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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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
As you know in processing medical billing for hospital based claims, location of services is everything and you must be certain that the correct place of service coding is used. That is where code 21 comes in handy. Place of service code 21 is used in medical billing for all inpatient hospital care. Code 23 is a lesser used code, but also useful.
Admittance of a patient to the hospital will make it necessary to use the inpatient hospital POS code 21. Many medical billers get confused when the emergency department comes into play. They question whether or not they should use place of service code 23 for emergency room-hospital, or place of service 21 for inpatient hospital if a patient is admitted from the emergency department. This becomes confusing when a patient is brought into the emergency room, taken into surgery, and then admitted after surgery. It is obvious the location after surgery should be POS code 21, but what about before the patient was admitted?
Fortunately the answer is simple. Medical billing hospital admission codes include absolutely everything that was done on that particular date of service. This means anything a physician does to a patient in the emergency room is included with everything a physician does once a patient is admitted on that day. So, Place of service code 21 should be used in medical billing for the entire day that a person is admitted.
The only time POS 23 is used is if the patient is not admitted to the hospital. POS 23 would be used for all services rendered on that day in the ED, including surgery as long as the patient wasn't formally admitted. Make sure you use the proper POS code and reap the benefits on your reimbursements.
Make sure documenting your POS correctly in your medical billing and attach code 21 and 23 as necessary and you'll see your reimbursements go up in a healthy fashion.
Make sure that you're using the proper medical billing codes when reporting CVA services, if you're not using CPT codes 76937 and 75998, you may not be getting the full reimbursement for this service.
If a physician performs an ultrasound guided procedure, the code 76937 will give additional money for the procedure. This code means: ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry. This means 76937 can be billed separately from the CVA placement code. One thing to note is that this code is only allowed one time per session in medical billing no matter how many sites were examined for the best entry. The CPT code 76937 should not be used if an ultrasound is used to only identify a vein to mark on the skin. The ultrasound must be used for medical billing purposes to guide a needle into the vein.
The other code used in medical billing to provide additional CVA payment is 75998. This is used for fluoroscopic guidance. This code is used when fluoroscopic guidance is needed to assist catheter placement or manipulation. It is reimbursed separately from the placement itself. It is important to note that any injection used to contrast the catheter's path is included in the CPT 75998.
Both of these CPT codes in medical billing require the use of modifier 26. Modifier 26 is only necessary when a surgeon is reporting in a facility. 26 means professional component. This allows the facility to medically bill separately for the equipment itself.
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.
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.
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.
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.
Modifiers can be a helpful addition to medical billing. However, there are certain modifiers that are constantly used incorrectly. The contractors for the Centers for Medicare and Medicaid Services are now keeping an eye out for suspicious modifiers. The medical billing modifier 59 is on the list of modifiers to flag for review.
Recently, the U.S. Office of Inspector General released a report that showed some daunting medical billing news. Modifier 59 has been the cause of over $59 million in overpayments to nursing homes and providers. Due this large number of overpayments, Medicare contractors will be closely scrutinizing each medical billing submission that contains the modifier 59.
Another medical billing guideline for modifier 59 is to use it in relation to group therapy sessions. It is perfectly fine to bill for a one-on-one therapy session AND a group therapy session if the two meet the Current Procedural Terminology definitions. The one difference is that you will bill using the medical billing modifier 59 for the group therapy and not for the one-on-one session.To prevent unnecessary medical billing audits, there are certain guidelines you should follow when deciding whether or not to use modifier 59. The first guideline is when you use modifier 59 for mutually exclusive Current Procedural Terminology code pairs. If there are two procedures performed, but completely separate from one another, you should use the modifier 59 to represent completely separate treatments.
Be wary when you use modifier 59 and make sure it's absolutely appropriate or you may pay the price in lesser paid claims and eventually audits!
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