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In Texas, a Bastrop physician and an Austin doctor were among the over 60 physicians that were disciplined y the Texas Medical Board. are among the 64 doctors the Texas Medical Board recently disciplined.
The Internalist that was disciplined, Dr. Rajeev Gupta, was disciplined because five patients were improperly billed and the radiology equipment was operated by a staff member that was unlicensed. Dr. Gupta was fined $1000 and required to take a course in medical billing.
The attorney for Dr. Gupta stated, "We realize there were mistakes, and we're taking steps to make sure there are no additional mistakes," said Alex Fuller, an Austin lawyer representing Gupta. "It wasn't an intentional act," and Gupta didn't make money from the billing errors, Fuller said.
Another doctor was disciplined because of overzealous advertising of services. Dr. Marci Roy, an Austin neurologist, must pay a $1,000 fine because of Web site advertising that suggests she has a superior ability to treat carpal tunnel syndrome at her clinic than other doctors who provide similar services, according to the board. Blaming the language on a typographical error, Roy said that it was not a violation of the board's advertising rules but that she changed the language after a complaint was filed, the order says.
The word "outsourcing" has become a dirty word for many physicians that have been burned by medical billing companies that either outsourced their claims to medical billing companies that use neither secure networks nor adhere to HIPAA regulation in order to maximize their profits; or the outsourcing company just turned out to not be reliable and it wound up costing the practice money to utilize their services.
Don't let a bad experience keep you from partnering with a legitimate medical billing company that can not only help you get your reimbursements faster but also realize great profits by maximizing every single medical billing claim that is filed to make sure that all services and procedures are counted by the carrier and reimbursed.
If you've been hesitant about outsourcing your medical billing because you aren't sure it would actually help your practice or you've been burned; do a little research on your own and ask for references. Ask the medical billing company what they will do for you. OMG will not only help you get the best reimbursements on your medical billing, they will also help you manage your practice by keeping your and your staff informed of coming CPT coding changes that will affect your practice as well as helping keep your patient accounts organized and you can log in and see where a patient's account stands for insurance payments versus out of pocket. This is a very efficient way to run your practice and when you have the extra time due to partnering with a competent medical billing partner, you will finally be able to help your practice really grow!
If you haven't already, make sure that your staff is using the updated CPT codes that were released in October 2008.
Not doing so can lead to kick backs that will require more staff hours to research, redo and resubmit and if this happens on a number of claims it can seriously affect your reimbursements and in turn - slow your revenue flow to a mere trickle.
One way to avoid this dilemma is to outsource your medical billing and yes, there are some horror stories out there about outsource companies that threw away patient billing, had lax attitudes towards billing submissions and wound up costing the physician a lot more money than they made through reimbursements. However, that's not how it has to be.
Do a little research and find the best fit for your practice. Your best friend may also be a colleague but the medical billing company he uses may be a terrible fit for your own practices. How do you find the right one? First of all decide what services are most important to your practice. Make a list of the tasks your office staff is performing the most in relationship to medical billing and see if a medical billing partner could possibly lighten the load. Also, find out if your potential medical billing partner can do your credentialing for you - it's a great way to maximize the amount of insurances you can take as well as cut the paper chase for yourself.
When a patient reports to the ED and requires laceration repair, the medical billing claim needs to address the length of the wound in order to be a properly filed claim. If the wound length is either not addressed or addressed incorrectly, the claim may be either denied, rejected or only partially paid. Additional factors can include whether or not there was a separate evaluation and how the service was managed during the encounter. Make sure all of these factors are documented in your medical billing claim.
Laceration repairs are very common in the ED, in fact a nationwide survey showed that every one in fifteen patients presenting in the ED needed some sort of wound repair; knowing how to file them correctly to get the maximum allowable reimbursement for the procedure will make a big difference to your practice. This will bring you into delicate territory, you want to be sure you bundle all the procedures however you don't want to overcode the claim which will almost always cause a denial of the entire claim and you want to be careful not to undercode as the physician will wind up not getting properly reimbursed and this too will affect the bottom line of the practice.
There are three basic complexity levels: simple, intermediate and complex. First of all use the documentation to ascertain which level the wound is and then apply the proper coding from there. Use modifiers as necessary and always make sure that your medical documentation of the procedure is iron clad. Using these tips, your medical billing claims should always be accepted and reimbursed!
Often, patients who are confined to beds for long periods of time develop pressure ulcers. They are painful and need to be treated as quickly as possible as infections can set up within them that can be life threatening when the patient is already in a weakened condition.
When a service is performed for a patient such as treatment of a pressure ulcer on an area of the body such as the lower back, the usual manner of treatment is to remove any devitalized tissue from the ulcer using a water jet and forceps. The area is then covered to allow it to not be rubbed on so the skin can begin to repair itself.
When you report this type of claim, read the description of the code carefully. You will notice the since the water jet is normally used, it is already bundled into the claim itself. If you report it additionally, you are setting yourself up for a total claim rejection. You would want to report this claim as follows (make sure you know the measurements of the wound being treated):
* report 97597 (Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high-pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters) for the debridement. You will also want to link 707.03 (Decubitis ulcer; lower back) to 97597 for the pressure ulcer.
Remember when medical billing used to be a simple affair of matching the procedure done with a couple of medical billing codes to describe what was done, attaching your documentation and then submitting your medical billing claim for reimbursement?
Now we have codes for codes and modifiers and the need to when to bundle and when to not bundle with the goal being fair reimbursement for procedures done. Modifiers cause a lot of confusion for many medical billers. One such confusing modifier that is worth clarifying is Q6.
This applies to Medicare medical billing claims only, but in a nutshell when one of your staff physicians takes a leave of absence for any reason and a substitute physician fills in, you need to add the Q6 modifier to Medicare claims the sub handles if you want to ensure reimbursement for the services that the sub provides.
If you're wondering why, the reason is that when a substitute or locum tenens physician handles patients, Medicare wants to see specific modifiers on claims. This is to make sure that the time limits on locum tenens doctors are strictly observed. In order to be reimbursed, make sure that modifier Q6 (Service furnished by a locum tenens physician) is attached to all codes for procedures performed by the substitute physician. This lets the Medicare carrier know that you are coding for a locum tenens physician. Without the modifier, you’ll likely receive a denial for the claim.
Since many private carriers are adopting more and more of Medicare's standards for payment on services; before filing a locum tenens claim with a private insurer, verify with the plans as to their requirements for locum tenens billing -- and whether or not they even recognize it. Some good questions to ask are * Do you recognize modifier Q6? * Which provider’s ID should be reported for the services? * Does the locum tenens provider need to be credentialed with the payer, even if only temporary privileges? As always - write down the full name and position of whomever you speak with and the time and date of your call in case you need to track that person down again.
Outsourcing your medical billing claims to a third party partner may be one of the smartest business moves you make in 2007.
You may have had every intention of doing your own medical billing for your practice from the day you opened until the day you retired, however with the never ending changes and nuances in medical billing claims varying from cancelled codes to nonpayment of certain procedures because they simply weren't reported correctly - there comes a time when you need to look at your revenue flow from your reimbursements and decide it might be time to outsource your medical billing claims.
Another reason to outsource is the small fact that many practices are losing up to one solid forth of their revenue due to small inconsistencies in reporting. Medical billing codes can change, the way a particular carrier wants their medical billing claim reported can change and Medicare never seems to stop updating and changing their criteria for what constitutes a fully reimbursable procedure.
Your staff can spend valuable office time researching medical billing claims or you can outsource your medical billing and let your staff do what they do best : service your patients and help keep your practice running smoothly.
If you're ready to get away from the paper chase of never ending medical billing changes, consider outsourcing a proactive way to begin 2008.
Long term care medical billing has it's own set of nuances that must be followed in order to ensure that you receive proper reimbursements for the services you provide. Since nearly every patient you treat will have a long term history of care - it's sometimes tempting to skimp on the medical documentation and necessity but since you have no way of knowing who is going to review your claim, you need to handle every claim as a fully individual manner complete with full documentation or you may wind up with partially paid claims or outright denials of your medical billing claims.
One important thing to learn is when you should also list a diagnosis code for the wound in I3. The I3 is important to complete when you're doing medical billing for long term care patients as it reports additional conditions that affect a patient's health.
Since pressure ulcers are extremely common in long term care for patients that are invalids, there is a Section M that provides options for identifying both pressure ulcers and stasis ulcers but not for other types of ulcers. If another type of ulcer is to be reported on your medical billing claim, use the form and then also list the corresponding ICD-9 codes at I3, says Smith. In this case, you should list:
A confusing part of medical billing for long term care comes from the I3 itself where some I3 coding training indicates that you don’t need to include diagnoses codes for conditions that are addressed elsewhere on the MDS. However, many carriers, including Medicare do require that the type of wound be specifically spelled out. Additionally, once the ulcer is healed, be certain to take it out of section I3.
Don’t even crack your codebook unless you’ve done the following three things:
Number 1 - Make sure that your ICD-9 codes book is from the current billing year. New codes are issued on October 1st of every year. Make that your Medical Billing New Years and put up the previous year's code book to ensure that you don't make a mistake and code from the incorrect set of codes.
Number 2 - State by reviewing the diagnostic statements and make yourself a side list choosing the conditions you need to code in order to make sure you don't miss anything when you're choosing the proper ICD-9 codes.
Number 3 - On your list that you put together, make a note of the severity of each diagnosis being treated. The first coded condition should be the most severe or root cause for the visit - this is your primary diagnosis and basis for your medical billing claim.
Use these three steps to ensure that your medical billing flows and is easy for the carrier to follow your claims. Doing so will help the practice that you code for realize better reimbursements and fewer denials or partial reimbursements. You can further make your medical billing ironclad by making sure that your documentation submitted with the medical billing backs up your claim.
A recent report showed that HHA's (home health agencies) and hospices are billing Medicare on an accurate level according to a report compiled by the CMS' Comprehensive Error Rate Testing.
The report showed that HHAs had a 1.4 percent error rate and hospices a 1.0 percent error rate in the November CERT report, which covers claims from April 2006 to March 2007.
DME (durable medical equipment) suppliers had a wide range of error rates broken out by supplier type. The lowest was 0.6 percent for a medical supply company with prosthetic/orthotic personnel certified by an accrediting organization while the highest was a whopping 51 percent for “unknown supplier/provider" where it could not be ascertained exactly what the DME device was that was issued to the patient.
A summary of the CMS' report showed that overall, the national error rate for Medicare was 3.9 percent. In terms of money this translates to $10.8 billion in improper payments, $1 billion of which were in the form of underpayments, according to the report. The good news is that this report shows that figure is down from 4.4 percent in the 2006-2007 report.
On October 17, 2007 - the Senate Finance Committee met to discuss ways to pay for a fix to physician payment rates in 2008 and 2009, according to press reports. The heart of the meeting was to talk about the
$30 billion in cuts needed to avert the doc pay cut and make other Medicare changes, and home care once again landed on the chopping block to have many home services radically reduced or have their funding cut all together. Some of the specifics of the home care that were discussed to be directly affected were wheelchair suppliers and oxygen providers are under discussion for reimbursement reductions to pay for the fix. The parties involved were sharply divided. The Democrats presented their plan which would finance the physician pay hike by cutting payments to certain Medicare managed care plans. Republicans, however, insist that rural patients depend on Medicare HMOs which would be affected under the Dem's plan. The goal of the Democratic leaders was to mark up a Medicare bill by the end of October, but “they’re dreaming,” Sen. Trent Lott (R-MO) commented to reporters.
The end of October has come and gone and no firm decisions have been made as of yet, we'll update you as soon as we hear changes are agreed upon for Medicare funded home visits.
Want to know why your emphysema claims aren't being fully reimbursed? Often, the reason is that you're lacking two things when you submit your claim. You aren't being detailed enough with your coding and your don't have enough detailed medical documenation to back up your full diagnostic testing that is required to accurately diagnose emphysema and narrow the degree and type. When you're compiling the medical billing for an established patient with active emphysema (492.8, Other emphysema) and they present and are complaining of shortness of breath (786.05); the physician provides inhalation treatment, trains the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity, how would you report this?
There will be multiple codes for this visit as the emphysema was the reason for the visit however the physician also provided services and consulted regarding the nebulizer so there will need to be additional codings on the medical billing to take all the services rendered into consideration.
Be sure and capture 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered-dose inhaler or intermittent positive pressure breathing (IPPB) device]) to cover the comprehensive service the physician provided regarding using the nebulizer. Additionally, add in 99213, and back it up with documentation to show that the physician performed an exam of an existing problem with low- complexity decision-making.
If your documentation shows that the physicians's primary intent was to treat the difficulty in breathing at the time of the visit, switch to 94640(Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).
It's important to always show if the emphysema is currently active at the time so further claims can use that diagnosis as part of the history where applicable.
As more research is done regarding the relationship between varicose veins, blood clots and other complications; more and more patients are having the simple surgery and as a result there has been confusion about exactly how to code this procedure to get the fairest reimbursement for this service. Once you know the basics for setting it up - it's easy!
A good example would be if a patient with varicose veins in her left lower leg presents to the ED and is stating she has severe pain in her leg. One of the veins is clearly bleeding so the doctor will use a standard suture ligation to stem the bleeding and winds up removing one of the veins in the procedure. Suture ligation isn't an uncommon way to treat a bleeding varicose vein, however there is currently no specific CPT code for it. The answer? Break it down!
A good way to report this on your medical billing would be to use code 37785 (Ligation, division and/or excision of varicose vein cluster[s], one leg) for the ligation. Be sure to attach ICD-9 code 454.8 (Varicose veins of lower extremities; with other complications) to 37785 to prove medical necessity for the procedure. You should be aware that 37785 has high RVUs and may be considered by some carriers to be more indepth of a procedure than was actually performed. A good rule of thumb would be to verify directly with the specific carrier that you are reporting to and make sure they will cover the procedure as such. If they won't a good alternative reporting method on the medical billing would be to report 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities which includes hands and feet]; 2.6 cm to 7.5 cm) for the repair and attach ICD-9 code 454.8 to 12002 to prove medical necessity for the procedure.
Include all your documentation and be as detailed as possible, especially in the case of not being certain what the carrier will cover - simply ask and document the time, date and full name of whoever you speak with - this will insure all bases on your claim are covered.
Since consultation requirements have increased in the last year as far as criteria for getting them reimbursed in your medical billing claims, there are some criteria you must be certain that your claims meet in order to justify using codes 99241-99255.
It used to be simple and medical billing consultant merely had to meet the three "R's" in order to justify medical billing claims for consultations. However the criteria for what does and does not constitute a consultation has changed and in order to make sure that your medical billing claims are paid, you need to reacquaint yourself with the three R's of medical billing for consultations.
The three R's are (1) Request for opinion; (2)Rendering of services; and (3) Report to the requesting source. The first big change in late 2006 applied to the qualifying requesters. The new CMS guidelines that were issued now require that a physician make the request. It's easy to meet this requirement by simply getting a written request; but that's not all. CMS officials still insist that the requesting physician has to document the request for a consult. The only change is that the consultant doesn’t have to verify that the initiating doctor has done so.
If you don't have the medical documentation to back up the consultation, chances are good your claim won't be reimbursed or at the very best only partially so. The best advice you can follow is to let your documentation guide your medical billing and coding. If you can't meet the three R's criteria prior to billing, attempt to get the proper documentation to do so, it will mean a little extra leg work, but the practice will reap the rewards in the form of accepted medical billing and reimbursements.
The injectable contract agent named Perflutren better known as Definity has caused a lot of confusion as many providers are billing the incorrect code and Medicare and most other large payors switched the code for this service in late 2005 and 2 years later it's still showing up on medical billing and causing numerous delays and rejections on medical billing reimbursements. If you’re a service provider that is still billing A9700, you could face delays in getting paid--or even denials on your medical billing claims.
If the carrier approves the main echocardiography procedure, then it will usually approve the use of Definity as contrast. If you are not sure of the current policies of the carrier that is being billed, put all doubt to the side and verify directly with the carrier that parts of the procedure will be covered and additionally what code they are approving for the use of Definity.
Make sure your medical billing documentation outlines the reason and necessity for the use of Definity and it's a good idea to show the steps leading up to the use of the contrast agent to show how the need was established.
Sending a doctor's letter is another way to establish the necessity of the procedure and try to show the need for coverage of the procedure. This will up your chances of reimbursement for the service.
When a wound needs closing and a tissue adhesive is used the medical billing coding can be different than when sutures or stitches are used.
There are specific guidelines for medical billing when tissue adhesives are used. All adhesives including Dermabond have their own unique way of being reported on medical billing. Consult with Medicare or the carrier to ensure that you are meeting those guidelines prior to submitting your medical billing.
There are five basic guidelines that Medicare requires in order to reimburse for this service and many carriers follow the same criteria for laceration closures utilizing Dermabond. You should report G0168 for Medicare patients only; the CPT code equivalent to G0168 is the 12001-12018 series (Simple repair of superficial wounds ...)is the equivalent to the G series used in Medicare billing. You can report G0168 for Dermabond-only laceration repairs in both the inpatient and outpatient settings
If the physician uses sutures or staples with Dermabond to perform a laceration repair, you can report only the layered laceration repair code based on the length and site of the wound, and you should not use G0168. Additionally, you should not report G0168 when the provider uses tissue adhesive strips for simple laceration repairs.
Here is a tip regarding reimbursements, Medicare assigns a payment status indicator of "N" to G0168, meaning it represents an incidental service. You can report the code, but you won't receive any reimbursement for it from Medicare payers.
Will inaccurate activities of daily living scores hurt you? You bet. ADL coding is something that auditors will be watching heavily and if you're not calculating yours correctly, you'll penalized and fined.
One way to make sure your facility is well within the guidelines of billing permissibly and ethically is to do a RUG profile of your residents and compare your facility to the state and national averages. You can compare at your facility to the other agencies in your state and against the national averages at the Centers for Medicare & Medicaid Services Web site (http://www.cms.hhs.gov/www.cms.hhs.gov/apps/mds).
If you find that your facility has far fewer rehab RUGs ending in C’s and far more A’s than the national or state average, than it's fair to assume that your building is probably downcoding ADLs and you're missing out on reimbursements.
It's a fine line and you need to check your facilities ADL scores on a regular basis or you could be billing incorrectly. That’s important to do because “if you accidentally upcode where the person goes into a higher paying RUG, you can get in trouble and owe Medicare (or Medicaid) money. Frequent checking will help you avoid this issue.
Check your records on a regular basis and ensure you both coding correctly and getting maximum reimbursements for your services to patients.
TB is in the news more and more and if you aren't already seeing an increase in TB screenings, it's likely your practice could experience it in the future. If you have a medical billing claim involving a patient that is at an increased risk for tuberculosis (TB) infection or is already having symptoms, a TB screening can be performed. If your practice runs these tests, be aware that in many cases, you can get reimbursed for the test as a medical necessity.
When processing the medical billing for a TB skin test (86580) or blood test (86480) due to pulmonary TB symptoms or known TB exposure or risk. The ordering diagnosis should be V74.1 (Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis),and be sure to back up the need for the additional test with ironclad documentation.
If you can show the medical necessity for the procedure and the history of the patient leading up to the reason for the test, you should be able to get reimbursed for any additional testing as a necessary procedure as part of the whole care for the patient. If you're tired of keeping up with the changes in the medical billing industry that directly affect the reimbursements your practice is getting, it may be time to consider outsourcing your medical billing claims to a professional company that get you the maximum reimbursements as quickly as possible. Look into outsourcing today and reap the rewards.
RVUs (relative value units) cause a lot of confusion in the medical billing world when you're dealing with imaging procedures. It's really just a matter of listing your services rendered logically then tallying them up from largest to smallest. For example, imaging codes aren't discounted under the multiple-surgery payment reduction, so you typically list surgical codes first, in order by RVU, then the imaging codes.
Your final coding report should look like this in order :
* 35471 main coding
* 36245 main coding
* 75722-26-59 procedure with modifier
* 75966-26. procedure with modifier
Just remember to list the "heavier" codes at the top of your list and the lighter codes such as imaging, at the bottom. You should include a diagnosis code where appropriate that is based on what the radiologist documents. Tie this in with what the treating physician documents and you should have a specific diagnosis for the patient to show exactly what the RVUs are that you are billing for.
Make sure that your medical billing has the necessary documentation to get the best reimbursements possible. Your documentation showing medical necessity for any service you're looking for reimbursement for should be clear to the carrier or you risk partial payments or outright denials on your medical billing claim.
In 2007 the OIG zeroed in on incident to billing claims. The HHS Office of Inspector General plans to issue a report on whether all the requirements for incident-to billing, including direct physician supervision are being followed. The OIG wants to know whether these services met the Medicare standards for medical necessity, documentation and quality of care, according to the OIG’s Work Plan. Other topics include:
Other things that will be closely studied in the report include global periods and how they are determined in the medical billing. The agency will also be in the lookout for assignment violations where the physician has billed the patient more than Medicare co-pays for a service. They will also be ascertaining if the physician is notifying patients of their right to not be overcharged.
Imaging services will also come under close scrutiny. Medicare paid out $7 billion in 2005 and will be looking at all imaging services for medical necessity and proper medical billing. To keep overpayments on this type of service at a minimum.
The popularity of eye surgery is also under the microscope of scrutiny. If the OIG suspects that you’re billing for cataract and LASIK eye surgeries in ways that don’t meet Medicare requirements, you could find yourself under audit and quickly. The smartest thing you can do is consult with a medical billing partner and make sure that every claim you file is to the letter proper and help you avoid setting off audit triggers.
Critical care is often confusing in the world of medical billing as a number of factors can come into play and whether you need to bundle services or not will also be an issue. Due to the nature of the critical care - notes are often made hurriedly and in many cases are incomplete and it is up to the medical billing professional to put it all together into a package that will be clear, concise and easy to read for the carrier to the services may be reimbursed.
A good example is if a surgeon performed 64 minutes of critical care for a patient in cardiac arrest. During the encounter, the physician also took a chest x-ray and performed ventilatory management. You need to show the medical necessity for all the procedures performed but in this case should most likely bundle all the services together as one critical care service as CPT guidelines bundle chest x-rays (71010, 71015 and 71020) and ventilatory management (94656, 94657, 94660 and 94662) into (not separately payable with) critical care codes (99291-99292) - so they would not be billed as separate services.
Do however report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care and link it with 427.5 (Cardiac arrest) to 99291 to represent the patient’s cardiac arrest.
Making sure you know when and when not to bundle services will result in better reimbursements for your practice.
Due to high usage and informational usage by the medical billing community at large, the Medicare website has revamped certain areas to make their site easier to search and access. When a medical biller is looking up information, at the Medicare coverage site located at www.cms.hhs.gov/mcd/search.asp, it is now easier than ever to search for the coverage limitations and other required information that you need.
The page is now set up to ask if the biller is asking for a local or national coverage determination to avoid confusion and misinformation that was previously disseminated as there are certain differences between local and national coverages for certain procedures.
Medical billers may also now search under geographic area, keyword, ICD-9 code, CPT/HCPCS code, coverage topic, and effective dates. After you've typed in your criteria, click "search now" and wait for the results to pop up.
This will make it much easier to find out what you need to meet your Medicare criteria to get the maximum reimbursements for procedures done and also if a procedure isn't fully covered, find out what components are indeed covered so that the medical billing superbill can reflect that and ensure that the physician receives the best possible reimbursements for procedures and services rendered.
A common occurrence in the emergency is the dislocation of various joints. They are sometimes incorrectly handled as breaks but shouldn't be and you could be setting your practice up for a denial at best and audit at worst if you report these procedures incorrectly on your medical billing.
Even if the reduction of the dislocation fails, the attempt should be reported on not only the medical billing as a procedure but also in the documentation as another procedure will have to be tried to relocate the elbow to its proper placement and you can show the timeline for the necessity of other and more involved treatments.
On the claim you would want to report 24600 (Treatment of closed elbow dislocation; without anesthesia) for the elbow reduction. Then attach ICD-9 code 832.03 (Dislocation of elbow; closed; medial dislocation of elbow) to show the reason for the reduction) and then add the modifier 52 (Reduced services) to 24600 to show that you are not reporting a fully successful reduction.
Some physicians may choose not to bill at all for a painful procedure that isn't successful however do include the medical necessity and documentation of the procedure to show the reason for another or more expensive procedure.
Cover yourself and make sure all your medical billing claims are thoroughly documented, this will result in better reimbursements and airtight claims from your practice.
For correct payment amount, accurate place of service codes are required. The failure to provide the correct place of service code with the correct current procedural terminology code for E/M services will cause your claim to get denied. One of the most important elements of medical billing is the place of service code.
In medical billing, the place of service codes for an evaluation and management are commonly misused. There are several current procedural terminology codes for an evaluation and management session that correspond to different medical billing place of service codes. When using CPT 99341 (Home visit for the evaluation and management of a new patient) through 99350 (which means the same as 99341 except with an established patient), the only POS code available for use is 12. This means home.
Many billers get confused with these medical place of service codes. If a patient is in an assisted care center, many people consider this a home and bill with place of service code 12. This would be incorrect. POS 12 is reserved for house, apartments, etc visits. There is actually a more specific code for an assisted care center in medical billing, the correct POS code would be Medicare Contracting Changes Could Bring Reimbursement Delays When billing to Medicare, expect some medical reimbursement delays in the upcoming years. The Centers for Medicare & Medicaid Services is currently reforming contractor workload for medical billing claims that come in. The speedy implementation of this medical billing reform may lead to reimbursement delays and errors.
Congress mandated that the Centers for Medicare & Medicaid Services reform their contracting system. This needs to be completed by October of 2011. However, since estimates of huge savings have been made, the Centers for Medicare & Medicaid Services wants to speed up this medical billing contractor reform. Their goal is to have it completed by 2009, which is two years earlier.
This change to the contractor method will take many Part A and Part B contractor work loads and transfer the loads over to the Medicare Administrative Contractor. Unfortunately, by making this reform too soon it is very likely that medical bills will be reimbursed incorrectly or with much delay. It seems as though the Centers for Medicare & Medicaid Services has not thought of possible medical billing and reimbursement problems of implementing this system too soon. The Government Accountability Office has suggested to CMS to wait until 2011, but they have refused.
If your practice is planning on billing Medicare in the coming years, it would be wise to keep close track of those medical claims. Make sure they are not lost in the cracks. Also be sure they are reimbursed at the correct rate. This extra effort could become a headache for your practice. Medical Billing firms can alleviate this stress. Their job is to make sure your claims are paid on time and accurately. They know how to deal with payers. Medical billing companies can save your practice much headache once Medicare makes contracting reforms.13.
Basically, for every current procedural terminology code, there is a correct place of service code that corresponds to it. if these medical codes are used incorrectly in billing, it will cost your practice time and money. Insurance companies will deny the claims and your office will have to correct the problem. With the use of an outside medical billing company, you can erase this problem from your mind. Medical billing companies are versed in the correct billing procedures for every medical service. They check claims for accuracy before they are submitted and take care of any claims that come back unprocessed. Correct medical billing POS codes are essential for maximum practice profitability.
If you work in the mental health area, you can expect there to be a coming clarification on how HIPAA and FERPA should be interpreted along with a other state and federal privacy laws dealing mostly with situations concerning mental health workers when dealing with patients in conjunction with educations and law enforcement. This change is largely in part to the misinterpretations of privacy laws that were contributed to the Virginia Tech shootings earlier this spring, however it was not attributed to the laws themselves, concluded federal officials in a report to the President.
The report was a compilation of data that was put together by several different agencies including The Department of Health and Human Services, the Department of Education, and the Department of Justice that all made the report after interviewing mental health professionals, educators, and law enforcement officials around the country. In part the report states, “Critical information sharing faces substantial obstacles, education officials, health care providers, law enforcement personnel, and others are not fully informed about when they can share critical information on persons who are likely to be a danger to self or others, and the resulting confusion may chill legitimate information sharing.”
In particular, the report addressed how three bodies of law influenced the actions of people who taught and treated Seung Hui Cho in the months before the shootings: 1) the Health Insurance Portability and Accountability Act (HIPAA), 2) the Family Educational Rights and Privacy Act (Ferpa), and 3) state laws and regs. The report noted that many state laws and regs are restrict information sharing more rigorously than federal laws. Mental health professionals routinely consider these laws when deciding whether to share information in order to protect a patient or those he might harm.
The problem that presented was this : “In some sessions, there were concerns and confusion about the potential liability of teachers, administrators, or institutions that could arise from sharing information, or not sharing information, under privacy laws, as well as laws designed to protect individuals from discrimination on the basis of mental illness.” But it was confusion about the laws, and not the laws themselves, that create the “information silos” that mental health professionals and educators sometimes create, the report argues.
Through this report a solution to help prevent tragic situations such as this was found. The report recommends the development of tools that help providers and educators assess the safety risk and identify instances where protection trumps privacy. Educators, law enforcement officials, and mental health professionals at Virginia Tech could have taken these actions before the shootings without breaking any laws.
Sometimes after a gastric band procedure, the band may slip during healing and need to be adjusted. The uncertain thing is how to bill the procedure since you have already billed the global.
HCPCS temporary code S2083 (Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline) or CPT code 43771 but both of these require that the physician use a laparoscope during the procedure and usually moving the band is done through injecting saline or removing saline from the band to make it easier to adjust through a subQ port.
For most instances you can use S2083, normally you will only use 43771 if patient is taken back into surgery due to complications in the moving of the band such as a prolapse or other issue. If a flouro is used in the procedure, code 77002 may be more fitting for your medical billing and another alternative that may be a better fit, depending on the situation, is 90779 (Unlisted Therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection...) which was one of the range added to the CPT in late 2006.
The key is obviously find the best fit for your procedure and back it up with the strongest documentation you can, especially since there isn't a specific code for this procedure at this time.
A little known fact about well-woman care is that in many cases, you can break out the breast exam and pap smear and realize a reimbursement for both procedures if the patient is covered by Medicare.
If the physician provides a complete well-woman exam for a Medicare patient, you should report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the breast and pelvic exams. When the physician also obtains a Pap smear, use Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory)and this will enable your practice to realize a reimbursement for both services.
Just make sure that you have the necessary medical necessity and documentation to back up the breaking out of both services and in most cases you must attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). An important thing to remember, for Medicare patients at normal risk, you can report a Pap smear only once every two years. The diagnoses your physician will use in these cases include V72.31 (Routine gynecological examination), V76.2 (Special screening for malignant neoplasms; cervix) and V76.47 (... other sites; vagina),
Using these techniques, you should be able to increase your Medicare coverage of this common service to your medical billing claims and see a better reimbursement when you perform this service.
Are you swamped? So overwhelmed with patients, billing, invoices, emergencies and other day to day practice worries that you don't even have the time to get yourself credentialed with all the carriers possible. No one has to tell you that the more insurances you accept, the more patients you can see and the more revenue you can generate for your practice. Credentialing is the key. Did you know your medical billing partner can take some of the heat off you and not only compile and submit your medical billing, they can also get your practice credentialed with any carrier you choose.
If you have a busy practice, you may be putting off getting credentialed with additional insurance companies because you just don't have the time to fill out the forms, questionnaires and other information in order to get approved with additional carriers.
You know from previously getting credentialed that the process can take months for the carriers to process the paperwork and you just do not have the time to fill out the detailed forms and then call the insurance company for follow-up on your application. Wouldn't it be great if someone else could take over the hassle for you?
Your medical billing partner can do this as well as your medical billing and coding. They have the knowledge and expertise to not only get your claims paid but to also get you credentialed with as many carriers as you want to be able to provide services through. This includes Worker's Compensation, most large insurance carriers and Medicare. Whether you want to be credentialed through an individual carrier or one large network, the choice is yours.
Once your application is submitted, your medical billing partner will stay on top of your credentialing request and keep checking the status and make sure your application is handled in a timely manner. This will enable you to do what you do best- service your patients without the headaches of getting yourself credentialed and chasing your medical billing claims.
Your provider number has a strong impact on your medical billing cost to charge ratio (CCR). If your hospital is merging with another hospital, it is important to figure in the possibly new Cost to Charge Ratio medical billing payments you will receive.
There are two avenues merging hospitals can take. The first method is when two hospitals merge together while one of the existing provider numbers is kept in tact. In this instance, one hospital keeps their medical billing number, while the other one drops theirs and joins the first. The hospital that drops their medical billing provider number will receive a new cost to charge ratio. The ratio will be figured from the hospital with the existing provider number.
The second scenario involves a brand new medical billing provider number for the merging hospitals. When each hospital forfeits their provider number, a new provider number is formed. In this instance, there is no prior history to conduct a cost to charge ratio study. Instead, the merging hospitals will use the statewide average medical billing Cost to Charge Ratio until they have history.
If the Cost to Charge Ratio assigned to your hospital is unsatisfactory to your liking, you can request a lower or a higher number. However, there must be substantial evidence to back up your claim. Medical billing cost to charge ratios are difficult to change because they need to be fair to all hospitals involved.
The bottom line is: make sure your hospital is ready for medical billing reimbursement changes if you are merging with another facility. The failure to prepare for such changes could severely impede your financial and medical billing departments for a long time to come. Once your revenue flow is slowed down it can take a long amount of time to recover.
It's a valid concern. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has had a major impact on health care providers who do business electronically as well as many of their health care business partners. Many changes involve complex computer system modifications.
HIPAA compliance requirements have been standardized into 4 main aspects.
1) Electronic transactions and code sets 2) Security; 3) Unique identifiers; and 4) Privacy
One common misunderstanding is that you are required to only report electronically to be HIPAA compliant; however that isn't accurate. HIPAA does not require a health care provider to conduct all transactions and medical billing electronically. Rather, HIPAA dictates that if you are going to conduct any one of these business transactions electronically they will need to be done in the standard secure format outlined under HIPAA. So in a nutshell, you're not required to submit your medical billing claims electronically, however you must be HIPAA compliant if you do.
That's one of the main questions to ask when you're looking for a medical billing partner. First ask if they do electronic billing, then ask if their billing methods are absolutely HIPAA compliant. If you get a long pause or the rep doesn't seem sure exactly what you're asking, keep shopping. Another qualifying question can be to ask about the submissions process from start to finish and, that can be a big clue as to whether the medical billing company has secure transmissions.
Remember, when you're looking for medical billing partner, the best fit for your company may not be located near your practice. If you're using secure data transmissions, it opens the field for you to use any medical billing company you choose, as long as they meet your criteria for HIPAA compliance and other issues such as claims follow up and the handling of denials and rejections, on the rare occasions they will occur once you switch to outsourcing your medical billing.
It's expensive to keep up with the technology required to be HIPAA compliant in your billing and it's also difficult for your staff to keep up with the never ending changes in the CPT. If you are finding your staff is spending more time chasing claims then helping service patients, it may be time to give outsourcing your medical billing a long, serious look.
Just when you got a handle of medical billing, another policy throws a curve ball at you. In some instances, the same CPT code is used for two different procedures. An example of this is when performing both and extra digit removal and a skin tag removal. The same medical billing CPT code, 11200, would be used in both of these instances.
The medical billing code 11200 means, removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions. This means that if an individual needs an extra digit AND a skin tag removed, than you would use 11200 to report both.
To let the payers know the reasons, you would report two separate medical billing ICD-9 codes. For instance, you could use 757-759 (congenital anomalies), for the extra digit. Then you would use a medical billing code such as 757.39 (other specified anomalies of skin) to report the skin tags. This way, the payer will know that there were two different procedures performed.
One thing to keep in mind when doing medical billing for 11200, is that it can only be billed once per instance. The code actually describes removal of up to 15 different lesions during the same session. This is why it is so important to report the correct diagnosis codes when doing medical billing. They payer will have no idea how many lesions your remove if the codes are not reported.
Make sure all your staff are aware of the correct medical billing policies that could affect your practice. If you are a radiology facility, make sure you staff are up to date on all radiological procedures. Although it would be difficult to keep current with all medical billing policies, staying as current as possible is extremely beneficial.
For help with performing the care plan oversight services if you are having a hard time with the 993xx series these steps should help to get you started.
Step one is to count these care services as 99374-99380. The 993xx series codes allows pediatricians to bill for coordination of care of special needs children without face to face visits. You can report these care plan oversight CPO codes as 99374-99380 for Doctor supervision. This is only for when the patient is not present for the following doctors services,
a) revision or development of care plans for multidisciplinary and complex modalities.
b) related lab and other studes review
c) patient status report reviews
d) assessment of care decisions by way of telephone calls and internet communication of healthcare professionals, family, primary caregivers and legal guardians.
e) new information assimilation into the medical treatment plan or medical therapy adjustment.
2. Code Set identification
The CPO codes facility supervision entities are going to be expanded in 2006, however these services may only be reported when the patient meets one of these three conditions:
a) the patient is under a home health agency care--99374 or 99375.
b) patient is on hospice--99377 or 99378.
c) patient is a nursing facility patient--99379 or 99380.
3. Make sure you have the Total Monthly Minutes for the Exact Code
CPO codes must be billed based on 30 minute segments. To document and perform 15-29 minutes of CPO services in a month, use the first code in each of the above sets which are: 99374, 99377, 99379). For services that are longer, 30 minutes or more, within a calendar month report the second set of codes 99375 and 99378.
When using 434.91 make sure you take all of the specifics into account. When a doctor says that a patient has had a stroke make sure that you know all of the details of the situation or else some procedures can be hard to justify and therefore your medical billing reimbursement may be denied.
In the past for diagnosis of a stroke the ICD-9 index listed 436, which is acute but ill defined cerebrovascular disease, as the code to use. Now the index has code 434.91 as the code to use. This is cerebral artery occlusion, unspecified with cerebral infarction. The new ICD-9 index automatically translates a doctors diagnosis of a cerebrovascular accident to an occlusion with an infarction.
This new listing is good news for you in that you might now get renumerated for services that were not covered in the past for patients of stroke. This is obviously good news and something that you will want to make sure that you are on top of.
Keep Documenting those Details
Consultant Sandy Nicholson with Pershing Yoakley & Associates in Atlanta, states that you should still make sure that physicians write down precise diagnoses. As of right now physicians can write down "stroke" without going into greater detail and you must discourage that. This means that you could be missing out on the diagnostic details that justify the procedures the doctor performed and therefore missing payment.
An example of this would be where the doctor doesn't note a cerebral hemorrhage with a stroke, which would understate the seriousness of the patient's condition. This is vital information for other providers so that they can realize how to treat the patient so not to kill him or her. Embolic strokes have 1/5 the death rate of hemorrhagic strokes and if there is nothing saying a patient has a hemorrhage and they are given coumadin or aspirin it could kill them.
The coder will use ICD-9 code 431 for Intracerebral hemorrhage if the doctor indicates that the patient has had a hemorrhage. There is a difference in what procedures Medicare will cover for differences in strokes. For a stroke without hemorrhage Medicare will not cover surgical or transcatheter interventions. So making sure that the diagnosis is specific and correct is very important.
The time to use 59025 to code a fetal non-stress test is when the patient records that she has felt the baby moving. If not then the fetal monitor is counted as routine.
What makes the NST Code True?
When you use the code 59025 for the fetal non-stress test for NST procedures you must make sure you are using them correctly. How that happens is that during the NST procedure the ob-gyn evaluates the patient and evaluates the well being of the fetus with out the use of IV medications. The test lasts for approximately 30-40 minutes, and the ob-gyn monitors the heart rate of the fetus using external transducers.
If the NST is reactive it will show the fetal heart rate go above the baseline which is 15 beats per minute for a minimum of 15 seconds twice in a 10 minute time frame. If after 20 minutes the fetal heart rate has not sped up then the doctor may try to get a fetal response with acoustic stimulation through the mother's abdomen or a vibration. The acoustic stimulation or vibration has the effect of waking the baby or causing it to react to the stimulus. The ob-gyn might then repeat this stimulation once every five minutes for a total of two to three times. If there is still no acceleration of the baby's heart rate then the doctor will determine that the test is nonreactive.
The most important thing is that the patient feels the fetal movements and marks it. The ob-gyn interprets the test and dictates a report that must be included on the patient's record. An example would be that the ob-gyn sees a patient that is at 31 weeks gestation who has a feeling that her fetus has not been moving much. For the first 20 minutes of the monitoring the doctor uses external transducers and finds no accelerated heart rate for the fetus. The doctor then tries an electronic larynx to get the fetus stimulated through noise through the patients abdomen. The patient marks when she feels movement throughout the test which is about 30-40 minutes.
This service would be reported with 59025 because the doctor is using the NST to determine the fetal status. This procedure takes longer than a labor check and also requires that the doctor use repeated stimulations to evaluate the fetal reactions or the lack of reactions.
Using these codes correctly and with the proper documentation will insure that you get the complete medical billing reimbursements for the procedures done.
In 2006 several changes were made to the CPT regarding skin graft procedures and this included the retiring of several codes and the addition of 37 new skin graft codes to make identifying the procedures more exact for medical billing claims. The skin graft section was also renamed to Skin Replacement Surgery and Skin Substitutes.
There are new codes for autografts, sections 15100 through 15261, allografts, sections 15170 through 15176 and xenografts, sections 15400 through 15431. These codes seem to have been created in order to represent some new procedures and techniques. Many of these new codes are also specific to a particular technology or product make sure that your medical billing claims reflect these codes or you may be missing a substantial amount of reimbursements for procedures done.
It seems that there has been a lot of struggle for payment to be received for some of the expensive and specialized products. This is especially true if a general skin graft code was used, observed John Bishop who is President of Bishop & Associates in Tampa FL. The products that are usually harder to receive payment for are Integra, Appligraft, Biobrane and Dermagraft.
Bishop states that paying attention to the amount and the composition of the synthetic product you are using is key. Many of the new codes cover the initial 100 cm and then have additional codes for more product used. Make sure that your staff is using the most updated codings to reflect services rendered and you should be able to receive better reimbursements instead of denials and delays for your skin graft claims.
Knowing when to use code 90782 in emergency department procedures can help with your medical billing reimbursements. For example, if a doctor examines a patient in the ED for an injury, and injects a preventative tetanus toxoid, your first instinct might be to use 90782 as a modifier for this procedure.
But you would not receive a medical billing reimbursement because the incident to provision does not apply in the emergency department so you would not be able to justify having the doctor administer this injection. There would be no way to justify the medical necessity of such a shot.
However, when you are in an office setting the CPT intructs that you are to select the name of the procedure and or service that ids as best possible the service that was performed. You want to make sure that you report as accurately as you can the service that was performed rather than just approximate it. The more accurate code here would be 90703 which is Tetanus toxoid absorbed for intramuscular use.
Medical Billing Hint: It is better to not append to modifier 51 for multiple procedures, to vaccine product codes or to the administration codes. If there is a significant separate service that the doctor performs you should report that separately. Also make sure that you remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
Are you ready for the updates coming on October 1? There are a number of changes that will affect that way Medicare reimburses your practice for the services rendered as well as adding and retiring other codings. All of these changes will be effective for service dates after October 1.
You can avoid a lot of paperwork hassles and denials by making the jump to outsourcing your medical billing. Your third party partner will keep up with the ICD-9 coding changes, rules and regulations and if you choose, can even do an audit of your current medical billing methods and show you how you can realize a better reimbursement rate on your services rendered. Many physicians are shocked to learn they've been basically giving away nearly 25% of their reimbursable income through faulty medical billing filing practices.
If you're ready to leave the paper chase behind and free your staff up to service patients instead of figure out what items on your medical billing got reimbursed, it's time to outsource your medical billing and you'll never have to sweat another CMS update again.
Knowing when to use code 90782 in emergency department procedures can help with your medical billing reimbursements. For example, if a doctor examines a patient in the ED for an injury, and injects a preventative tetanus toxoid, your first instinct might be to use 90782 as a modifier for this procedure.
But you would not receive a medical billing reimbursement because the incident to provision does not apply in the emergency department so you would not be able to justify having the doctor administer this injection. There would be no way to justify the medical necessity of such a shot.
However, when you are in an office setting the CPT instructs that you are to select the name of the procedure and or service that ids as best possible the service that was performed. You want to make sure that you report as accurately as you can the service that was performed rather than just approximate it. The more accurate code here would be 90703 which is Tetanus toxoid absorbed for intramuscular use.
Medical Billing Hint: It is better to not append to modifier 51 for multiple procedures, to vaccine product codes or to the administration codes. If there is a significant separate service that the doctor performs you should report that separately. Also make sure that you remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
Often, patients who are confined to beds for long periods of time develop pressure ulcers. They are painful and need to be treated as quickly as possible as infections can set up within them that can be life threatening when the patient is already in a weakened condition.
When a service is performed for a patient such as treatment of a pressure ulcer on an area of the body such as the lower back, the usual manner of treatment is to remove any devitalized tissue from the ulcer using a water jet and forceps. The area is then covered to allow it to not be rubbed on so the skin can begin to repair itself.
When you report this type of claim, read the description of the code carefully. You will notice the since the water jet is normally used, it is already bundled into the claim itself. If you report it additionally, you are setting yourself up for a total claim rejection.
You would want to report this claim as follows (make sure you know the measurements of the wound being treated):
* report 97597 (Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high-pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters) for the debridement. You will also want to link 707.03 (Decubitis ulcer; lower back) to 97597 for the pressure ulcer.
Let these tips make your ulcer reporting easier and reap the rewards of full reimbursements for these procedures.
Remember when medical billing used to be a simple affair of matching the procedure done with a couple of medical billing codes to describe what was done, attaching your documentation and then submitting your medical billing claim for reimbursement?
Now we have codes for codes and modifiers and the need to when to bundle and when to not bundle with the goal being fair reimbursement for procedures done. Modifiers cause a lot of confusion for many medical billers. One such confusing modifier that is worth clarifying is Q6.
This applies to Medicare medical billing claims only, but in a nutshell when one of your staff physicians takes a leave of absence for any reason and a substitute physician fills in, you need to add the Q6 modifier to Medicare claims the sub handles if you want to ensure reimbursement for the services that the sub provides.
If you're wondering why, the reason is that when a substitute or locum tenens physician handles patients, Medicare wants to see specific modifiers on claims. This is to make sure that the time limits on locum tenens doctors are strictly observed.
In order to be reimbursed, make sure that modifier Q6 (Service furnished by a locum tenens physician) is attached to all codes for procedures performed by the substitute physician. This lets the Medicare carrier know that you are coding for a locum tenens physician. Without the modifier, you’ll likely receive a denial for the claim.
Since many private carriers are adopting more and more of Medicare's standards for payment on services; before filing a locum tenens claim with a private insurer, verify with the plans as to their requirements for locum tenens billing -- and whether or not they even recognize it.
Some good questions to ask are : * Do you recognize modifier Q6? * Which provider’s ID should be reported for the services? * Does the locum tenens provider need to be credentialed with the payer, even if only temporary privileges? As always - write down the full name and position of whomever you speak with and the time and date of your call in case you need to track that person down again.
Long term care medical billing has its own set of nuances that must be followed in order to ensure that you receive proper reimbursements for the services you provide. Since nearly every patient you treat will have a long term history of care - it's sometimes tempting to skimp on the medical documentation and necessity but since you have no way of knowing who is going to review your claim, you need to handle every claim as a fully individual manner complete with full documentation or you may wind up with partially paid claims or outright denials of your medical billing claims.
One important thing to learn is when you should also list a diagnosis code for the wound in I3. The I3 is important to complete when you're doing medical billing for long term care patients as it reports additional conditions that affect a patient's health.
Since pressure ulcers are extremely common in long term care for patients that are invalids, there is a Section M that provides options for identifying both pressure ulcers and stasis ulcers but not for other types of ulcers. If another type of ulcer is to be reported on your medical billing claim, use the form and then also list the corresponding ICD-9 codes at I3.
A confusing part of medical billing for long term care comes from the I3 itself where some I3 coding training indicates that you don’t need to include diagnoses codes for conditions that are addressed elsewhere on the MDS. However, many carriers, including Medicare do require that the type of wound be specifically spelled out. Additionally, once the ulcer is healed, be certain to take it out of section I3.
Medical billing changes occur throughout each and every year and keeping up with those changes can be confusing. Aural Rehabilitation has become one major area of confusion since the 2006 update. The medical billing changes to Aural Rehab CPT codes has wrongly caused many people to believe Aural Rehabilitation is no longer a reimbursable service.
Medicare actually assigned status code "I" to all new medical billing codes for auditory rehabilitation. These codes are 92630 and 92633. This means that the Centers for Medicare and Medicaid Services will not pay for auditory rehabilitation, only diagnostic audiology. However, this is only true if an audiologist performs the service and the medical billing.
There are several other medical professionals that could possibly perform medical billing for aural rehabilitation. A speech language pathologist is one example of a provider who could get reimbursed by CMS for aural rehab.
It is important when reviewing new medical billing changes not to jump to any conclusions. If you did this, you could be missing out on money. For example, there may still be speech pathologists who perform aural rehabilitation, but don't perform medical billing for the service. Having a partner firm to help your staff review and alert you of any coming changes that will affect your reimbursements is invaluable.
Not to mention that hiring a medical billing firm to review new coding changes and to handle your claims will take a lot of the paper-chase and workload off your in-house office staff. Get a free consultation and find out exactly how much of your reimbursements you've been missing through handling your own medical billing, most practices are astounded to learn they are losing up to 25% of their revenue through unpaid claims that are simply filed incorrectly or procedures that could be billed separately.
When do I use medical billing modifier 59? This is a great question. It is one that many don't ask, but most don't know the correct answer to. One of the most important things to know about the medical billing modifier 59 is which code on which to append it. There are some basic medical billing rules that can teach you which code to use with modifier 59.
The general assumption about modifier 59 (Distinct procedural service) is that it should be linked to the lower-valued code of the pair. Although this may be true a lot of times, it is not always true. There is a much better rule to follow to have correct medical billing documents.
The better rule to use with the medical billing modifier 59 is to append it with the component code, or the code in column two. The NCCI (National Correct Coding Initiative) code list consists of different edits with two types of codes. The edits have columns. One column is the comprehensive column, and column two is the medical billing component column. If on the same day, you report from both columns, the Centers for Medicare and Medicaid Services will only reimburse for the first column.
The medical billing modifier 59 should be used if you bill from both columns on one date of service. You should always append the modifier to the code in the second column. This will ensure correct medical billing reimbursement. Many times this is the lower valued code, but not always - as always with medical billing, it's usually a judgment call based on other factors in the medical billing claim.
Coding for tissue adhesives can be confusing because there isn't one set procedure for this. The coding that is used is determined by the type of wound and the severity of the repair when tissue adhesives are used for wound closures.
The answer to this question will be different depending on which entity is paying the medical billing claim. When you code for the use of tissue adhesives, including Dermabond; Medicare has its own guidelines for reporting this procedure that you need to follow to be reimbursed. You should report G0168 for Medicare patients only. If you are reporting the procedure for a non-Medicare patient, you should use the CPT code that is the equivalent and that is 12001-12018 series (Simple repair of superficial wounds ...).
Another tip for reporting this claim to Medicare is you may only use G0168 for Dermabond-only laceration repairs in both the inpatient and outpatient settings. If sutures or staples were also used you will have to report this as a layered laceration code on your medical billing form.
Something you may not be aware of is that Medicare assigns a payment status indicator of "N" to G0168, meaning it represents an incidental service. You can report the code but you won't receive any reimbursement for it from Medicare payers.
Private payers will have different guidelines, a quick check with the payers to see if they follow Medicare guidelines for this type of procedure will let you know whether or not to expect a reimbursement for the service.
As a medical biller, you may be seeing an increase in the number of gastric bypass claims that you are handling as more and more insurances are covering this procedure as a measure to remove the patient from danger of developing more serious, chronic and costly illnesses that can stem from being grossly obese.
After a patient has undergone gastric bypass surgery, eventually they will have the band removed. Many medical billing professionals are amiss at whether to include modifier 59 with their claim in order to obtain reimbursement for the procedure.
Under The Correct Coding Initiative (CCI), normally the procedure of removing the band and port removal would be bundled and reported using code (43774, Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components) to the gastric restriction (43644, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less]).
The edit will already include a "1" modifier indicator, meaning you can append modifier 59 (Distinct procedural service) to report 43774 separately. But here is the hitch for this type of claim and the reason it is usually bundled, is because the surgeon would have to remove a previously placed adjustable band and port, if present, before performing the gastric bypass, which makes charging for the removal as a separate part of the procedure to put the band on when the gastric bypass was performed almost impossible.
The bottom line of this type of claims is that although Medicare and other carriers may pay for the initial procedure, they are normally going to expect the claim for removal of the gastric band to be a logical part of the procedure and in the majority of cases there will no separate reimbursement.
The Centers for Medicare and Medicaid Services have recently made it known that the reimbursement for procedural code 92696 is going to be increases by a rather large amount. To clarify a little bit further, the reimbursement to providers for such a procedure will come in at approximately four times the amount being received currently. This should make any of the providers of language, speech and hearing much happier when it comes to medical billing.
This entire thought of reimbursement may be a lot clearer if it is broken down a bit. For example, the code 92626 which is known for the description of Evaluation of Auditory Rehabilitation Status; first hour, is going to nearly quadruple in value. The old amount to be reimbursed was only $22.07, compared to the changes where the reimbursement amount is a whopping $81.76. The whole reason for the change in reimbursement is because there were previous errors in the calculations, which made the American Speech Language Hearing Association one of the main focal points.
Because of a certain decrease in malpractice costs, another medical billing code to be lowered is 92627 (each additional 15 minutes). The actual difference in the rate for this code is $22.07 down to $20.62.
As long as you are constantly aware that reimbursement rates along with all of the other medical billing policies are always changing, you should be able to remain one step ahead of the game. Being able to charge more for certain medical billing codes, such as 92626, will only be able to help out your practice in the long run, although many of the changes in medical billing reimbursement have been shown only to even out after an extended period of time.
Did you know that you can actually bill separate tests performed from your practice for separate payments? Certain practices have been taking advantage of larger reimbursements by doing just that. Say that you have a patient that is new to your practice and they are coming in for an exam. You can both bill for that exam and then bill separate for any other tests or screenings that they will be having performed.
Although you may feel as though you are doing something wrong when it comes to medical billing practices such as these. However, the important Centers for Medicare and Medicaid services have been doing a good amount of research in this area. In turn, they will be sending out a wealth of information to be able to explain separate billing procedures for the hopes of better reimbursements down the road. This will help all medical practices learn a few new tricks when it comes to setting up their medical billing.
If you would like another example, if you have a patient who will be coming in for a check up and they will then be scheduled for diabetes testing, this can be billed separately. This can even be done if the patient seems to have been at prior risk for diabetes.
This is a great way to recoup losses you may have previously suffered by bundling separate testing claims. Separate out your services whenever possible and get the reimbursement you deserve for your patient services.
More and more carriers are cracking down on medical billing claims that have a lack of or incorrect place of service code. Even with the correct current procedural terminology code for E/M services, a medical billing claim that does not have a correct POS code will get your claim denied.
It is a common occurrence in medical billing for the place of service codes to be misused or left out. There are several current procedural terminology codes for an evaluation and management session that correspond to different medical billing place of service codes. When using CPT 99341 (Home visit for the evaluation and management of a new patient) through 99350 (which means the same as 99341 except with an established patient), the only POS code available for use is 12. This means home.
Many billers get confused with these places of service codes. If a patient is in an assisted care center, many people consider this a home and bill with place of service code 12. This would be incorrect. POS 12 is reserved for house, apartments, etc visits. There is actually a more specific code for an assisted care center in medical billing. It is POS 13.
Basically, for every current procedural terminology code, there is a correct place of service code that corresponds to it. If these medical codes are used incorrectly in billing, it will cost your practice time and money. Insurance companies will deny the claims and your office will have to correct the problem. With the use of an outside medical billing company, you can eliminate this problem. When you partner with a medical billing company, your claims are checked to make sure the correct billing procedures are used for every medical service performed and they check claims for accuracy before they are submitted. You will see your denial rate drop off and your reimbursements will arrive faster than ever before. Make sure you're maximizing your reimbursements with the correct POS codes.
A question that comes up often is exactly how should a medical practice dispose of the hard copies of files? The answer isn't rocket science, shredding is the only good answer. When you are ready to dispose of hard copies medical files, anything with a patient's name on it should be shredded.
If you don't have the staff available and you don't want to invest in an industrial-sized shredder, a good alternative would be to hire an outside shredding service that will either come to your offices and shred on site; or pick up your files, lock and store them in sealed containers and put them on a closed end truck that is locked. Many of these companies will ask you to sign off on both the containers as well as the truck before they leave to get your documents shredded.
It may seem like taking extra steps but it eliminates the horror stories that you may have heard about such as boxes of patient medical files falling off open pick up truck beds or boxes of files simply left by dumpsters. Many physicians are now requiring that outside services only shred the documents on site.
If you don't already have a shredding policy in your office, make sure to take the time to implement one and make every employee aware of it. You can further protect yourself by having your employees sign off that they understand the shredding policy and put that signed copy in their files.
This is another simple way to protect your practice from a simple mistake an employee could make regarding patient files. The more you educate your employees on good practices for keeping private information secure, the less likely your practice is to become a statistic for a patient privacy violation.
"Chronic pain syndrome" can be considered as a vague description of a vague diagnosis by your carrier and unless you back up your medical billing with the reasons for using this catchall term for several pain conditions, you may be seeing only partial reimbursements to denials for this condition. Traditionally, ICD-9 directs you to code 338.4 (Chronic pain syndrome) for the condition.
However, you may need to couple this diagnosis with other probable causes backed up by symptoms and doctor's notes. Other diagnosis possibilities for chronic pain syndrome include fibromyalgia/muscular pain (729.1, Myalgia and myositis, unspecified); reflex sympathetic dystrophy/regional pain syndrome (337.2x, Reflex sympathetic dystrophy) or peripheral neuropathy (337.0, Idiopathic peripheral autonomic neuropathy) caused by either diabetes (250.6x, Diabetes with neurological manifestations) or amyloidosis (277.30, Amyloidosis, unspecified). Among the listed alternatives for 338.4, coders choose 729.1 most commonly as a substitute for the generic chronic pain syndrome diagnosis code.
The best route to getting a better reimbursement on a vague diagnosis is to check with your physician to clarify what type of pain the patient has. The patient might initially report pain "everywhere" but he may be able to pinpoint his worst pain sites, such as the lower back (724.2, Lumbago) or the hip (719.45, Pain in joint; pelvic region and thigh).
Also it's a good practice to verify any of the patient's pain-related symptoms before reporting the physician's final diagnosis. Good examples of those would be back muscle spasms (724.8, Other symptoms referable to back) or derangement of joint (718.95, Unspecified derangement of joint; pelvic region and thigh).
When in doubt, ask the attending physician which diagnosis in their opinion best suits the claim. Using the notes can help you also pin it down and if you show that you have a vague claim that needs more exacting information to get a better reimbursement for the practice, putting the need for exact information in dollars and cents is usually a good way to get the proper information you need to process the claim for the best return on services for the physician.
If you haven't taken the time to evaluate your data; both the data that you actively send as well as the data at rest. If you don't you could be in violation of the new HIPAA violations. The last security rule made by HIPAA (and while the final ruling does not mandate that you encrypt all of your email transmission)it does require that you examine how all of your data is transferred on an overall scale.
There are two key items that will help you evaluate how your data is transmitted. (1)integrity controls and (2)encryption.
Integrity control sounds a little confusing, but it really just means proper access controls and login procedures, password restriction and other user authorizations; which are the basics of most companies' e-mail policies. Integrity control is also a policy approach to e-mail security; that is, making sure your staff members know what e-mail procedures are permitted within your organization. It's important to keep in mind that your organization may not need to encrypt e-mail. But it's a good security measure if you do.
A good strategy to adopt would be for provider-to-patient e-mail messaging, encrypt all data. After giving the patient cautionary information about e-mail security, the provider must obtain a signed patient authorization to permit e-mail communications. Keep this in the patient's file and you will have no questions about whether or not the patient authorized e-mail communications in case a problem or question arises in the future.
Here are some good questions to ask yourself when accessing your data transfer security: #1 How critical is the information being transmitted?
#2 What is the completeness of the information? That is, is this a complete medical record or is this just a snippet of information?
#3 How many individuals might be represented in the information? In other words, information about one person would have a different weight than information about a group of people;
#4 What is the level of the network's security? That's where you start to consider whether it's a local network or the Internet.
If you can not answer all these questions about your data transmission, it is likely that you will need to encrypt to ensure the integrity of your data and stay compliant with HIPAA.
Make sure that you and your staff are up to date on using Q Modifiers as these were updated in 2007. Make sure you are getting the best reimbursements by using the currently preferred modifiers to be reported when the physician is performing foot care.
Modifiers Q7 (One class A finding), Q8 (Two class B findings) or Q9 (One class B and two class C findings) tell insurers why your physician is performing foot care. To determine which modifier applies to your physician's claim, check out the following list of what Medicare and other payers include in each description:
Class A Finding: Nontraumatic amputation of foot or integral skeletal portion thereof
Class B Findings: Absent posterior tibial pulse
Advanced trophic changes such as (three of the following sub-categories qualify as one class finding): hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), skin color (rubor or redness)
Class C Findings: Claudication
Temperature changes (e.g., cold feet) Edema Paresthesias (abnormal spontaneous sensations in the feet, e.g., numbness, prickling, or tingling) Burning
For proper use, be sure to place the Q modifiers to indicate class findings before modifiers LT (Left side) and RT (Right side). Additionally, not all carriers will require it but it is a good idea to include detailed documentation about the necessity of the foot care and tie in the use of the Q modifier.
There are some new guidelines for reporting a nerve block with a circumcision. In the past you may have reported this as two separate procedures using 54150 to document the circumcision and 64450 for the accompanying nerve block.
However the AMA has revised code 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block) in the new edition of CPT 2007 to include the accompanying nerve block in the description of the service. As such, it would now be unnecessary to report 64450 (Injection, anesthetic agent; other peripheral nerve or branch) with 54150 for this purpose, and the National Correct Coding Initiative (NCCI) bundles 64450 into 54150 for this reason.
It is however, permissible to append a modifier because the NCCI edit carries an indicator of "1,"; physicians can append a modifier (such as modifier 59, Distinct procedural service) to 64450 along with documentation showing that they used 64450 as regional anesthesia for other reasons. As always, make sure that your medical billing documentation is iron clad and it will ensure that you get the correct reimbursement for this procedure.
Keeping up with the CPT codes can cost your practice money if your staff submits claims using outdated coding. Make sure that your practice gets the proper reimbursements for the services you provide; if you're experiencing rejections or partial payments - it may be time to consider outsourcing.
Pediatrics is one of the most complex areas of medical billing. It has many medical billing codes that were created just for the use of describing procedures. However, there are other areas of medical billing that do not have these specific codes for children. This can make coding hit or miss unless you know the nuances of what the carrier wants in order to get the maximum reimbursements for procedures performed. A common dilemma is with CPT code 99293 and its use for outpatient emergency room exams for an infant or if code 99291 should be used.
The medical billing code 99291 means critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. You would use this code if a patient came into the emergency room and was there for a half and hour up to 74 minutes. This is pretty straight forward in medical billing. The confusion comes in when using code 99293. This means Initial inpatient pediatric care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age. This code should only be used if the infant is admitted inpatient.
When doing medical billing it becomes confusing because there is no code specifically for outpatient emergency room visits for children. There is only a child specific medical billing code for inpatient visits. A simple rule of thumb in medical billing is that the location of service must match the CPT code. This is because inpatient evaluations get reimbursed at different levels then outpatient emergency room visits.
If your staff is getting overwhelmed at the paperchase of keeping up with the current codes or you're experiencing denials or partial payments of your medical billing claims; it may be time to consider outsourcing your medical billing to a partner that can make sure the latest coding regulations are followed and your practice receives the maximum reimbursements allowed for procedures performed.
It can happen to any individual who is involved with coding, dealing with MUEs can end up being a nightmare if you do not know when and how to use them. MUEs, which is short for the term Medically Unlikely Edits, happen to be put in place to try and help limit the amount of billing errors. The more you understand them, the better off you will be when you find that you need to use them. If you are worried about dealing with MUEs, then you really should know that you are not alone. Luckily, there are a couple of things that you can look to and keep in mind to make sure that you use MUEs the right way every single time.
If you happen to be involved with a Medicare situation, you just might end up seeing that a case with MUEs. There is a chance that you can end up exceeding the MUE limit, which can then lead to the unfortunate ending of denial. As any practice knows first hand, a denial of a medical claim is one of the very last things that you will want to deal with. This is why it is so important that you never try to guess because it can lead to quite a nightmare of gross billing errors.
Take the time to look over all of the medical documentation that you have. Then you can look forward and begin to report the number of units, being careful not to exceed the limit and reap the benefits of tightening up your medical billing claims!
Foreign bodies as you are well aware present often as people get in all sorts of accidents at the home and on the job. From the splinter in the eye from the weekend warrior who decided he was too cool to wear safety glasses when he was building a table to the kid that came into the ER with multiple embeds under the skin; they are all reimbursable procedures and if you aren't getting half or better reimbursements, then you need to brush up on your coding and make sure your medical billing claims are airtight.
Generally, it is always best to use only one code for foreign body removal in each particular site on the body. Even if there are several foreign bodies that need to be removed from each particular spot, you can go ahead and list only one code. This will still need to be the case even though the physician at your office will have to undertake a bit more work.
Make sure and back up your FB removal with ironclad medical necessity for any additional procedures needed and note especially if the FB is elevated to a complex status as you can usually file those and realize a reimbursement for the necessary procedures to locate the FB or multiple FB's if absolutely necessary.
Normally, complex foreign body removals don't present in the ER, however if the physician does wind up doing a complicated soft-tissue FBR, you may be able to increase your revenue for the service. If you get a medical billing claim to process for this procedure, you should code the service with 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated).
There are a few things to look for when making the determination if you have a simple or complex FBR. A complex soft-tissue FBR may also involve localization techniques with a C-arm fluoroscopy device, ultrasound, or x-rays with radiographic markers and extensive dissection.
This can also occur when the FB itself isn't necessarily complex however the object couldn't be initially located and something could be palpitated beneath the skin, however attempts to locate the FB fail. Using C-arm fluoroscopy guidance may be necessary and for most carriers, this will meet a basic need for being considered a complex FBR procedure.
Make sure you attach the correct modifier and if you go with a complex claim, make sure to show the failed attempts that led to the elevated procedure to remove the FB. Using these tips, you should be able to break out from partial payments and realize better revenue reimbursements on your more complex foreign body removal medical billing claims.
There have been questions regarding the use of carotid Doppler (93880) being performed on the same day as venous Doppler (93965, 93970, 93971); some insurance companies do not want to reimburse both procedures as it is unusual to perform both with one service period.
National Correct Coding Initiative edits don't prevent you from reporting these codes together, but the payer may be questioning the medical necessity of performing both services on the same day. Doctors don't usually order both of these exams for the same patient on the same date of service. If there was a reason and you can show hard documentation as to the necessity of having both procedures performed on the patient on the same day, then you can document the need for the request and show circumstances that required both procedures be performed.
The medical billing industry is non-stop unusual situations for coding and constant judgment calls are necessary. When you have an unusual situation arise with the services rendered to a patient - a good rule of thumb is to show all the documentation you can to show the request was necessary and when in doubt - contact the payer directly and document who you talk to if you were told to file your claim in a specific manner.
If you are tired of chasing the never ending updates and edits to the fast paced world of medical billing, you're most likely not being fully reimbursed for the services you perform either. It might be time to consider outsourcing your medical billing claims to a partner that will keep up with the changes, advise your office of any coming changes that will affect your practice as well as get you the best reimbursements for the services rendered to patients.
No one has to tell you that the world of pediatric medicine is fast paced and along with unpredictable kids come unpredictable medical billing situations. If you process medical billing for pediatric physicians, you may or may not have run across a situation for determining what diagnoses would apply when parents come in to discuss their child's health issues.
If you're wondering if there is a single code, the answer is yes. A parent conference falls under V65.19 (Other persons seeking consultation; other person consulting on behalf of another person). In other words, the code describes a person seeking "advice or treatment for non-attending third party." Since a parent has the right to discuss the treatment and medical issues for their minor child it's permissible to bill for the consultation.
The counseling diagnosis code can be used when the patient is present or when counseling the parent/guardian(s) when the patient is not physically present as in over the telephone. Although carriers may require supporting documentation for coverage of the encounter, so make sure you indicate the discussion's topic and the documentation should be signed off on by the attending physician. In case of an as yet undiagnosed concern, you can also check if payers want a secondary diagnosis that indicates the topic.
There are numerous reasons for consultations that include these top four common reasons: * ADD/ADHD -- 314.00, Attention deficit disorder; without mention of hyperactivity; 314.01, Attention deficit disorder; with hyperactivity * anxiety -- e.g., 300.00, Anxiety state, unspecified * depression -- e.g., 311, Depressive disorder, not elsewhere classified * obesity -- 278.00, Obesity, unspecified.
Use the total face-to-face time that the pediatrician spends with the parents to select the service code. Careful supporting documentation of the time elements is critical and will result in reimbursement for your medical billing claim.
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.
The smallest patients can present the largest and most confusing problems in medical billing. There can often be confusing scenarios that occur during neonatal procedures that many medical billings can find confusing. It could be due to the fact the patient is so tiny that many of the procedures seem related to split out but in many cases, claims for neonatal services are incorrectly bundled together.
A good case in point would be if a neonatal patient presented with a fever. The physician then did a urine catheterization (51701) and a spinal tap (62270) in the office. In many cases, the medical biller might have bundled these claims together but that would be incorrect as they are two distinctly different procedures even though they were performed at the same visit.
Also, a urine catheterization (51701, Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) and lumbar puncture (62270, Spinal puncture, lumbar, diagnostic);do not have edits placed on the code pair by NCCI so no modifier would be required for reporting this procedure. If you do use modifier 51, expect Medicare to reduce reimbursement by roughly 50%.
However, in all your neonatal claims, be sure to show ironclad documentation for the reason for the procedure as well detailing each procedure done to validate the fact they are being reported separately when possible.
Patient history, or PHI is an aspect of medical billing that has a myth attached. Contrary to popular belief, it is safe practice to allow any permanent office member to take the review of systems and the family social history.
These two evaluation and management history elements can actually be taken by absolutely anyone that is employed by the practice. It is ok in medical billing for even a parent or a secretary to take down this information as long as the information is reviewed and signed off on by the acting pediatrician.
The only part of an evaluation and management visit that the physician or nurse practitioner must complete for medical billing purposes is the history of present illness or the reason for the visit. By allowing your administrative staff to complete some of the patient documentation, a practice can save time and money as it frees up the pediatricians and nurse practitioners to have more time for the actual servicing of the patients.
Another great way to save your practice time and money is to outsource your medical billing. Your medical billing partner will make sure your pediatric practice gets the maximum return and if you're not using a medical billing company, you could be losing almost 30% of your medical billing revenue by simply not knowing how to get the maximum reimbursements that your practice is allowed for services rendered and general errors that occur when practices file their own claims.
When a patient presents with an abdominal aneurysm, there is usually a graft repair procedure performed. This usually involves exposing the affected portion of the aorta with a large incision (via a transabdominal or retroperitoneal approach), temporarily occluding (stopping) the blood flow, opening the aneurysm, and inserting a tubular prosthesis. The wound technically remains open during this time and should be handled as an open repair.
The medical billing code to use for this type of open procedures is 35081 (Direct repair of aneurysm, pseudoaneurysm, or excision [partial or total] and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta) for repairs confined to the abdominal aorta or 35102 (… for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels) for repairs that involve the abdominal aorta and one or both iliac vessels. The key to making an exact determination will be found in the PH or in the notations of the physician and refer to them when you're building your medical documentation for the necessity of the procedure.
However, this reporting will chance if the site has been previously closed. Open repair following endovascular attempt calls for special coding expertise to be used. An example would be when an open cholecystectomy follows an attempted laparoscopic cholecystectomy, you should report only the open procedure.
A variation to this scenario would be when the surgeon must perform an open AAA repair following an attempted endovascular repair (either during the same session or during the global period of the endovascular repair), you won’t report the standard open repair codes and should instead rely on 34830-34832 (Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair…), depending on the type of prosthesis the surgeonultimately places (tube, aorto-bi-iliac or aorto-bifemoral).
And last but not least, if the open repair occurs during the global period of an earlier endovascular repair attempt, be sure to append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to procedures that fit code range 34830-34832, as the situation calls for.
Medical billing for pregnant patients is a fairly cut and dried process. It's easy to create medical necessity for the visits and it's easy to show the reasons for the continued visits. That is, unless the patient transfers practices in the middle of her prenatal care. Pregnancy transfers scare many medical billing personnel, however you can use three easy tips and make your maternity patient transfers a breeze.
How you do medical billing for a maternity transfer all depends on how many times she was seen in the clinic. If she was seen 1-3 times you always want to code those visits as evaluation and management visits. One thing to keep in mind is that the first antepartum visit is not as straight forward as you may think. Always keep track of the level of service (level 4 or level 5) before doing medical billing for this date.
The next tip deals with visits 4-6. This means that the maternity patient was fairly established with your practice before transferring. It is quite simple to do medical billing for these visits. Simply use CPT code 59425. This code covers every antepartum care visit in your office. It is by far, the simplest way to do maternity transfer medical billing.
Last, if the pregnant patient is seen in your office seven or more times, there is a code that encompasses all of those visits as well. The CPT code is 59426. You should never bill for a global fee because a global fee in medical billing means that your physician also delivered the baby. This is coded with 59400-59622.
Some payers can also get confused when the initial transfer is made. In some cases they will ask for you to report separately. Most of the time, they still want you to code 59425 or 59426, but want all the dates listed in chronological order by date of service.
Patient history is valuable any time you're building up your documentation to show medical necessity for reimbursement of any procedure. Any time you are coding for problem visits that a patient has, it is important that you take into consideration any other office visits that they may have recently had. Basically, you are going to want to look to see if there is a connection between visits for preventative medicine as well as current health issues that may be in place, which also needs some attention.
Many times, a physician will end up seeing a patient that shows up in search of a visit to fall into the category of preventative medicine. Then, upon further evaluation, the doctor will then need to look at the patient further for some sort of significant problem that they have. As a coder, you may end up finding yourself in a situation where you are not sure if you are to code the visit under a new or established patient.
This type of a situation will call for a fast judgment call on your part. In order to make sure that the practice receives reimbursement and avoids denial, you can always go with a new patient code to begin with. Then, after you look through and take all of the medical documentation into account, you can see if there is a modifier that you can add on. A good rule of thumb is to always take the procedure, documentation and time lapse between visits into account before you record the code.
There were two new codes issued in 2006 that continue to confuse many medical billers still over halfway into 2007. These two codes were created to specifically address the after-hours and red-eye services for procedures done by physicians outside the normal hours.
Previously when compiling the medical coding for medical billing, a coder would have used 99050 as a "catch-all" coding. Now CPT has revised the original code and added new codes. 99053 is " "for services between 10 p.m. and 8 a.m. in 24-hour facilities," and will be used by both physicians on call and hospitals.
Please note that code 99053's wording to include "24-hour facility" will put a new limitation on using late night service codes. Previously a coder would have simply used 99052 to designate a meeting between a physician and a patient after 10PM but before 8AM.
The new coding language will mean the proper way to report this incident will be to determining the POS (Place of Service) and use the proper new code. In order to use 99053, the service must occur at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency room (POS 23).
CPT has made it easier and more exacting to do your coding so carriers can better determine the eligibility of the medical billing claims. Previously, many 99050 claims were submitted without proper modifiers or with enough documentation to ascertain the time or POS. The updated coding system will make it easier to pinpoint the time and place of services,
There may be some tighter clarifications coming for this code group in 2007, until then - make sure you use the correct CPT code and back it up with good documentation and your reimbursements should be unaffected.
B-12 injections are a very common procedure. If you're only receiving partial payments or experiencing rejections of your claims, you may need to tighten up your handling of these claims as the codes and procedures for filing criteria have undergone changes in the past year. To eliminate potential medical billing problems, there are five steps to follow to ensure smooth B-12 reimbursement for your claim.
The first medical billing step is to replace the injection administration codes for the B-12. These codes include the current procedural terminology codes 90782, 90788, and G0351. These medical billing codes were deleted from the 2006 CPT list and should no longer be used. The new policy is to use one CPT for the injection: 90772 (Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscularly).
The second step when doing medical billing for B-12 is to make sure a family physician is present during the entire administration. The medical billing CPT 90772 clearly requires direct physician supervision.
Third, it is very important to check on the insurance company’s incident-to policies. The medical billing current procedural terminology code 99211 is usually allowed without direct physician supervision, but the Centers for Medicare and Medicaid Services requires the service to be incident-to.
The fourth medical billing step is important. Since direct supervision is required for the CPT 90772, make sure you make it perfectly clear that there was a physician present. One tip is to create a stamp that clearly states “Physician supervision”, and attach this to your medical billing claims. This way, your medical billing will not be denied for such reasons.
The fifth, and final step to ensure B-12 medical billing reimbursement is to forget CMS issued G codes. The Centers for Medicare and Medicaid Services needed prescription drug codes in 2005, however, there were no CPT codes available at that time. For this reason, G codes were introduced for medical billing purposes. Once the newer CPT codes were introduced -the G codes were no longer valid.
One of the common dilemmas in medical billing for Ob-Gyn services is how to report the birth of a baby when there was no doctor on hand to deliver the newborn. When the delivery is progressing trouble-free, it isn't uncommon is for a nurse to deliver a baby when the ob-gyn is in the next room doing a procedure on another patient such as an episiotomy; then the question arises, can the service still be billed globally?
Fortunately in many cases you can. It is up to the individual payer and you can find out quickly by either checking their guidelines or website to see if the service will be a covered module in the overall procedure. In the event that is, you can use a global code such as 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care). To cover the delivery and then back it up by adding modifier 52 (Reduced services) to explain that the ob-gyn was not present at the time of the delivery.
Make sure that the medical documentation notes all the procedures leading up to the delivery that the physician did participate in as well as the services rendered by the nurse to show exactly which medical professional performed which services. This will help lessen the chance of a reduced payment or partial reimbursement on the medical billing claim.
In the most recent updated of the Correct Coding Initiative (CCI) there are a number of edits you won't want to miss if the services to the patient include debridement and treatment on the same burn site.
CCI version 13.1 outlaws reporting a pair of debridement codes with certain burn treatment codes in most situations. However, CCI now bundles 11000 (Debridement of extensive eczematous or infected skin; up to 10 percent of body surface) and 11040 (Debridement; skin, partial thickness) into 16020 (Dressings and/or debridement of partial thickness burns, initial or subsequent; small [less than 5 percent total body surface area]), 16025 (... medium [e.g., whole face or whole extremity, or 5 percent to 10 percent total body surface area]) and 16030 (... large [e.g., more than one extremity, or greater than 10 percent total body surface area]).
These edits were developed to reduce the amount of redundant coding that was happening on debridement of burns medical billing claims. The burn code descriptions include debridement, so you should not report both codes when treatment occurs on the same wound as this type of service can be bundled.
Another key for handling this type of claim is to look for exceptions. All of these burn/debridement edits contain a modifier indicator of "1." The "1" means you can report both of these codes for the same encounter in certain situations--and with modifier 59 (Distinct procedural service) attached to the component (bundled) code.
In addition, be sure to attach a correct diagnosis code to the debridement to support the need for the separate service. You should link the burn diagnoses only to 16020 in this case. You should link a skin ulcer or open wound code (as appropriate) to 11000 to clarify why the surgeon performed the separate debridement.
Use these tips and make sure you're maximizing your debridement/burn claims in your medical billing claims.
At the beginning of 2007; medical billing claims that are submitted to Medicare for reimbursement need to have a zip code or you can count on a delay. A National Provider Identifier requirement to include your zip code on all billing transactions took effect Jan. 1. This included all bills including RAPs, and providers must report a five or nine-digit zip code for their primary facility and its subparts.
Claims without the zip codes will be returned to provider (RTP'd) with reason code 32114. This will affect any facility that does medical billing claims for Medicare reimbursement. Many providers were unaware of the new requirement and a large amount of medical billing claims have already been rejected with reason code 32114 in the first 2 weeks of January.
If you handle your own inhouse medical billing claims,make sure your staff knows to double check that the zip code is included or you'll be part of the large number of facilities receiving rejected claims with reason code 32114. If you're tired of keeping up with the little changes like this that can cause you revenue flow to slow to a trickle; it may be time to consider outsourcing your medical billing claims.
It's hard to let go of what you might deem the financial control of your practice. Hiring a medical billing consultant can seem like you're adding expenses instead of cutting them down, especially if you have never outsourced your billing. If you've always discounted outsourcing your medical billing claims because you feel as though you would be relinquishing control over your billing, read on - you'll find that is not the case.
Actually outsourcing your medical billing and coding needs through a consultant is one of the smartest business moves you can make. Don't think you have to use a local company, many medical billing firms have branch offices in an area near you, but others may be miles to hundreds of miles away, and thanks to the power of the internet with secure connections and software advances that allow you to transfer your patient billing records while upholding the utmost in privacy standards, with just a click of your mouse, makes the job of shopping for a medical billing consultant to hand the billing paperwork for your busy practice all the easier.
Your staff won't have to spend long hours at the copy machine when you outsource, most records can be transferred via computer to computer using secure, encrypted technology. Many medical billing consultants offer real time updates of patient accounts, so if information is needed on where a particular claim stands, your staff can click and see!
Outsourcing to a medical billing consultant will insure that your claims are coded and submitted properly because that's their business! There are no interruptions, patients asking questions, and general day to day running of your practice. A medical billing consultant can devote 100% of their time to handling your coding and claims. That way your cash flow is steady and your practice will grow!
Time is money in your practice and if you outsource your medical billing through a consultant you are definitely making the most of your time and because of your smart choices, you'll see an increase in your revenue flow for your practice.
When you have a procedure that can cover two close but distinctly different areas such as a facial and a dental nerve block, you need to make sure that your claim encompasses exactly the procedure that was done or you may wind up with a denial of your claim.
A common situation would be if the ED physician performed a diagnostic nerve block on a patient complaining of pain in the floor of her mouth and her bottom set of teeth. You would want to be certain that you chose 64402 (Injection, anesthetic agent; facial nerve) for facial nerve blocks, not blocks in the mouth or jaw. The determining factor is that the surgeon treated a branch of the trigeminal nerve, not the facial nerve.
On the claim, report 64400 (... trigeminal nerve, any division or branch) for the nerve block. Other 64400 scenarios: Areas affected by the trigeminal nerve and its branches, and therefore coded with 64400 for nerve blocks, include: * the body of the mandible and the lower portion of the ramus * upper and lower teeth * floor of the mouth * anterior two-thirds of the tongue * gingiva on the lingual surface of the mandible * gingiva on the labial surface of the mandible * mucosa and skin of the lower lip and chin.
To ensure proper payment, back up your medical billing claim with the proper documentation to show the reason for the facial or dental block and that will allow the carrier to see why this code was chosen along with the necessity of the procedure. This will enable you to realize reimbursements instead of rejections on these type of claims.
When the surgeon removes lymph nodes during a partial mastectomy, it may be confusing as to how to the mastectomy and the lymph excision. A common point of confusion is whether they should be bundled or reported separately.
The answer is pretty cut and dried. In most cases, with partial mastectomy, the surgeon will perform an axillary lymphadenectomy to remove the lymph nodes between the pectoralis major and the pectoralis minor muscles. The surgeon may also remove the nodes in the axilla through a separate incision at the same time.
When this occurs, you should not report the mastectomy and lymphadenectomy (38745, Axillary lymphadenectomy; complete) separately. Instead, you should use a single, combined code to report the work of both procedures. CPT eliminated partial mastectomy with lymphadenectomy code 19162 for 2007 and has replaced it with 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrant-ectomy, segmentectomy]; with axillary lymphadenectomy).
With the updated CPT codes that went into effect on Jan. 1, 2007, you should report 19302 only for most combined partial mastectomy lymphadenectomy procedures. The exception to that rule will be if there is a "staged" exception: Following some partial mastectomies (19301), the surgeon may return during the postoperative period to see if there has been any lymph node involvement and, if so, may choose to remove the nodes at that time. You will want to add the lymphadenectomy as a staged procedure using 38745 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended to the claim.
Under-reporting medical billing claims is unfortunately common and it costs revenue as you're not being fully reimbursed for services rendered. Learning the exceptions to the bundles will allow you to break out services that can be billed alone - once you start investigating neonatal services you'll realize quickly that you may have very been missing legitimate reimbursements.
A scenario that isn't uncommon is when a doctor attends a delivery of a 28-week gestation baby. The infant received positive pressure ventilation (PPV) in the delivery room (DR) with mask and bag for absent respiratory effort at birth. The baby was then intubated in the delivery room and received PPV on transfer to the neonatal intensive care unit (NICU) where mechanical ventilation was initiated.
Three steps will clear the way for you to choose the best way to report this procedure. Number one, in most cases you will bill 99436/99440 Separately From 99295. When coding resuscitation with initial neonatal critical care, you should always remember one rule: Newborn resuscitation services (99440) may be reported in addition to 99295. In a nutshell, that means, in the above scenario, as well as anytime a pediatrician attends a delivery and provides resuscitation, you should report both 99440 and 99295.
Next, make sure that you code the necessary preadmit procedures. You will want to address whether or not normal resuscitation procedures such as endotracheal intubation (31500, Intubation, endotracheal, emergency procedure). But these bundles reflect inpatient services performed as part of critical care management. This will be a bundled service unless these services were medically necessary in the delivery room prior to admission, the procedures are exempt from the bundle. “The initial-day neonatal critical care code (99295) can be used in addition to codes 99360, 99436, or 99440 as appropriate, when the physician is present for the delivery (99360 or 99436) and newborn resuscitation (99440) is required,” states the AMA in the introductory notes to the “Inpatient Neonatal and Pediatric Critical Care Services” subsection.
The third part of deciding whether to bundle this claim or not will be your use of modifier 59. You may report medically necessary delivery-room procedures in addition to inpatient critical care services because the care occurs at different sites of service. That’s what makes preadmission procedures distinct procedural services from inpatient critical care. If you want to indicate the pediatrician performs the intubation at a separate site from the critical care, you should append modifier 59 (Distinct procedural service) to the delivery-room procedure: 31500-59.
Check with the carrier before you file modifier 59, some carriers want these CPT codes with out modifiers while other require it as part of the medical billing claim.
Pediatrics has many medical billing codes that were created just for the use of describing procedures. However, there are other areas of medical billing that do not have these specific codes for children. This can make coding hit or miss unless you know the nuances of what the carrier wants in order to get the maximum reimbursements for procedures performed. A common dilemma is with CPT code 99293 and its use for outpatient emergency room exams for an infant or if code 99291 should be used.
The medical billing code 99291 means critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. You would use this code if a patient came into the emergency room and was there for a half and hour up to 74 minutes. This is pretty straight forward in medical billing. The confusion comes in when using code 99293. This means Initial inpatient pediatric care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age. This code should only be used if the infant is admitted inpatient.
When doing medical billing it becomes confusing because there is no code specifically for outpatient emergency room visits for children. There is only a child specific medical billing code for inpatient visits. A simple rule of thumb in medical billing is that the location of service must match the CPT code. This is because inpatient evaluations get reimbursed at different levels then outpatient emergency room visits.
There are many rules and regulations when it comes to current procedural terminology codes. Sometimes, you can find they are too much to keep up with; if you're finding your staff and yourself overwhelmed chasing billing and medical documentation, it may be time to consider outsourcing your medical billing to a partner that can make sure the latest coding regulations are followed and your practice receives the maximum reimbursements allowed for procedures performed.
If you're getting claims denied or kicked back - the answer is yes. If your staff has gotten sloppy in their compilation of your medical billing claims and your office is so busy that no one has time to follow up on medical billing claims; it is costing your practice in the form of real dollars.
If you're not already outsourcing your medical billing, your practice is most likely part of the statistic that shows that nearly one fourth of all medical practice income is lost due to under pricing, under coding, missed billing and claims that go unreimbursed. Imagine if you could add up to one extra fourth of your business income; would you expand your practice? Add newer equipment? The limits are only your imagination.
Chances are very good that your practice is being under-reimbursed on many or not the majority of your medical billing claims. Get a consultation from OMG and see if your practice could benefit from outsourcing. It's not the right choice for every practice, but for most the partnership between a thriving practice and a competent medical billing partner that will do everything to make sure your coding is correct and your claims are fully reimbursed can be a very beneficial partnership indeed.
If you're been looking into outsourcing your medical billing but you aren't sure it will be a good fit for your individual practice, talk to a consultant with OMG and let them answer your questions and show you the true bottom line benefits of outsourcing your medical billing.
Since consultation requirements have increased in the last year as far as criteria for getting them reimbursed in your medical billing claims, there are some criteria you must be certain that your claims meet in order to justify using codes 99241-99255.
It used to be simple and medical billing consultant merely had to meet the three "R's" in order to justify medical billing claims for consultations. However the criteria for what does and does not constitute a consultation has changed and in order to make sure that your medical billing claims are paid, you need to reacquaint yourself with the three R's of medical billing for consultations.
The three R's are (1) Request for opinion; (2)Rendering of services; and (3) Report to the requesting source. The first big change in late 2006 applied to the qualifying requesters. The new CMS guidelines that were issued now require that a physician make the request. It's easy to meet this requirement by simply getting a written request; but that's not all. CMS officials still insist that the requesting physician has to document the request for a consult. The only change is that the consultant doesn't have to verify that the initiating doctor has done so.
If you don't have the medical documentation to back up the consultation, chances are good your claim won't be reimbursed or at the very best only partially so. The best advice you can follow is to let your documentation guide your medical billing and coding. If you can't meet the three R's criteria prior to billing, attempt to get the proper documentation to do so, it will mean a little extra leg work, but the practice will reap the rewards in the form of accepted medical billing and reimbursements.
When you're compiling the medical billing for an established patient with active emphysema (492.8, Other emphysema) and they present and are complaining of shortness of breath (786.05); the physician provides inhalation treatment, trains the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity, how would you report this?
There will be multiple codes for this visit as the emphysema was the reason for the visit however the physician also provided services and consulted regarding the nebulizer so there will need to be additional codings on the medical billing to take all the services rendered into consideration.
Be sure and capture 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered-dose inhaler or intermittent positive pressure breathing (IPPB) device]) to cover the comprehensive service the physician provided regarding using the nebulizer. Additionally, add in 99213, and back it up with documentation to show that the physician performed an exam of an existing problem with low- complexity decision-making.
If your documentation shows that the physicians's primary intent was to treat the difficulty in breathing at the time of the visit, switch to 94640(Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).
Back up all your billing with iron clad documentation to show your choices for your medical billing and you'll reap the rewards in the maximum allowed reimbursements.
Varicose vein treatments are becoming more and more frequent as more patients are urged to get them treated to stave off the possibility of blood clots and other issues that can crop up later if they are left unaddressed by the patient. However reporting the varicose vein treatment procedure on the medical billing may be a little confusion for some; once you know the basics for setting it up - it's easy!
A good example would be if a patient with varicose veins in her left lower leg presents to the ED and is stating she has severe pain in her leg. One of the veins is clearly bleeding so the doctor will use a standard suture ligation to stem the bleeding and winds up removing one of the veins in the procedure. Suture ligation isn't an uncommon way to treat a bleeding varicose vein, however there is currently no specific CPT code for it.
A good way to report this on your medical billing would be to use code 37785 (Ligation, division and/or excision of varicose vein cluster[s], one leg) for the ligation. Be sure to attach ICD-9 code 454.8 (Varicose veins of lower extremities; with other complications) to 37785 to prove medical necessity for the procedure. You should be aware that 37785 has high RVUs and may be considered by some carriers to be more indepth of a procedure than was actually performed. A good rule of thumb would be to verify directly with the specific carrier that you are reporting to and make sure they will cover the procedure as such. If they won't a good alternative reporting method on the medical billing would be to report 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities which includes hands and feet]; 2.6 cm to 7.5 cm) for the repair and attach ICD-9 code 454.8 to 12002 to prove medical necessity for the procedure.
Make sure your medical necessity backs up your claim and in the case of not being certain what the carrier will cover - simply ask and document the time, date and full name of whoever you speak with - this will insure all bases on your claim are covered.
When claims require modifier 25, there are some simple tips you can use to know the modifier's details, such as which code to append it to, as well as when to use the modifier.
It is important to identify the claim makeup in order to solve the problem of which code to use modifier 25 with. Modifier 25 is a significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service. Do you attach modifier 25 to the well visit or to the sick code? Modifier 25 can be applicable on either code. Therefore, the answer depends on the claim makeup.
2. Put 25 on Problem E/M Following Well
You should put modifier 25 on the problem E/M following well when the encounter meets the following criteria: -the pediatrician provides a sick and preventative visit at the same time -the preventative visit was the reason for the scheduled visit
The reason for this is that the pediatrician has provided the sick service secondary to the preventative services. Because of this, the modifier 25 goes on to the sick visit in order to indicate that the problem is significant and separate from the preventative services.
You should charge the sick visit (in addition to the preventative medicine) only under the following conditions:
-When the physician performs a separate E/M service -Documentation for the problem portion is separate from the preventative service -The encounter involves a separate and distinct problem. This is determined when the problem involves treatment with a prescription, when the problem would have required a return visit had it not been addressed at this visit, and when you have a separate and distinct ICD-9 diagnosis code for the problem.
You should use modifier 25 when well visits result in a procedure. This indicates that the well visit is separately identifiable. Follow the payer policy for E/M and screening.
All too often, the problem in the case of team procedures, where multiple physicians are involved, is that the first physician's claim that gets submitted wins. This is especially true when another provider takes credit for radiology services.
Let's take a look at a few examples, to help you figure out how to code your claims to make sure you get a radiology claim to your payer quickly.
Example 1: Do both a radiologist and a speech language pathologist need to be present to code a modified barium swallow procedure?
They may both need to be present. Guidelines recommend that the service be provided in a team setting. Note the use of the word "recommend" instead of "require." This means that the real decision making is left to individual states and payers. They may choose to be more strict.
Example 2: If you are coding a situation where a surgeon placed a gastrostomy tube percutaneously without an endoscopic component, and you are coding for the radiologist who provided the ultrasound or the fluoroscopy as guidance, which CPT code(s) do you report?
When a radiologist provides guidance for these services, you should report 74350 (this is the radiological supervision and interpretation). The surgeon will report 43750 (this is the placement). If the radiologist simply reads the films though, and isn't present for the procedure, then you need to use modifiers 52 (reduced services) and 26 (professional component) to the code. This tells the payer that the physician supervised or interpreted, but not both. The surgeon should report the same way.
Be careful when coding multiple physician situations, and you should have no problems with payers. It's generally a good idea to coordinate with the other physicians, in order to ensure that all parties are reimbursed appropriately.
Let's say an otherwise healthy man reports to the ED with lacerated index and middle fingers on the palmar surface, but there is no significant bleeding. The patient cut himself on a table saw. There is a 1.5cm jagged laceration with protruding fat located on the pad of the distal phalanx of both fingers. The physician uses Marcaine to apply digital blocks to both fingers, explores the wounds and finds no foreign bodies, and then closes the wounds.
This encounter should be coded with a pair of E codes, in order to identify the cause of injury. Report this claim as follows:
Report 12002 for the wound closure (this is for a simple repair of superficial wounds 2.6cm to 7.5 cm)
Report 99283 for the E/M service (this is for ED visit for evaluation and management) to show that the E/M and the wound closure were in fact separate services
Append modifier 25 to 12002 and to 99283 to represent the cut fingers (this is for significantly, separately identifiable evaluation and management on the same day)
Attach 993.0 to 12002 and to 99283 to represent the patient's cut fingers.
Attach E919.4 to 12002 and to 99283 to represent the cause of the patient's injuries (this code is for accidents caused by machinery; woodworking and forming machines).
Attach E849.3 to 12002 and to 99283 to represent the location of the accident (which was, in this case, at the patient's place of work. This E code is for industrial place and premises).
The new edits coming in July 2007 will mainly affect ER room practicioners and physicians and nurses that treat patients in nursing home facilities. These updates will be items you need to know in order to avoid denials and get maximum reimbursements on your medical billing claims.
The codes that were changed in the upcoming release were codes 99281-99285 (Emergency department services) are considered component codes of the more global 99304-99306 codes (Initial nursing facility care). This means if a single physician provides a level-two ED service along with a level-two initial nursing home service, you should only report 99305 (Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity).
Do not include 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) on the claim, because it is bundled into 99305.
Another item to be on the lookout for: if you have more than one physician or nurse that admit patients to nursing homes and oversee care, remember they will be reporting under the same tax identification number because they work out of the same hospital or specialty group. This can get kicked out by the carrier as a duplicate billing so be sure to show in your documentation that separate charges are being submitted to avoid delays and denials in reimbursements.
In medical billing, code recognition is not the only reason for denial. If a claim containing a new code is denied, go through your medical billing claim and make sure it is absolutely accurate. Then you can probably narrow down the reason to simply a matter of the carrier not recognizing the CPT code.
When new medical billing codes are introduced there is a lag period that lets coders and payers get adjusted for that specific code. HIPPAA sets an effective date for all medical billing codes that states when companies must begin using the codes or accepting the new codes. It is illegal to deny claims for no recognition if the code effective date has passed.
There are instances in medical billing where code no recognition is acceptable. A payer can deny a claim with a new code if the effective date has not yet passed. If HIPAA released a code on January 1, but deemed the effective date to be March 1, then the payer doesn’t have to recognize the code until March 1.
Another big reason for denial is no coverage. If a payer rejects your new medical billing code, many times the rejection is due to no coverage. If you find that an insurance company is wrongfully denying your medical billing claims due to wrongful no recognition, there is something you can do. Since HIPAA makes this no recognition illegal, you can either complain directly to the carrier or opt to register a complaint against them.
These medical billing denials can easily slip through the cracks on both sides of billing. Both the physicians and carriers need to be on the alert for changes and making sure that their claims are reimbursed as fairly as possible or you'll be losing valuable revenue for your practice.
One of the most difficult medical billing feats is inpatient consultation coding. There are many instances when a follow-up inpatient consult should be replaced by a subsequent hospital care visit. To eliminate these medical billing errors, there are four facts to consider when coding for inpatient consults.
The first fact is very obvious. If your report an inpatient consultation exam, the patient must be inpatient, not outpatient. Very often physicians see patients on a consultation basis when they are outpatient. Medical billing mistakes can be made easily. Double check your work.
It is important in medical billing to always report one initial consultation. This code will correspond with the very first meeting between the physician and the patient. The medical billing codes to use are 99251-99255. If the patient is discharged and then readmitted, remember that another initial inpatient consultation code may be reported.
The third point is to make sure subsequent same stay consults are allowed. There are two rules that deem additional consults necessary. First, the doctor sees the patient again because he/she was not able to finish the consult the first time. Second, if the attending physician requests a second consult due to changes in medical condition. The medical billing codes to use for subsequent inpatient consults are 99261-99263.
The final part of inpatient consult coding is to rule-out subsequent hospital care. If your physician assumes responsibility for a patient's care after the initial consult, you should not report additional consult codes for that stay. Instead, the correct medical billing policy is to bill subsequent hospital care codes 99231-99233.
Patient evaluation codings can be very confusing. The patient initial evaluation code is 97001 (also, 97003, 92506, 92610) however if the patient is reevaluated (97002- patient reevaluation) within a 12 month period only one unit of service may be billed to Medicare Part B patients no matter how much time was spent actually servicing the patient.
If you make a mistake and bill the carrier for the evaluation and a unit of service for the reevaluation, your claim will be denied based on incorrect coding no matter how much medical documentation you provide showing the necessity of the reevaluation of the patient.
Keeping up with the fast paced changes of the medical billing industry are what your medical billing partner does best! They stay on top of the current changes as well as the coming coding changes that will directly affect your practice so your staff knows the proper codings to use for patient services rendered and when to begin using them.
Your medical billing partner can also help you eliminate errors in your medical billing by knowing the correct way to use the codes and bundle claims to get your practice the maximum returns allowed on your medical billing claims.
Outsourcing is just smart business. Your error rate will fall on the average from nearly 30% of your medical billing claims to less than 1% and your claims will also be reimbursed nearly 2 weeks faster than self-filed medical billing claims.
Sometimes in medical billing it is difficult to decide when to use current procedural terminology codes 58661 and 49322-59. These codes, like many others seem similar, but in actuality, are quite different. When performing medical billing it is necessary to know when to use current procedural terminology code 58661 versus 49322-59.
There are several instances in medical billing where it seems as though several codes would fit the description. The truth is that most of the time there is only one possible current procedural terminology code that would explain a procedure best. It is important that the personnel that perform medical billing for your practice are educated on these slight differences. It could mean the difference between getting reimbursed on a claim or getting denied.
The medical billing code 58661 (laparoscopy, surgical; with removal of adnexal structures) is used when any part of the ovaries or Fallopian tubes are removed. For example, If a surgeon was doing a cystectomy of an ovarian cyst and ended up removing some of the ovary as well, they physician could do medical billing with 58661.
The current procedural terminology code 49322-59 (laparoscopy, surgical; with aspiration of cavity or cyst) should only be used for the aspiration of an ovarian cyst. If the cyst(s) were removed, this medical billing code would not be valid since it is for aspiration only.
There are several medical billing firms that are designed to keep your practice as profitable as possible. Their staff is trained about the different CPT and ICD-9 procedures for billing to get you the maximum reimbursements. By hiring a medical billing firm to file your claims, you are eliminating the responsibility of having to train your own staff about billing. Medical billing is a skilled process and should be handled by skilled professionals.
Therapeutic and antibiotic injections went through some changes in 2006 and make sure that your medical billing claims reflect those updates or you might be suffering from partial payments or rejections of your medical billing claims.
In the past there were separate injection administration codes for a therapeutic, prophylactic, diagnostic, and antibiotic injections. Instead of choosing to report administration of a prophylactic Synagis treatment (90378) with a 90782 (Therapeutic, prophylactic or diagnostic injection , you now simply use 90772 as a universal injection code. On E/M coding, you will generally still need to attach modifier 25 to insure your claim is handled. Modifier 25 states that this procedure or other service was performed the same day.
If you have a medical billing claim that has been denied, refile your claim using modifier 25 and include the new instructions from CPT to insure that the underwriter making the decision can see you are following the new billing procedures to the letter. Unfortunately, underwriters may not have the most current billing information at their disposal and it's up to you to make sure that you back up every line on your medical billing claim to show it was necessary and in a logical sequence to ensure proper reimbursements on your filed claims.
If you have a number of medical billing claims getting rejected, once you rule out any larger reasons, you might start looking for the key in the use of; or rather the lack of not using modifiers as a part of your medical billing claims.
Two of the main modifiers that get people in trouble with their medical billing claims in the forms of rejections are modifiers 25 and 57. Modifier 25 reads , "Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service" is kind of a catch all modifier for procedures that may not have an exact coding you can assign.
Previously, modifier 25 was easily confused with modifier 57 and 57 was then updated in 2006 to reflect the following wording, " Decision for Surgery". It's easy to determine if you need to use modifier 57, simply check the notes and determine if there was a decision for surgery - is yes then use 57 as part of your medical billing claim. If there was no such decision made on your medical billing claim, be sure not to use that particular modifier.
Another way to almost completely eliminate errors and omissions in your medical billing claims is to outsource your medical billing claims and let the pros that make it their job keep up with the lightening fast changes in the medical billing industry and leave you with the time to help your practice grow even more successful.
If you feel like you've been missing out on reimbursement revenue or your staff is simply pushed to the limit handling medical billing claims, it is definitely time to consider outsourcing your claims to a third party partner. It can seem like a huge task to find a medical billing partner to handle your claims but you can narrow down your search to the best fit for your practice quickly if you use these tips.
First of all, ask your potential medical billing partner if they handle your type of medical billing claims. Not all medical billing partners will handle chiropractic medical billing claims and many still do not handle DME (durable medical equipment) claims. Next, if you do find a potential company to do your specialized type of medical billing claims, ask what their experience is in doing claims and make sure that you can have a comfort level with the experience level of the company that you're considering transferring the responsibility of your medical billing claims to.
Turnaround time will be another consideration. Ask what the average turnaround time will be on your medical billing claims. Additionally, find out what the error rate on the medical billing claims will be. Many physicians are thrilled to find that outsourcing will drop the error rate in their claims from nearly an average of one-third of their claims to less than 1% of claims. This conversion rate alone will have an amazing effect on the revenue stream for your practice.
Consider if you will need credentialing. Many medical billing partners will handle that aspect of your practice for you and further free up your staff to help run your office instead of chasing paperwork.
If you've been considering outsourcing your medical billing claims, make a short list of what is important to your practice and use these tips to narrow down the best partner to handle your medical billing claims.
Think about it, would you ever think that sending your medical billing claims outside of your office could actually get them paid quicker? It doesn't sound logical at first glace, but it's very true the outsourcing your medical billing claims will usually get them paid faster.
Think about how often your in-house staff gets interrupted, how often the crisis of the moment rears its ugly head and day to day managing of the office prevents them from filing, double checking accuracy, and following up on your submitted claims.
Time is also lost re-submitting claims when they get kicked back for the smallest of errors in coding. As you know, Medicare is extremely strict as far as coding and re-submissions can seriously delay your medical claim reimbursements. Keeping up the changes in the CPT can also be a daunting task.
As you can see it makes a lot of sense to outsource your medical billing. You can send your claims to professionals who will uphold the ultimate in privacy for your claims, submit your medical billing claims, handle tracking of your reimbursements, and always be ready to give you or your staff a status of your medical billing claims with just a phone call or click of a mouse?
Your office will be able to concentrate on delivering quality patient care instead of spending a lot of time handling the detailed work that medical billing requires. If you want your claims done right the first time, paid faster, and handled with the highest of privacy and professionalism, look into outsourcing your medical billing and reap the benefits.
When you have a patient that has had multiple procedures performed, make sure that the group of procedures that were performed actually require modified 51 before you attach it. The CPT has a list of certain coding that are exempt from modifier 51. The CPT manual designates modifier 51 (Multiple procedures) exempt codes with a "circle with a slash" symbol to the left of the code for the services rendered.
There is usually a complete listing of modifier 51 exempt codes in an appendix. The list is "a summary of CPT codes that are exempt from the use of modifier 51 but have NOT been designated as CPT add-on procedures/services," according to CPT. As an example look up a code in your CPT. Arterial catheterization code 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous) and you will see a symbol with a circle and a slash to the left of the code. This means you should report just the code without a modifier as it is assumed that other services will be performed along with the catheterization.
Be wary about using modifier 51 on each and every claim without checking. Many carriers and most importantly Medicare, will lower your reimbursement amount if you use Modifier 51 on your medical billing claims. The carriers sort the procedures from highest to lowest RVU and the highest ranked RVU gets paid at 100% reimbursement the rest get 50% or less reimbursement on procedures.
Get the best reimbursement possible for the procedures your practice performs and make sure that your staff is coding and billing your medical billing claims properly.
Along with documentation, medical necessity is one of the most important parts of medical billing. You tell exactly how the procedure was performed, be sure to meet the criteria for medical necessity of the procedure by telling why the procedure needed to be performed.
It used to be that Medicare was the only payer that cared what ICD-9 code was used. Now all payers, including insurance companies, are looking for any reason not to pay the bill or at least delay it. ICD-9 codes have become the target for close scrutiny.
ICD-9 codes range anywhere from a three-digit code to a five-digit code. Obviously, a five digit code is more descriptive then a four digit code. Similarly, a four digit code is more accurate then a three digit code. Very rarely will insurance companies pay a medical bill with a three-digit code anymore. Three digit codes don't give all the medical billing information necessary to determine medical necessity. They are very generic codes. It is important when a medical biller decides to use an ICD-9 code, that is the most descriptive and accurate code available. Most of the time, this means a four or five digit code is in order.
Each and every year more ICD-9 codes are added to the list. Many medical practices are stretched to their limits and are unable to keep up with the changes. They end up resorting to generic three digit codes in their medical billing. When the payer gets the claim, they deny it for a lack of medical necessity and offer to review the case if a letter of medical necessity is sent. When this comes back to the practice, the office personnel must then put together a letter. This ends up stretching their time even thinner.
This is one of the big pluses for outsourcing your medical billing, no more paper chase and you can have the knowledge that your claims will be handled with full documentation on every claim.
Coding a medical billing claim for oxygen administration can be a tricky beast because there is not a specific oxygen administration code assigned. Normally the administration of oxygen is bundled into an emergency visit.
When a doctor prescribes the oxygen, you should use the appropriate office visit code that describes the procedure and services performed by the physicians that necessitates the need for oxygen. Full documentation of the medical billing claim will insure that your bundled oxygen administrations codings get full reimbursement.
For example if you have a physician who performs a detailed examination on a patient and decides to administer oxygen to a known patient who is in the emergency room for anything from a possible reaction to an injection or other diagnostic issue, you will want to use 99214 (Office or other outpatient visit for the evaluation and management of an established patient...), as well as any additional procedures and special services.
Outsourcing your medical billing can eliminate a lot of the "when do I use ...' headaches a lot of members of your staff may be having. The CPT changes frequently and in many cases codes are deleted or changed and not keeping up the changes can cost you in the most literal sense of the word. If you have frequent partial payments or rejected claims, it is probably either due to low medical documentation (not enough documentation to pay the claim) or using the incorrect CPT code. A code that was correct for a procedure one year ago may have been modified this year and will no longer exactly fit the bill.
Good news if you're a physician that performs central venous access services, your services rendered may qualify for extra payment. The CPT codes 76937 and 75998 can be used in medical billing to provide extra CVA payment. When a physician performs an ultrasound-guided procedure, the code 76937 will give additional money if the vascular access required ultrasound guidance. The medical necessity of this procedure must be documented or the qualification for extra payment.
When used, CPT code 76937 can be billed separately from the CVA placement code. Please note that this code is only allowed to be used one time per session with the patient not matter how many sites were checked on the patient for the best entry point.
Follow this guideline closely to avoid denials, do not use CPT code 76937 if the ultrasound was only used to identify a vein to mark on the patient's skin. The ultrasound must have been used to actually guide the needle into the patient's vein.
Another valuable code that can be used to provide additional payment for a CVA procedure is 75998. This is used for fluoroscopic guidance. This code is used when fluoroscopic guidance is needed to assist catheter placement or manipulation. When used, this procedure is reimbursed separately from that actual placement procedure. In order to receive additional payment, both of these procedures require medical documentation and the use of modifier 26.
Use these tips and make sure you're getting the maximum reimbursements for your medical billing claims!
Here is a perplexing problem. When a surgeon meets with a patient an recommends a breast biopsy, we report a consult for this particular visit. On the day of the biopsy procedure, the surgeon will re-examine the patient, answer questions, an so on. The time that is spent prior to the procedure is ten minutes. In a case like this, you will not report a separate E/M with the biopsy.
It is important to remember that all procedures include an inherent E/M component, according to CPT and CMS guidelines. In order to qualify as a separately billable service, any E/M the physician provides must be both signifigant and separately identifiable from the E/M component that has already been included in the procedure.
If the surgeon had provided the initial E/M service and biopsy on the same day, then you would be able to report the E/M service separately, by using modifier 25 (which is significant, separately identifiable evaluation and management service by the physician on the same day of the procedure or service). However, in this case the surgeon has already conducted a full E/M workup before the biopsy, and it has been coded already.
At the time of the biopsy, if the patient in this case has no new complaints, and has no substantial change in her condition (that would prompt a new history, exam, and decision making process) then you should not report a second E/M. You should report only the biopsy for this particular visit.
It's a dirty little secret in the medical industry that many physicians fail to get the maximum reimbursement on their medical billing claims because they undercode their medical billing claims. Doing this on a frequent basis can cause your practice to lose up to one quarter of your reimbursement revenue.
Undercoding also happens because the coding is left up to the staff in the office to perform and this method is guaranteed to have errors and omissions because the staff has no way of knowing exactly which services occurred in the exam room and which did not. Since notes don't always get made at the time of the procedure, reimbursable procedures can be missed and many staff members will undercode the claim in order to insure they are well within the limits of reimbursable services.
In capitated care issues, a lot of money is lost by physicians who don't code for supplies reimbursement on their medical billing claims. Worse, elective services and carve outs are miscoded and that causes the services to be bundled into the capitation rate which results in a lowered reimbursement rate for the physician.
One jaw-dropping example included an audit of a family physician's records and his medical billing had over 70-percent errors in their coding on their medical billing. This resulted in a loss of nearly $185,000 for the practice. While your issues may not be that big in your medical billing, it can certainly get out of hand and any loss that could be prevented should be unacceptable. A recent statistic said all practices that do their own medical billing are losing about $10,000 per year on the average simply from undercoding on their medical billing claims.
If you have only been thinking about outsourcing your medical billing, look into it today, you can save your practice a lot of money and streamline your claims submission process and realize a greater profit for all your hard work! Work with your medical billing partner to get the maximum reimbursements for your medical billing. You deserve to be compensated for all your hard work - not just some of it.
In late 2006, the CPT added some new codes in their revision. Previously there would have been a need to bill for extra units to capture a procedures base units. With the release of the new moderate sedation codes (99143-99150). The need to bill extra units to capture the procedure's base unit amounts. Therefore, you should ignore billable units and instead use new time-based codes.
A good example would be if a doctor did a procedure that involved 30-minutes of sedation. Previously you would have use 01922 anesthesia designation, you would have used 7 base units and 2 time units (15 minutes = 1 time unit) and you have used the method of billing 01922 x 9. Now with the revised coding you would simply use the age appropriate procedure coding for the services and the range of time units to be billed.
A word of caution, do not use the physical status modifiers with the new claims as they do not apply. Make sure you have proper documentation with your medical billing claims to insure the carrier makes full reimbursement. If your medical billing claim is submitted with little to no documentation, the carrier may make the decision to only pay a portion of the claim or to outright reject your medical billing claim, which means a little more paperwork and time lost on the reimbursement for having to refile your medical billing claim.
Keep up to date with the fast changes in the medical billing industry and make sure your office is coding your claims properly. Using outdated coding can cause you to be receiving less on your reimbursements. If you're tired of doing the paper chase, consider the benefits of outsourcing your medical billing. You and your staff don't have to spend time coding and filing claims, appealing rejections and tracking reimbursements, your medical billing partner can do all of that for you and give you time to keep your practice running smoothly and continuing to grow.
In 2007, Medicare is going to continue their close scrutiny of chiropractors and podiatrists. The claims submitted by these fields will continue to get looked over due to the extreme amount of fraud that has occurred in these two branches of medicine. Additionally, the stringent guidelines that are currently in place for chiropractors and podiatrists in order to meet payment requirements for certain procedures and debridement services will be getting looked at very closely and continue to be required in order to get their medical billing claims paid.
If you perform these services or you are a medical billing company that does claims for these types of practices, check and double check your medical billing for the proper documentation before filing your claims to avoid delays in reimbursements or outright rejections of your medical billing claims. The modifiers used on these claims will be getting extra close scrutiny. Make sure you are descriptive in your medical billing as possible and don't just use the maintenance visit coding on your medical billing claims, that is sure to raise a red flag and get your claim denied. Make sure to document all procedures done on your medical billing claim that can add up to the necessity of all procedures performed, this gives the whole picture to the carrier and will result in full reimbursement of your medical billing claims.
The last estimate in the Red Book is Medicare could save nearly $285-million dollars per year if chiropractic procedures such as maintenance services, were no longer covered by Medicare. Over $186-million dollars were paid out to chiropractors in previous years for non-covered maintenance services performed.
One way that many medical billing claims get rejected for the smallest of errors. In many cases it can be something as simple as an incorrectly used modifier causing your claim to be rejected by the carrier. There are two modifiers that get a lot of people in to trouble in the form of rejected claims as they can be confusing and those are modifier 25 and 57.
Modifier 25 which reads , "Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service" is kind of a catch all modifier for procedures that may not have an exact coding you can assign.
In the previous wording for Modifier 57 it caused some confusion with Modifier 25. If you haven't updated your CMS coding, be sure you have the latest as 57 now simply reads, " Decision for Surgery". If there was no such decision made on your medical billing claim, be sure not to use that particular modifier any longer.
If your busy practice doesn't have time to keep up with the fast changes in the medical coding industry, you're costing yourself a lot of revenue in terms of unpaid and rejected medical billing claims that will significantly affect your cash flow.
Consider outsourcing your medical billing claims to the pros who make it their business to stay ahead on the industry changes and get your medical billing claims reimbursed normally within 14 days. Plus your staff won't have the headache of compiling the coding and having to remember which modifier is used at which time. Look into outsourcing today!
Doctor Disciplined - Told to Take Medical Billing Classes
