The pMD Blog

Welcome to the
pMD Blog...

where we cover interesting and relevant news, insights, events, and more related to the health care industry and pMD. Most importantly, this blog is a fun, engaging way to learn about developments in an ever-changing field that is heavily influenced by technology.



Here's The Latest in Health Care:


One year ago, when the COVID-19 pandemic upended life as we know it, some revenue cycles were better positioned than others to deal with the demands of the emergency. Organizations that had revenue cycle analytics, denial management tools, employees working remotely, and automated check-in processes in place at the beginning of 2020 were perhaps better positioned than other organizations to manage the operational demands of the pandemic.  Read More

People on dialysis who contract COVID-19 are at far greater risk for serious illness and death, so now, dialysis centers will be getting thousands of COVID-19 vaccine doses to vaccinate their patients and employees. The doses will be provided directly to dialysis centers for patients who receive treatment at least three times a week.  Read More

According to a new Kaufman Hall analysis, nearly 40% of hospitals could operate in the red this year even if the vaccine rollout is smooth and COVID-19 hospitalizations decline. The analysis, conducted on behalf of the American Hospital Association (AHA), gives a glimpse of the lingering financial impact of the pandemic on hospitals.  Read More

CMS has opened applications for the second cohort of the Primary Care First (PCF) value-based payment model which seeks to drive down costs and increase the quality of care. the PCF model will explore if switching from fee-for-service to Medicare performance-based payments could increase the quality of care and reduce overall Medicare costs.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.


Welcome to the "Biller’s Corner" of the pMD blog, your trusted source for updates, tips, and tricks provided by seasoned medical billing and coding experts!

Medical coding is often a moving target, especially during a pandemic. But have no fear, we’re here to provide guidance on some recent coding updates you need to know about!

NEW COVID-19 VACCINATION CODE ALERT

Speaking of the pandemic, the AMA recently released the CPT® code 91303 for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, for intramuscular use.

Here’s what you need to know:


* This is the code used for the one-dose COVID-19 vaccine developed by Janssen Pharmaceutica, a division of Johnson & Johnson.


* It should be used in conjunction with the CPT code 0031A, Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, single dose.


AMA PROVIDES ADDITIONAL CLARITY ON THE UPDATED E/M CODE SET

Another hot topic this year has been the significant updates to E/M office codes (99201-99215). The primary intention behind the changes is to reduce the administrative burden of unnecessary documentation, in turn, allowing for more time to interact with patients. While the intention is great, there has been a lot of confusion surrounding the revisions made to this code set, and many physicians have reported that the ambiguity of the new revisions is actually leading to additional time spent on documenting. This is obviously the opposite of what they were going for, so the AMA is acting on that feedback and has released the following revisions, retroactive to January 1, 2021.

TIME-BASED BILLING

For time-based billing, you should not account the following:


* Performance of other services when reported separately


* Travel time


* Teaching that is not required for the management of the specific patients' care


Also, remember Medicare and private payers’ policies can differ when it comes to reporting prolonged services for time-based billing. Although the AMA has established the CPT 99417,  Medicare has assigned a status indicator of “I” for this code which denotes the code as invalid. Instead, Medicare will accept HCPCS code G2212 when reporting 15 minutes of prolonged care, performed on the same encounter as E/M codes 99205 and 99215. When billing for either code, be sure that it is listed separately in addition to a level 5 office/outpatient E/M service.

MEDICAL DECISION MAKING

When it comes to medical decision making (MDM), you should account for tests that are analyzed as part of MDM and are not reported separately when interpreting the study. These may be counted as ordered or reviewed when selecting an MDM level.  When determining the complexity of problems and the number of problems addressed, also consider the following:


* If the presenting symptoms are likely to represent a highly morbid condition, this may “drive” MDM even when the ultimate diagnosis is not highly morbid. Multiple low severity conditions may equate to a higher risk level due to interaction.


* When determining data reviewed and analyzed, pulse oximetry is not considered a test.


* When considering data elements reviewed, a combination of three data elements can be counted by reporting a unique test ordered, plus a note reviewed and an independent historian. However, it does not require each item type or category to be represented.


* Ordering a test may include those considered, but not selected after shared decision making due to patient health risk or a discussion to forego further testing due to lack of medical necessity.


UNDERSTANDING THE KEY TERMINOLOGY

The AMA has also provided clearer instructions to interpret the definitions that make up the elements of MDM. Understanding the following terms as they are laid out by the AMA is crucial:


* Analyzed: Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.


* Discussion:  Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). The discussion can be asynchronous and occur on a later date following the encounter but must be completed within a short time period (eg, within a day or two).


* Independent Historian: When collecting the history, it does not need to be obtained in person but does need to be obtained directly from the historian providing the information.


* Risk: The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.


* Surgery (minor or major): The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. Be advised that CPT guidelines indicate that it is the provider's clinical determination whether surgery is considered major or minor and is not dictated by global days. However, if the surgery occurs in an office setting, you will have a hard time justifying it as a major surgery. Major surgeries will most often require the use of an operating room.


* Surgery (elective or emergency): Elective procedures and emergent or urgent procedures describe the timing of a procedure as it relates to the patient’s condition. An elective procedure is typically planned in advance and scheduled, while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures. 


* Surgery (risk factors): Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.


A full list of revisions can be found on the AMA website. Plus, be on the lookout for even more revisions that will become effective in 2023. 

Make sure to check back in soon for more billing and coding updates! And if you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you! 


To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.



Here's The Latest in Health Care:


U.S. vaccination efforts have gotten a big boost, thanks to increased supply. As of Wednesday, 147 million COVID-19 vaccination shots had been delivered, with roughly 39 million people, or 8 percent of the population, having been fully vaccinated. By the end of March, the number of shots produced is expected to be at least 200 million, and by summer it is expected to hit 700 million, according to HHS.  Read More

Many of the Center for Medicare and Medicaid Innovation’s value-based care payment models are currently undergoing a review. CMS quietly updated and delayed several payment models, including pulling a controversial model that ties payments to geographic health outcomes.  Read More

New research has revealed that staggering numbers of health care workers, more than one in five, have experienced anxiety, depression, or post-traumatic stress disorder during the pandemic. While North America ranked the lowest of all regions, it still saw nearly 15 percent of health care workers experiencing anxiety and close to 20 percent experiencing depression.  Read More

In 2020, at least 600 clinics, hospitals, and health care organizations were hit with ransomware attacks. These attacks affected more than 18 million patient records, and cost almost $21 billion in lawsuits, ransom paid, lost revenue, fees to rebuild lost data and more. Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.


You’ve made your way to the physician’s corner of the pMD blog, welcome! Here you’ll find information written for physicians, by physicians. 

This post is written by Richard E Lehman, MD, Pediatric Critical Care Medicine

Ask any physician why they started practicing medicine; I promise you’ll never get the answer “because I love billing and documentation.” That being said, there’s really no way out of it as it’s part of the business of medicine.  It’s an essential part of the job we all have to deal with on a daily basis, but the more you know and understand about what goes on behind the scenes, the better off you are and the easier it is to do. Unfortunately, many physician’s billing questions often go unanswered or are told “if it isn’t broken, don’t fix it.”  Some just do the bare minimum to get by and are fine with the reimbursement, others question the whole system and what we can do to improve it.

Full disclosure, I’m not a biller. I am, however, a pediatric critical care physician who has spent over 20 years asking a lot of questions and identifying ways to minimize my administrative and clerical burdens, while still maximizing potential revenues. I’m here to pass on some of that knowledge and provide answers to a few questions commonly asked by physicians regarding billing and documentation I've heard over the years.

WHAT IS THE FINANCIAL IMPACT OF DIAGNOSIS CODES?

I hear providers asking this question a lot. Will my reimbursement change based on the number of diagnoses codes I use, and if so, how much will it increase per diagnosis? The short answer is no, the number of diagnosis codes won’t change the amount paid for a procedure. But this doesn’t quite tell the whole story. The natural follow-up question from providers is often “then can I save myself some time and only put one diagnosis code?” I asked this same question myself and have been told it’s not a great idea. If we routinely underreport diagnoses, we could find ourselves in some trouble with Medicaid payers if we get audited.  If payers are receiving some bundle of payment from the government based on the patient’s risk profile and they then under-report risk based on our under-reported diagnoses, it can result in hefty fines. So, although it may take a little bit of extra time, it’s usually a best practice to report dx codes accurately, with the most predominant one, typically most severe, first.

WILL I MAKE MORE MONEY THE QUICKER I DO MY BILLING?

This is a really interesting question. Will you actually make more money if a bill is submitted and processed today, versus days or weeks later? Well, one smart director of coding explained it simply, a bird in the hand is worth two in the bush…or so the saying goes. When it comes down to it, the longer it takes to collect, the less the money is worth. While we’ll normally get paid the same per our contracts as long as we file within the claims time limit, which can range from 60-365 days depending on the payer, at the end of the day the money is worth more the longer we have it in our pocket. So, ultimately the quicker you can get your billing submitted and processed, the quicker claims can be collected, and the more the money could potentially be worth.

WHAT ARE THE MOST COMMON DOCUMENTATION MISTAKES THAT AFFECT REVENUE?

Although time-consuming, poor documentation can significantly impact reimbursement amounts. Avoiding some common documentation mistakes can mean the difference between a claim being rejected or achieving maximal reimbursement. For example, failing to completely describe an assessment and plan, can derail a claim. Physicians sometimes assume an auditor can review lab values and understand what they were trying to do. They can’t. Since they’re not physicians, they’re not allowed to make those assumptions. If you’re looking for your maximum reimbursement, it’s important to include what diagnostic values were run and how they factor into your decision making. Document what you were thinking, what you reviewed, and what you plan to do about it. While not an exhaustive list by any means, other common documentation mistakes that can lead to missed revenue include:

* Using an incorrect date of service, which tends to happen when notes are retroactively created late


* Failing to include total time spent for a time-based service


* A sparse history and exam or exam template that wasn’t individualized and conflicts with other areas of the medical record


* Failing to sign a note, although this has become far less common these days


* Providing an incomplete sedation record


Overall, when it comes to maximizing your revenue there’s a ton of variance in best practices depending on your specialty, state, payer contracts, etc. I encourage everyone to ask questions and keep yourself informed as much as possible.

If you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!

Dr. Rick Lehman is a veteran critical care physician, providing care to pediatric patients across the country. He’s “grown-up” with the changes in health care over the last 20 years related software and has been directly involved with implementing new EMR systems at multiple hospitals, often transitioning them from paper to digital systems. His frustrations surrounding inefficient EMRs while managing his critical care patients have driven his passion for changing these health care systems to create better provider workflows.

 

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.


Source: Getty Images

Here's The Latest in Health Care:


Physician reimbursement for services performed by a doctor working for a hospital or health system is significantly higher than that paid to independent physicians for the same services. According to a new study, Medicare physician reimbursement would have been $114K higher per physician a year if the doctor was integrated with a hospital system.  Read More

Cybercriminals continue to see health care as one of the biggest, most lucrative targets for attacks. According to The National Cyber Security Alliance (NCSA), the exponential growth of the digital transformation of health care makes cybersecurity more important than ever and organizations should act now to protect patient data by replacing outdated software and instituting cybersecurity training and drills.  Read More

Over the next decade, Gen Z is expected to account for an estimated 61 million new employees in the global workforce, the majority of whom have never lived without the internet, smartphones, and immediate access to information and products. This is leading organizations to significantly adapt to new digital preferences and patient experiences.   Read More

The American Telemedicine Association (ATA) and the American Board of Telehealth (ABT) are partnering to expand access to training and education for virtual care. The partnership comes on the heels of the ABT's recently launched CORE Concepts in Telehealth Certificate, which consists of seven telemedicine-focused training models. As part of the collaboration, members of the ATA will receive discounted access to the ABT's certificate programs.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.


2020 was a difficult year across the globe and it affected everyone in dramatically different ways. My wife and I sold our home and moved across the country the day lockdowns started. We did so in preparation for our twins who were scheduled to arrive in mid-2020. Any parent will tell you how stressful and exciting it is to deliver your first child, but throw a pandemic into the mix and everything becomes a little bit more daunting due to health risks and restrictions. Despite being a high-risk pregnancy and hitting a few bumps along the road, my wife was able to carry our twins to almost 37 weeks and no issues were expected.

On July 15, we welcomed a beautiful baby girl and boy into our lives. Tiny but mighty, we felt a sense of relief to have such a smooth delivery, but after their first day in the hospital, both of our kids were whisked away to the NICU in the middle of the night with unexpected complications. Luckily, we were blessed to have an amazing team of neonatologists and nurses who made a very stressful time a little bit easier. We feel very fortunate that we were able to have both our children back at home before the end of July due to the amazing care they received.

During my years at pMD, I’ve certainly worked with my fair share of neonatology providers, but I now have a newfound appreciation and understanding of the incredibly difficult job they have. One that can only come from placing your newborn’s life in someone else’s hands. 

As 2020 progressed and our days were filled with balancing the “new normal” of childcare, work, and endless video calls, I had the opportunity to help get nearly 4,000 pediatric and neonatology providers up and running on pMD. As I was learning daily how to be a dad of twins, I was simultaneously finding a new connection to my work as I now had a profound appreciation for neonatologists and the impact they had on our family. I approached each call and meeting with greetings of my personal story including the sleepless nights with the occasional addition of crying in the background. Not only that, but each call gave me the opportunity to personally thank the providers for the work that they do - work that is so impactful. 

I have walked into 2021 with a new motivation to help ensure our providers aren’t being bogged down with complicated systems and processes that divert their attention away from patient care. If pMD can make the business side of medicine as easy as possible for physicians and allow them to focus on what matters most, like taking care of our families and friends, it ultimately leads to the best possible experience and outcomes for others like us. I realize that I am no longer “just” selling or implementing software, I am supporting the health and wellness of our loved ones.

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.



Here's The Latest in Health Care:


As the pandemic has created the need to optimize health care delivery, nursing and clinical leadership will need to address three major problem areas; workforce management, capacity management, and patient outcomes. While problems in these areas were present long before the pandemic, the events of the last year have brought them clearly into focus.  Read More

Telemedicine implemented without attention to workflow runs the serious risk of falling into an unsafe “doctor-does-it-all” model. The AMA recently published some recommendations to help provide patient-centered care and create an overall better telehealth experience for patients and physicians.  Read More

CMS will automatically apply the extreme and uncontrollable circumstances policies to all MIPS eligible clinicians for the 2020 performance period because of COVID-19. The automatic exception policy, however, will not apply automatically to MIPS eligible clinicians who submit 2020 performance data as an individual in two or more performance categories or whose practice reports as a group. Read More

Medicare physician spending declined $9.4 billion, or 19%, in the first six months of 2020 due to the pandemic, according to a new report. While spending on physician services declined precipitously, telehealth claims increased dramatically after the federal government increased flexibility for physicians to get reimbursed by Medicare.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.


Information technology is supposed to make work-life more efficient, accurate, and effective. The promise to eliminate duplication of effort and minimize fat-finger typographic errors is the core reason for adopting much of the IT used in the modern medical office. Nothing delivers on these promises more directly than establishing interfaces among the various computer systems in the health care delivery universe.

SHOULD YOU HAVE TO PAY FOR AN INTERFACE?

At pMD, our stated raison d'être is to save patient lives by reducing the risk of medical errors stemming from miscommunication and non-communication resulting in care gaps.  pMD was created to improve efficiency, accuracy, and information exchange among caregivers and patients.  Since interfacing is so integral and critical to achieving this goal, pMD has never charged our clients for an interface.  

When dining at a restaurant, you are paying for the food, but you are not charged extra for utensils or a plate.  When investing in a system to improve business efficiency and accuracy, getting quality data into and out of it should not cost extra.  This principle is at the core of the pMD approach to interfacing with other systems, including hospitals, practice management, answering services, and billing and revenue cycle management (RCM) services.  

Unfortunately, most other participants in the industry have a different view on the subject.  While pMD does not charge for interfaces, the reality is that most Practice Management (PM) System vendors do charge thousands of dollars for them.  Some hospitals and health systems also charge for data feeds to private practices as well, although can vary with the practice’s relationship with the hospital.

INTEROPERABILITY IS IN OUR DNA

Our commitment to core principles drove the way we designed our interfacing technology and continues to drive our methodology.  While many players in the industry are unwilling or unable to modify the format of the data they send or expect to receive, pMD has developed a system that allows us to be very flexible within the HL7 standard for interfacing.  Not only do we not charge providers, but we will flex to suit the needs of the systems we are exchanging data with.  

We have a huge existing and growing library of interfaces to a large number of systems that allow us to implement many interfaces with off-the-shelf modules quickly.  Our approach allows us to easily make adjustments to those existing interfaces for practices with unique requirements and workflows.  We’re also not limited to the systems we’re currently interfaced, we can adapt existing packages to quickly develop new interfaces with systems we have not previously encountered.  

pMD can process data for new and existing office and hospital patients, appointments scheduled in a practice management system, and can of course send charges in pMD back to the PM or RCM systems, customized to their unique requirements. The best part of it all, it is all included in the complete service that pMD prides itself on.

If you are interested in learning more about our interfacing capabilities, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.



Here's The Latest in Health Care:


The COVID-19 death toll in the U.S. topped 500,000 this week, a staggering number that all but matches the number of Americans killed in World War II, Korea, and Vietnam combined. The U.S. toll is by far the highest reported in the world, accounting for 20 percent of the nearly 2.5 million coronavirus deaths globally.  Read More

COVID-19’s impact on front-line health care staff will unfold for years to come, but it appears to have already had an effect on physicians’ career plans. According to a new survey, a surprisingly large percentage of physicians are considering leaving the practice of medicine entirely, retiring early, or leaving to work for another employer.  Read More

The massive amount of data available in health care makes it a prime area for artificial intelligence (AI) and machine learning (ML) automation. Implementing these technologies has the potential to advance preventive care, but for that to be possible, health systems need to adopt "high-level" AI and ML processes. Read More

Revenues across U.S. hospitals could be at least $53 billion lower in 2021 compared to pre-pandemic levels, according to the American Hospital Association. Health systems are still dealing with the fallout from delaying non-urgent procedures, depressed volumes, higher expenses as well as the physical and mental health toll of COVID-19 on their staff.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, secure messaging, clinical communication, and care navigation software.

With the health care landscape continuing to be impacted by the COVID-19 pandemic, the Merit Incentive Payment System Program (MIPS) has also continued to evolve. The Centers for Medicare and Medicaid (CMS) has released updates to the program that are being implemented for MIPS Year 5. With patient care and safety being the top priority, the pMD team continues to closely follow the changes and keep you up-to-date. 

As a qualified MIPS registry, pMD has been keeping an eye on the changes and requirements for reporting in 2021. We continue to offer our customers the tools to submit their 2021 MIPS data to CMS and navigate some of these changes using our robust dashboard and being in close contact with our excellent account management team.

Interested in what has changed for 2021 MIPS? Please review the updates below. A full list of changes to the Year 5 Final Rule and the most up-to-date information can be found on the Quality Payment Program (QPP) website

Reporting Requirements 

If your practice is unsure of your reporting requirements, the QPP has a readily available tool for determining your eligibility. The QPP Participation Lookup tool provides insight into provider eligibility as well as special status. To review your 2021 eligibility, simply enter your NPI into the tool and review! 

Scoring Requirements

CMS has increased the data requirements and score requirements for 2021 MIPS:

1) Quality measures must meet 70% of data completeness this year. 
2) Improvement Activities must apply to 50% or more physicians within a group to attest.
3) The performance threshold has been raised to 60 points to avoid a penalty and 85 points to get an exceptional performance bonus.  

There also have been changes to performance category weighting for 2021 MIPS:

1) The Quality performance category will be weighted at 40% (5% decrease).
2) The Cost performance category will be weighted at 20% (5% increase).

Promoting Interoperability will be weighted at 25% and Improvement Activities will be weighted at 15% - these are the same weightings as 2020. 

Avoiding the Penalty

With the minimum required score increasing substantially, CMS lists guidelines that will help your practice avoid the penalty: 

1) Groups should submit a combination of quality measures, Improvement Activities, and/or Promoting Interoperability. Groups can review 2021 measures on the QPP site. 
2) Groups should submit 6 clinically relevant quality measures. At least 1 of these measures should be a high-priority or outcome measure. 
3) If your group does not have 6 clinically relevant measures selected, you will be required to submit a specialty measure set. 

Bonus Points

Certain practices and measure selections can help your practice earn bonus points. You can earn bonus points by doing the following: 

1) Submit 2 or more outcome or high-priority quality measures.
2) Small practices that submit at least 1 measure can earn six bonus points for the quality performance category score. 
3) Practices can earn up to 10 bonus points if their quality performance category score improves. 

We are accepting new practices to report MIPS with us in 2022. If you are interested in learning more, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!


To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.