TIPS to improve REVENUE

Every office need an oustanding billing team. The billing team is the key to a successful revenue cycle. Here are some tips and tricks to take advantage and improve your revenue.

You are a Par or Non-par provider?

A Par providers has a contractual agreement with an insurances plan render care to eligible beneficiaries. Is important the billing team knows the details of the contract.

A Non participant provider is a physician without a contractual agreement with an insurance plan to accept an allowed amount and to render care to an eligible beneficiary. In this case the provider may decide to obtain a full payment at the time of the service. Be aware that insurance plans will cover a less amount of the claim when you are non-par provider.

How it works?

Billed amount                               $332.00

Allowed amount                            $189.89

Write off amount                           $142.02

Member responsibility                     $0.00

Reimbursement amount               $189.98

Allowable Charge: also referred to as the Allowed Amount, Approved Charge or Maximum Allowable Charge. This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. The Allowable Charge is typically a discounted rate rather than the actual charge. If you aren’t a network provider then you can bill the beneficiary for the amount the health insurance company will not pay.

Write-off Amount: Is the difference between the billed amount and the allowable charge, which a network provider cannot charge to a patient who belongs to a health insurance plan that utilizes the provider network. This amount is written off unless it can be billed to the patient under the payer’s rules (Non-par providers)

What to do with the claims?

• Work with payers in order to have claims processed as quickly as possible.
• Be familiar with the payers’ claim-processing procedures, including:

o   The timetables for submitting corrected claims.

o   How to resubmit corrected claims that are denied for missing or incorrect data.

• Monitor your claims by implementing a claim status monitoring program.
• Monitor claim status closely by tracking accounts receivable (A/R = the money that is owed for services rendered). The accounts receivable is made up of payments due from payers and from patients. For this reason, after claims have been accepted for processing by payers, the person in charge need to monitor their status. This require two types of information.

1.       The amount of time the payer is allowed to take to respond.

2.       How long the claim has been in process.

• Monitor the aging (how long a payer has had the claim) of claims and claim turnaround time. Just as providers have to file claims within a certain number of days after the date of service (DOS), payers also have to process claims within the claim turnaround time. The contract often specifies a time period of 30 to 60 days from claim submission. States have prompt-pay laws that obligate state-licensed insurance carriers to pay claims for both participating and nonparticipating providers within a certain time period, or incur interest penalties, fines, and lawyers’ fees. Research the law in the state where claims are being sent to determine the payment time frames and the penalty for late payers.

** TIP**

A payer may fail to pay a claim on time without providing notice that the claim has problems, or the payer may miscalculate payments due. If the problem is covered in the participation contract, the recommended procedure is to send a letter pointing this out to the payer. This notice should be sent to the plan representative identified in the contract.

•   Review EOBs to double-check the remittance data:

1. Check the patient’s Id information and date of service against the claim.

2. Verify that all billed CPT codes are listed.

3. Check the payment for each CPT against the allowed amount which may be a percentage of the usual fee. Look for discrepancies needing review.

4. Analyze the payer’s adjustment codes to locate all unpaid, downcoded, or denied claims for closer review.

5. Decide whether any items on the EOB need clarifying with the payer, and follow up as necessary.

Adjustments on the EOB means that the insurance is paying a claim or a service line differently than billed. The adjustment may be that the item is:

o   Denied

o   Zero pay (if accepted as billed but no payment is due)

o   Reduced amount (most likely paid according to the contract)

o   Less because a penalty is subtracted from the payment

** TIP**

Billing code PR (patient responsibility) on an EOB with an associate reason code indicates whether a provider may or may not bill a beneficiary for the unpaid balance of the furnished services.

 

E/M clinical documentation errors and EHR compliance failures summary

COMMON E/M CLINICAL DOCUMENTATION ERRORS SUMMARY

F Incomplete patient identification info (Ex. Member ID info on all pages).

F Missing date of service (DOS)

F Chief complaint not documented.

F HPI documented by a non-provider and without the provider review acknowledgement. 

F Incomplete review of systems.

F No status on chronic conditions review.

F Mix of body areas with organ systems.

F Lack of documentation on the exam (Ex. Abnormal results without findings).

F Lack of documentation on the assessment and plan (Ex. Incomplete medical decision making).

F Incomplete documentation of diagnosis, orders and medication.

F Incomplete documentation of interpretations/lab review, procedures and/or ancillary services performed.

F Incorrect documentation of time based and consultation visits.   

F Inconsistent documentation (Ex. Unknown abbreviations).

F Medical necessity not supported.

F Multiple non-identified authors.

F Out of time completion (Ex. DOS vs. closing date).

F No provider signatures, license and/or specialty.

Electronic Health Records documentation compliance failures

F Doesn’t follow E/M 1995 or 1997 rules.

F The provider was not involve in the design or implementation phase.

F Non customizable notes with little or none free text.

F Missing documentation specific to the practice (Ex. Specialty appropriate).

F Inconsistency with clinical workflow.

F Click friendly, not story teller or reader friendly.

F Repetitive documentation (Ex. Copy/paste notes).

F Easy to skip parts.

F Ending and closing the note without review or authentication.

F Non-automated signatures, license, specialty and DOS.

F No alerts for incomplete notes.

Your office needs strategies to improve documentation compliance?

CONTACT US we can help you develop and maintain a compliance program based on your practice needs.

Why your cash flow is decreasing?

Today’s increased federal scrutiny of billing practices has made providers revenue decrease. Increased insurance carriers and federal regulatory demands and scrutiny mean it’s more important than ever to have accurate coding, billing and documentation.

With the complexity in the billing process, even a small number of billing errors can result in significant losses. Your practice may face fraud and abuse issues if billing personnel do not understand insurance complexities and their impact on the process.

Inexperienced or improperly trained billing personnel can unwittingly create cash-flow difficulties for your practice through inappropriate claim filing. The lack of proper training and failure of the office personnel to follow up on unpaid claims can quickly result in a backlog of outstanding claims. Too often, billing personnel do not have the time or the expertise to research and resolve claim problems, as it is the complicated tasks of reviewing claims for accuracy and compliance with payer rules, following up on denials and researching claims with payment variances (ex. write-off). Write off can drain your finances.

Most of the medical practices have the wrong perspective when it comes to clinical and billing departments it is there where all go wrong. The communication between the clinical personnel and the coders is essential to maintain a successful practice. Example, the record has an injection procedure but for some reason the information is incomplete, if the coder notice the error it can be corrected right away. But this information is mostly clinical and if there is no communication between the departments it will go unnoticed and when the insurance request the record it will be deny for lack of information.

It’s also important that every provider office have regular coding, billing and documentation audits to identify risk areas and minimize the revenue loss. In offices without compliance managers make sure the billers and coders have knowledge on clinical documentation compliance for a successful financial and professional practice.

Have in mind that every year, state and federal regulations changes along with coding and documentation standards.

  

“If it isn’t documented, it hasn’t been done”

Evaluation and Management Appropriate Level Selection and Documentation Compliance

       **Includes a Quick E/M level selection guide**

WHAT DO PAYERS WANT AND WHY?

Health care insurance companies may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

ü    The site of service;

ü    The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or

ü    That services furnished have been accurately reported.

WHAT DO PAYERS LOOK FOR?

ü    Complete and legible medical notes

ü    Reason for the encounter and relevant history, physical examination, findings, and prior diagnostic test results

ü    The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented

ü    Assessment, clinical impression, or diagnosis

ü    Medical plan of care

ü    Date and legible identity of the observer.

SELECTING THE BEST CPT CODE

When billing for a patient’s visit, select codes that best represent the services furnished during the visit.

Billing for an E/M service requires the selection of the CPT code that best represents:

Patient type;

1.                  New Patient

2.                  Established Patient

Settings of service;

1.                  Office or other outpatient setting

2.                  Hospital inpatient

3.                  Emergency department (ED)

4.                  Nursing facility (NF)

E/M LEVEL

There are three key components when selecting the appropriate level of E/M service;

Ø    History

Ø    Examination

Ø    Medical Decision Making

Counseling and/or coordination of care are an exception to this rule, the key to qualify for a particular level is the TIME.

HISTORY

Chief Complaint (CC) is required for all E/M levels. It describes the reason for the encounter.

History of present illness (HPI) is a description of the development of the patient’s present illness. There are two types of HPIs: Brief and extended. ***See the image attached ***

REVIEW OF SYSTEMS (ROS)

ROS is a review of body systems in order to identify signs and/or symptoms. There are three types of ROS: problem pertinent, extended and complete. ***See the image attached ***

PAST, FAMILY and/or SOCIAL HISTORY (PFSH)

There are two types of PFSH; Pertinent and complete. ***See the image attached ***

Ø    Past history includes previous illness, surgeries, injuries and treatments.

Ø    Family history includes hereditary conditions that may place the patient at risk

Ø    Social history is an age appropriate review of activities (drinks, sports, etc.)

EXAMINATION

The levels of E/M services are based on four types of examination:

Ø    Problem Focused – limited examination of the affected body area or organ system.

Ø    Expanded Problem Focused - limited examination of the affected body area or organ system and any other symptomatic body area or organ system.

Ø    Detailed – extended examination of the affected body area or organ system and any other symptomatic body area or organ system.

Ø    Comprehensive – general multi-system examination or complete examination of a single organ (and other symptomatic body area or organ system).

MEDICAL DECISION MAKING

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:

ü    The number of possible diagnoses and/or the number of management options that must be considered;

ü    The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and

ü    The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

GENERAL E/M DOCUMENTATION GUIDELINES

In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.

The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

It is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer.

If a previously obtained ROS and/or PFSH is updated an evidence must be recorded in the record describing any new information and the change date.

The ROS and/or PFSH can be obtained by ancillary staff. However there must be a notation from the physician supplementing or confirming the information recorded by others.

If the physician is unable to obtain the history, the physician should describe the patient’s condition.

Specific abnormal and relevant negative finding during the examination must be described. A notation of “abnormal” is not sufficient.

The initiation or changes in treatment, surgical or diagnostic procedures ordered, planned or scheduled at the time of the encounter should be documented.

If referral is made the documentation should indicate the consultation details. (Whom, where, etc.)

If a diagnostic service is ordered, planned, scheduled or performed at the time of the encounter it should be documented as well as the review of any diagnostic test. (Radiology, labs etc.)

Direct visualization or independent interpretation of images, tracings, etc. should also be documented.

In addition to the individual requirements associated with the billing of a selected E/M, the service must also be considered reasonable and necessary. Therefore, the service must be:

ü    Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (that      is, not provided mainly for the convenience of the beneficiary, provider, or supplier); and

ü    Compliant with the standards of good medical practice.

Today’s Tip

“Remember to add the correct place of service (POS) on your bill. If you enter the incorrect POS to your E/M service bill your claim will be automatically deny” 

The nitty gritty of NCCI edits and modifiers

Did you know most private insurance use the NCCI edits for automatic system denials?

What is the Medicare National Correct Coding Initiative (NCCI)?

The Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together.

In addition to PTP code pair edits, the NCCI includes a set of edits known as Medically Unlikely Edits (MUEs). An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary.

NCCI tables and manual can be found under the following links.

MEDICARE

MEDICAID

Why Would a Health Care Professional, Supplier, or Provider use the NCCI edits tool?

Accurate coding and reporting of services are critical aspects of proper billing. The NCCI tools help providers avoid coding and billing errors and subsequent payment denials. It is important to understand, however, that the NCCI does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination.

How the NCCI coding decision are made?

Coding decisions for edits are based on conventions defined in the American Medical Association’s (AMA’s) “CPT Manual,” national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. Prior to the implementation of MUEs, the proposed edits are released for review and comment to the AMA, national medical/surgical societies, and other national health care organizations, including non-physician professional societies, hospital organizations, laboratory organizations, and durable medical equipment organizations. Similarly, proposed PTP code pair edits are released to various national health care organizations for review and comment prior to implementation.

MODIFIERS

The PTP code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used. Many procedure codes should not be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same beneficiary encounter.

Modifiers 24 – 25 – 57 – 59 are used for separate reimbursement of a service. These modifiers generally bypass claims systems edits. The use of this modifiers must be substantiated in the medical records. Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier.

A modifier should not be appended to a HCPCS/CPT code solely to bypass a PTP code pair edit if the clinical circumstances do not justify its use.

The CPT Manual defines these modifiers as follows:

Modifier 24 = “Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period”

The E/M service was performed during the postoperative period of a major surgery but for a reason unrelated to the original procedure. If the diagnosis codes is not a clear indication that the visit was unrelated to the surgery, supporting documentation specifying the 'reason' the visit was unrelated must be submitted with the claim.

Modifier 25 = “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service”

Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).

Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules. Since minor surgical procedures includes pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work.Furthermore, Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient.

Modifier 57 = “Decision for surgery”

Evaluation/Management (E/M) services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, these services may be billed and paid separately. In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Insurance companies may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of, or the day, before a procedure with a 0 or 10 day global surgical period.

Modifier 59 = “Distinct Procedural Service”

Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

Note: Modifier 59 should not be appended to an E/M service.

Common appropriate uses;

·         Different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ. The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. (Example; Arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site)

·         Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day. For surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day and that cannot be described by one of the more specific modifier.

RECOMMENDATIONS

I recommend that you carefully review the chapters of the NCCI manual that pertain to the code ranges you most often bill. These chapters include detailed information about correct coding and use of NCCI-associated modifiers for separately reportable services, and much more.

This is the first step to end insurances denials and the correct road for COMPLIANCE.