get it.

The costs and regulations vary from state to state. Some states require extra coverage. You should shop around to find what is right for you in the state that you are located. You do not want to go strictly on price, you need to compare the details of the policy as well. See what coverage you will need for your business. You may need to modify the policy as your business grows. Since I'm still not sure that we've convinced you of the need for O&E insurance, here is a real situation that happened where the O&E insurance saved the owner of the Medical Billing Service:

The names have been changed to protect the innocent!

I have a friend (really I do) with a Billing Service in Florida. One of her first accounts was an outpatient addiction facility that was just starting up. He signed a contract with her for the billing and she outsourced the credentialing to us. The provider, an MD with a colorful past, was a little uhhh, unstable. He was difficult for her to work with and didn't listen to her advice. After several months of frustration, she gave him notice that she was terminating the contract and would no longer bill for him. She did everything according to the rules of the termination and ended the contract.

The practice management system she used was a web based system that charged a monthly fee for each provider. That was part of her contract, the provider covered that fee. She had notified the provider in writing that he would no longer have access to the system as of November 1st if he didn't pay the fee. Several notifications were sent. I'm sure you've guessed that the provider did not pay the fee, or respond to any of the notifications.

A month after the termination, she was served with papers. He was suing her stating she caused him to lose $600,000.00 in patient balances because she denied him access to his account information. The ironic thing was that one of the main reasons she terminated her services was because he refused to charge the patients for their portion.

Well, you may be thinking "that's crazy, she notified him". I'm sure you're thinking other things as well. But bottom line, she had to defend herself and her actions. Without E&O insurance, her business could have been lost because let's face it, our judicial system is not always perfect.

Anyway, if you ever do find yourself in court and at the mercy of a jury, you have to remember, those jurors are not medical billers. They may not understand what your business is, and what the job of medical billing entails. So you are at the mercy of your lawyer's (who also doesn't understand medical billing) ability to explain to them what happened and why you are not to blame. E&O insurance protects you from losing everything if you ever find yourself in a situation where your business may be on the line.

Copyright 2010 Michele Redmond - Solutions Medical Billing Inc.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   How Under-Coding Affects the Financial Well-Being of Your Medical Practice   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   

Protect Your Business With Your Medical Billing Service Contract

When we started our Medical Billing Service in 1994 there was very little information available on medical billing services let alone medical billing service contracts. In fact, some of the information indicated that you really didn't even need a contract if you didn't want one. That couldn't be further from the truth! Having a contract for your Medical Billing Service is very important to protect both you and the provider.

Many new billing services ask us for a sample contract or a copy of our contract. Using a sample contract or somebody else's contract is not a good idea. It would be like taking somebody else's will, whiting out their name and writing in yours. The only time it will hurt you is when you die, and then your family could be in trouble. The same can be said of a sample contract. If nothing bad ever happens, the sample contract is fine. But if a problem occurs it may not work out so well.

When starting your new business no one wants to think about things going wrong, but unfortunately in this business things do go wrong and we all need to be covered by a comprehensive contract when this happens. It may not be anything you did wrong, and it may not even be anything the provider did wrong, but sometimes things happen that are beyond our control. If you do use a sample contract and then two years later find yourself in court with a former client you are going to wish you had looked into writing the contract a little more.

Just having a contract doesn't cover it. You need to make sure the contract is very specific to your company. When we started we used a very simple contract that really didn't cover much at all. When situations arose that were problems our contract was no help. We had to re-write it once we had been in the business for a while and knew what needed to be covered.

So where does a new billing service start when they haven't been in business long? It's hard to write a contract covering all areas and what to do when you haven't experienced it yet. Most new billing services are working on limited capital and don't like to spend money on a lawyer writing a contract for them. Unfortunately many new services cut corners here to save money, but that's not a good idea.

Your contract should be at least looked over by a lawyer, if not written by one. If possible you should try to find a general practice attorney who specializes in contracts. All the better if he or she has some experience in the medical billing field. You can save money by preparing carefully before you meet with your lawyer.

Start by making a list of things you want to cover in your contract. List all of the services you will be providing and how you charge for them. In addition to how you will charge you will want to list how and when you expect to be paid. Add the provider's responsibilities to the list. List how you will receive the patient and claims information, and what information you expect from the provider. Other terms you will want to cover are what happens if you don't get paid, how either party can terminate the contract and what happens when you do term.

There are really a lot of important issues that you need to cover - many potential situations to think about. It is a good idea to try to think of everything that can go wrong in the relationship and write down your feelings about how those situations should be handled. You should be able to come up with a long list. In the circumstances of a new biller it can be difficult to know what can go wrong. It has been sixteen years since we started our medical billing business and we are still learning about new things that can go wrong.

Most providers expect to sign some form of contract when using a third party service and generally expect the billing service to produce it. They want to make sure they are covered as well as the medical billing service. Going over the contract with a provider starting out with you can set the stage for a successful relationship. You can go over the terms carefully making sure the provider understands what you need to make it a beneficial partnership. Most of us when we are starting our businesses do not realize how much a good contract can affect their business.

Contracts are kind of like insurance, you don't need them until there's a problem. But when there is a problem, it's a relief to have one. There are really a lot of areas that you need to make sure you are covered in and a contract is really the only way to do that.

Copyright 2010 - Michele Redmond - Solutions Medical Billing Inc

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   TV Medical Leads   Important Difference in UK Vs US Health Insurance Models   CMS Announces "Meaningful Use" Rules   

Expert Billing Improves Healthcare Providers' Bottom-Line

Saving lives is a very noble act. Since humans have their expiration dates here on earth, being able to extend that period before expiration is something that everybody reveres. This is probably why medical practitioners like doctors and nurses have received high regards from society. They have been in a continuous service to people in times when lives are put in danger by diseases. But then again, it is an indubitable fact that no matter how noble curing diseases may be, a clinic is still a business - in fact, these days it is becoming more and more costly to run a successful practice.

Health practitioners charge for every kind of assistance that they give. Particularly in private hospitals, patients can always be expected to go home with a bill. That is why medical practitioners are also expected to somehow have the business management skills to be able to run a profitable practice.

The office clinic as a business office is a place where fees are charged in exchange of medical services. After the consultation and other clinical procedures, the doctor is entitled to payment. However, when payment time comes, the most tedious part comes along - the paper work. Medical billing specialists come in wide range of capacities, but they all help healthcare providers maintain a healthy revenue stream.

So how does a medical billing service reduce overhead costs for healthcare providers? Here are just a few examples:

Lower overhead expenses

Processing payments can be very tedious especially to the doctor that needs to focus his attention mostly on the patients. That is why he may decide to hire his own employees apart from the secretary who is already full of workload-on-hand. When this happens, just like in any other business, the overhead expense will inevitably increase due to the additional salary expense. But with a medical billing service that is provided by a third party vendor, additional costs can be avoided and expenses can be controlled.

Less paper work means time for more patients

To be able to finish all important tasks at any given time, delegation is the key. In the healthcare practitioner's case where more paper work won't fit in to his schedule, somebody else's help can be very useful. As someone who is also working for a living, a third party who provides medical billing services can afford the doctor more time for additional patients. He will be able to accommodate more people who are in need of medical attention, bringing in more income to cover his expenses.

Eliminates Wasteful Spending

Most healthcare providers shell out handsomely for inefficient and outdated Practice Management software. Even worse, software and hardware are frequently in need of costly upgrades or updates. A truly expert medical billing company can provide physicians with top of the line software as a part of their service, an instant savings for the medical practice.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   Important Difference in UK Vs US Health Insurance Models   CMS Announces "Meaningful Use" Rules   How Under-Coding Affects the Financial Well-Being of Your Medical Practice   

ICD 9 2011 - Relatively Few Changes For Urology This Time

Every year during the month of October, you get to see new diagnosis codes, code deletions and code revisions. And this year too it's no different. But compared to previous years, urology coders will see fewer changes this year. Here are some urology coding changes that you need to know to code right for your practice.

If we go by the proposed changes, we might see the addition of one new personal history code specific to genitourinary congenital corrections: V13.62. This is one of the most important changes for urology coders as your urologist may need to indicate this history for some patients.

For instance: Your urologist tends to chronic prostatitis in an adult patient who had a hypospadias penile repair as a child. If you add V13.62 to your claim as well as use 601.1, it'll add to the reporting accuracy of your overall clinical scenario.

Occasionally, you may also use five new fecal impaction and incontinence codes in your urological practice. This time ICD 9 deletes 787.6 and comes up with five new codes.

Your urologist may use one of the new diagnoses for a thorough ICD-9 clinical description in a patient with severe urinary incontinence as well as fecal impaction or fecal incontinence.

ICD 9 2011 has expanded the BMI codes to show higher BMIs with five new codes.

Benefit: BMI has become an important health tool and the new codes will certainly provide more data.

There are seven key signs that count for the constitutional bullet in the E/M physical exam coding, and there are those who think that BMI should be an eight option. If that eight bullet gains traction and comes into play for medical coders, the new V codes could help significantly.

To review these changes for urology coding, sign up for an audio conference. When you sign up for one, you'll stay on top of the changes in both diagnosis and procedure codes for the coming year, apart from staying tuned to all the changes taking place in the coding world. The best part of such conferences is that even if you missed out on a scheduled conference, you can always listen to the recordings in CDs and PDF transcripts. And to top it all, you also stand to acquire CEUs on attending the same.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   TV Medical Leads   

Obama Signs Payment "Fix"

On June 25, President Obama signed into law a 2.2% increase in the Medicare fee schedule (MPFS) retroactive from June 1 to Nov 30.

The political wrangling over this update has resulted in substantial delay in payments from Medicare providers, as claims submitted after June 1 were held pending the expected update. It is expected that claims will be processed after July 1, and will be processed normally after that time.

The politics of this issue are longstanding and complex. In order to justify blatantly optimistic budget assumptions, Congress put a yearly automatic decrease in Medicare reimbursement into the law. As the law is written, the decrease in Medicare reimbursement rates would be cumulative, totaling almost 21%. This decrease has been routinely overturned by each congress at the urging of physicians and senior groups. However, this year, because of partisan wrangling over the budget and linkage of the bill to unemployment insurance, the routine revision was not passed before the June 1 deadline.

The immediate result was a substantial drop in payments to all providers, as most claims were held pending the change. It is expected these claims will be paid relatively quickly now that the law has been signed.

The long term implications are far more daunting. The underlying issues of underfunding of Medicare, unprecedented federal deficits, and runaway medical costs are not being addressed or resolved.

Congress is hard pressed to solve this issue, and there will be substantial incentive to cut provider reimbursement as one method to address these funding problems.

Strong forces are lining up on both sides of the issue, with insurance companies, unions, and deficit hawks on one side clamoring for lower costs, with doctors, senior groups, and some care advocates claiming dire consequences if draconian cuts are instituted. It is our opinion that such cuts will greatly reduce the ability of physicians to provide quality care and result in multiple unintended consequences such as decreased access to specialists and massive increases in emergency care.

Needless to say, medical providers have much at stake in this battle. We will keep you apprised as to the progress of the issue. We strongly recommend you write your congressman, as well as get involved in your local medical organizations.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   CMS Announces "Meaningful Use" Rules   How Under-Coding Affects the Financial Well-Being of Your Medical Practice   

Using a Plan to Lower Your Medical Office Insurance Accounts Receivable

When you take a look at your insurance accounts receivable are you cringing today? It may be higher than usual and that is not uncommon for this day and age. However, now is the time to take control and get it down into those single digit percentages again. Here are some tips to help you do just that:

1. Eligibility is the beginning of your service.

There are many reasons that a claim can go unpaid. The first thing you can do to stop the accounts receivable bleeding in your practice is to begin regularly checking eligibility on each and every patient you see in your medical practice that has insurance. Collecting insurance cards and verifying eligibility of coverage up front is the best indicator of:

Coverage - verifying coverage dates, limits, co-pays and deductibles Subscriber - verifying who is the covered individual Priority - verifying which insurance is primary and which one is secondary for filing claims Services - verifying if your services are covered

If you are not checking patient's insurance eligibility at the time of service then you are gambling on whether your claims will be paid or not.

2. Utilize your aging reports to work oldest balances first.

It makes perfect sense to attack oldest balances first when working your accounts receivable. However, it is most important to look at the insurance aging report and define which balances are the highest. You want to begin following up on the oldest and the highest balances first. If you see that one insurance in particular has the highest outstanding claims, then work that insurance first. Then work the next plan with the highest balances.

Ultimately, you want to be able to track insurance payments that are being filed electronically within 30 days by following up on rejections and denials immediately after filing. However, many medical offices have not been able to track insurance and it has now aged over 120 days. The sooner you can work a claim the more success you will have, but it does not mean you want to ignore the aged accounts beyond 120 days. For timely filing purposes these are the accounts you want to attack first when working an accounts receivable plan.

3. Refiling and Sending Appeals.

Phone calls could quite frankly slow you down with insurance company claim denials and/or rejections. It is not uncommon to be on hold with an insurance company for the better part of an hour before you have a chance to discuss a claim. If you have access to your clearinghouse rejection reports you can usually tell immediately why a claim has rejected or been denied. Correct and refile claims as soon as possible to get them back to the insurance for review and payment.

Appeal letters for denials will need to be written and sent via certified mail with return receipt if possible to follow the process. If additional operative notes are being requested, those will need to be sent via mail also. For procedures that continually require notes to be sent, begin sending the notes with the original claim to reduce the waiting time for payments.

4. Develop a working tickler system.

You must have a working tickler system to know which claims you have worked, called on or refiled so that you can systematically follow up at the appropriate time. Some practice management systems have built-in collection modules with tickler systems for tracking accounts for review. If you have one, begin using it immediately to keep a record of your communication with the insurance company and also to remind you of which contacts to make next.

It is recommended to utilize your software system to track comments and communication with insurance companies. If you do not have a practice management system to do that then an expandable tickler file will always work to keep you on track of who to follow up with next.

5. Document your processes.

By documenting your process you develop not only a process, but also a collecting procedure to be utilized by anyone who joins your practice in this capacity. Anyone who inquires about your policy on accounts receivable and collecting procedures can readily see you have a process and it is documented. It also makes it very easy for new employees to adapt to your processes if they are clearly written.

6. Recoupment and billing agencies.

If you find that you cannot work your own accounts receivable or do not have the staff to do so, you can always look into recoupment agencies, billing, or collection agencies who will work your outstanding insurance balances for a fee. The fees will vary so you need to investigate these companies to determine which type would best suit your practice needs.

Your accounts receivable does not have to be intimidating anymore. You can achieve the percentage goal that you desire once you put a plan in place. Just remember that it will not correct itself and you must make a practice manager decision to take charge of it now.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   TV Medical Leads   Important Difference in UK Vs US Health Insurance Models   

Medical Billing Mistakes That You Need to Avoid

Medical billing is an absolute joke. That is exactly what it is, a big hilariously funny joke. The only problem with that is that it's not a joke...it's a problem. A really big problem. If you have medical problems or medical problems in your family you know what I am talking about. Your insurance didn't pay the bills like they were supposed to or the doctor didn't file it correctly with the insurance company.

There is a huge misconception that it's the doctor to hospital's fault that your insurance isn't taking care of your bill. This is wrong - it is in legal terms your fault. Let me explain. When you sign up for insurance with any insurance company the contract that you sign is between you and them. This means that the insurance that you have is only by law an agreement between you and your insurance company. This in turn means that by law a medical facility doesn't even have to file your insurance. This is technically a courtesy. Of course they will try and file your insurance for you because it helps them get paid easier.

The problem is that when the insurance doesn't go through correctly the responsibility to make sure it gets done correctly falls solely on you. What you have to do is actually put some effort in. You need to do a little research find out exactly what your bill is for. Call up your insurance company and find out why they didn't pay the bill. You will want to continue to bug your insurance company and not bug your creditor. Your insurance company works for you so call them up over and over until they have all the information that they need to process your claim. The earlier you get proactive on this the better because sometimes there is a time limit on whether your insurance company will pay your bill or not.

Another big problem that you have to realize is the complications of multiple bills. Some medical facilities, especially hospitals, will give you tons of different bills all for the same date of service. This happens a lot in hospitals. You go to the emergency room and the next thing you know you have a bill for the doctor that saw you, a machine they used, for the ambulance that took you, for the anesthesiologist, for the EKG, and pretty much anything you can dream up. This is terribly hard to keep track of because you don't always get billed correctly. What you need to do is call the hospital up and give them as much information that you can and call all of the different billing departments. Give them your name, social, address, date of birth or pretty much anything you can think of that would help them look up all of those accounts. After you have done that get copies of all those bills and get them to your insurance company to make sure they all get filed on your claim.

-Don-

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   CMS Announces "Meaningful Use" Rules   How Under-Coding Affects the Financial Well-Being of Your Medical Practice   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   

CPT 99213 - Learning the Basics of E & M Coding Guidelines

CPT 99213 is defined as: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:

• An expanded problem focused history; • An expanded problem focused examination; • Medical decision making of low complexity usually, or straight forward as the presenting problem(s) are of low to moderate severity.

A physician will be left with the options of billing E/M for either code 99211 thru 99215 for an established patient. Usually, the correct level of CPT code (ignoring coding by time) can often be narrowed down to two or three choices by a proper evaluation of the patient and documenting the office visit correctly. The usual choices that remain for the physician at the end are 99212, 99213, 99214.

There might be times when the physician wants to put a code down without really understanding the complexities of the coding system and that will end up leaving money on the table which we are trying to avoid.

For example:

If an established patient presents for a second follow-up of a single complaint such as chronic cough and it is decided that it is stable or improving, a CPT 99212 may be warranted.

However, in the evaluation of the patient, if the provider takes an expanded history and the physical exam is re-evaluated to include performance and documentation of at least six bulleted elements from one or more organ systems or body areas. Then it will qualify as an expanded problem focused exam. That being said, if your History and Physical Exam meet criteria, then the Medical Decision Making is not needed in the calculation of the level and you may capture your 99213.

Remember, in an established patient, you need only meet two out of three criteria; History, Physical Exam and Medical Decision Making to qualify.

That being said, we certainly will be making a medical decision, but according to the 1997 guidelines (which I prefer to use for a variety of reasons) we capture our 99213 as long as the medical necessity is apparent.

In another example, If the same patient has a single straightforward new complaint to discuss with the examiner, during the follow up for the chronic cough, such as an orthopedic complaint that is worsening, a CPT 99213 and even a CPT 99214 depending upon the complete exam fulfilling two out of the three main components (that being History Physical Exam and Medical Decision Making (MDM) may be appropriate. Of course, medical necessity is required to substantiate the level of service billed.

As a physician, if you consider billing by time then a 99213 requires an average of visit of 15 minutes in which at least 7.5 minutes or 50% of your time was spent in counseling or coordinating care.

Remember, CPT 99213 requires documentation of at least one system when you compare it with CPT code 99212 and an expanded problem focused (EPF) history is required as well for a 99213.

The revenue captured from properly documenting a 99213 over a 99212 can add up to thousands of dollars annually. You want to make sure you are properly documenting your medical records and capturing the revenue you deserve based on the work you are performing. You do the work, get paid for what you do.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   CMS Announces "Meaningful Use" Rules   Important Difference in UK Vs US Health Insurance Models   

Part B Benefits of Medicare

Within the total benefits of the Medicare system, Part B covers some of the most common medical expenses. Medicare Part B is a public insurance program that helps qualified citizens pay for medical expenses like going to be doctor and covering some preventative procedures. This type of coverage is useful for all different types of outpatient doctor's bills including home health services and other medically-necessary services.

Part B is different from other parts of the Medicare plan because you do pay a monthly premium for this type of coverage. Part B coverage payments are typically standard no matter what your income is. There are adjustments that can be made to a person's payment amount if their modified adjusted gross income from two years prior was above a certain amount. This coverage is generally automatically received when a person begins to receive Social Security, but if a person enrolls in Part B coverage later than their enrollment in Social Security a penalty fee may be included in their insurance payment.

These benefits are automatically extended to a person on the day they begin to receive either Social Security payments or Railroad Retirement Board payments. This typically occurs the day that a person turns 65 unless their birthday is on the first day of the month. There are also conditions that allow a person to receive Part B benefits if they are under the age of 65. Typically, this type of coverage is extended to people who are disabled or diagnosed with Lou Gehrig's disease.

For more information regarding Part B coverage from Medicare, please contact the California Medicare insurance agents at Catherine Michaels Insurance Services.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   CMS Announces "Meaningful Use" Rules   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   

CMS - Medicare PECOS Ruling May Affect Payments by Medicare

CMS originally had a deadline of July 6, 2010 for all ordering and referring providers to be enrolled in the PECOS system, or the Provider Enrollment, Chain and Ownership System but in the June 30th news release they announced that they will not be making the changes that will automatically reject claims based on ordering or referring providers who have not yet had their PECOS applications approved. What does all of this mean?

Well it's actually good news for any providers who order services or refer patients enrolled in Medicare, and have not enrolled yet in PECOS. Basically if a provider has not enrolled in Medicare or submitted changes or updates to their Medicare Information in the past 6 years, then they probably are not enrolled in PECOS. If a provider has enrolled or submitted changes/updates in the last 6 years, then they should be already enrolled in PECOS. The Medicare contractor would have automatically input the application into the PECOS system, even if they submitted a paper application.

So if the provider has been enrolled in Medicare longer than 6 years and has not submitted any updates or changes, then they still need to enroll in PECOS. The PECOS system can be accessed at the Medicare website. They should use their NPI login username and password to access the system.

CMS has been encouraging providers to use the PECOS system to enroll in Medicare or submit any updates or changes to their Medicare information for quite a while. Now they are mandating the use of PECOS by denying any claims for services that were ordered or referred by a Medicare provider who is not enrolled in the PECOS system. This makes things tough because the provider submitting the claim cannot control if the ordering or referring provider has enrolled in PECOS. This may be why they announced that they would not make the changes that would result in the denial of claims that were ordered or referred by providers not enrolled in PECOS.

At some point, this mandate probably will be implemented so it really is in a provider's best interest to make sure they are compliant. If you do not know if you or your provider is enrolled in PECOS then you should check. There is a national list available. It has the names and NPI numbers of all providers in the US who are enrolled in the PECOS system. You can check that list to see if you or your provider is enrolled. You can also call the local Medicare carrier provider enrollment line and ask if you or your provider is already enrolled.

If you or your provider is not enrolled you will either need to enroll by completing the application online through the PECOS website, or by submitting a paper enrollment application re-validating the information, even if nothing has changed. I would suggest that you don't wait until claims do start to get denied. If you are a billing service you should check the list for all of the providers you bill for and advise them if they are or are not all set. If they are not, you should advise them what needs to be done.

Copyright 2010 - Michele Redmond - Solutions Medical Billing Inc

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   CMS Announces "Meaningful Use" Rules   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   Important Difference in UK Vs US Health Insurance Models   TV Medical Leads   

Electronic Medical Billing Software - What You Must Know Before Buying

What can you do when you are trying to streamline the efficiency of a medical office? As the cost of medical care gets harder to bill and collect, this is an important question for all businesses in the health care industry. Medical office managers, single practitioners and large health-care organizations like multi-hospital systems are all looking for ways to improve their billing efficiency, to receive the maximum payment with as little profit loss as possible. If your current billing system gives you a migraine, try reducing the stress and simplifying your organization with electronic medical billing software.

Just like medicine itself and everything else, record keeping of payment for medical treatment has advanced tremendously. The frontier doctor paid in chickens or grain has gone the way of the general store, and the billing for physicians and treatment has gotten as confusing as most tax codes. Bringing in a third-party billing company just adds another line for communication to break down, with the headache of having to monitor that company's work performance, as well as keeping an eye on your bottom line. Just like any cure, if the potential negative side effects outweigh the possible benefit, does it really help?

Keep your medical billing like your medical expertise: in house. There is a nearly endless assortment of electronic medical billing software systems available, when you consider the ability to personalize these software systems to work for your practice. Online purchases are easy, and allow you to evaluate all the systems you consider. Many of the software options offer demos to help you make the best choice. The peace of mind of a having tested the product makes the choice even easier, and once purchased online support can provide more reassurance in the event of questions or problems.

Like most business decisions, electronic medical billing software may seem like a big step for your medical practice. Potential customers are often wary of technology that they aren't familiar with. But when reviewing the many pros of bringing your medical under the direct control of your own business, it's tough to come up with any valid cons. The accountability becomes your own, as most business owners prefer. The additional responsibility is taken away from a third party charging you to utilize what is most likely the same software you are looking to purchase, and brought under your direct control and supervision. And isn't that the way most business owners prefer it?

Why pay someone else for something you can easily accomplish in your own business? There's no need for a middle man in health care. Doctors don't evaluate patients through the reports of an outside company, and patients and customers prefer to deal with their service provider for payment. Electronic medical billing software generates the data to keep billing responsibility in your hands. And when you eliminate the third-party billing cost, it will increase profits so they can be directed where they belong - back into growing your business.

Employee and Employer Concerns   How to Choose the Best Medical Billing Service   CMS Announces "Meaningful Use" Rules   Medical Billing And Coding Service - Reasons To Pick As Your Career Option   TV Medical Leads