Sick Visit Claims Could Be Costing Your Practice

Did you know you might have a cash flow leak and not know it? It’s not uncommon for practices to file medical billing claims without meeting requirements for the use of Modifier 25 in bundled sick claims and doing so could very well be costing your practice valuable reimbursement revenue.

Fortunately, there are some simple rules to follow to ensure that you’re getting the best reimbursements for your claims. First of all, make sure that you know exactly what the payer requires for reimbursement on these claims. Next, make sure you document exactly what caused the encounter and what the outcome was. This shows a logical flow of information and will better help the payer see that the services rendered will qualify for full reimbursements.

Additionally, be aware that the RVU system makes no adjustment for codes with modifier 25. Although a plan may pay such claims as the policy allows, insurers that follow CPT rules should generally be paying each CPT code in full in this instance as long as a distinct entry is made on the medical billing form. Additionally, make sure that your charges are consistent and reflect real pricings for services rendered.

A red flag for many payers is two of the following scenarios:
* Enter a $0 charge for the sick visit service (99201-99215), and bill the preventive medicine service (99381-99397) above the contracted rate

* Split the well care charge in half and apply it to the sick visit.

Final point, raising your price on a single visit may get your entire claim denied. The best way to file your sick claims is to charge the usual amount for services rendered and then back up your claim with strong documentation. Filing this way will give your practice the best chance at reimbursements for sick visits.

View all Articles by: Melissa Clark, CCS-P