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POSTS BY TAG | Medical Billing

Increasing medical practice revenue


Medical coding is a key component of the claim cycle and is necessary for claim reimbursement. Inaccurate coding can affect your practice in many ways, which can lead to missed revenue, potential overpayments, and allegations of abusing reimbursement policies. Inaccurate coding may also result in staffing challenges as the demands of follow-up on claims denials increase. In this blog post, we’ll focus on ways that practices can improve medical coding accuracy and avoid the consequences of inaccurate coding.

FIND AREAS OF OPPORTUNITY


Contracting with a consulting or auditing organization to perform an independent third-party audit is a great starting point when determining where your practice should focus in order to improve medical coding quality and accuracy. Not only is your practice being proactive, but audit findings can guide you to the areas that need the most attention and help you avoid unknowingly committing abuse of reimbursement policies or missing out on valuable revenue opportunities. After each audit, consultants or auditors should educate the practice regarding areas in which to improve, and subsequent audits should ensure that previously identified areas of struggle have been corrected or addressed. Practice size, patient type, and regulatory changes should all be considered when determining how frequently to perform audits. A consultant can help you determine what cadence and sample size are best for your practice, but at minimum, the Office of Inspector General (OIG) recommends that at least 5 patient charts per provider per year are reviewed. 

STEP UP YOUR DOCUMENTATION GAME


Documentation is perhaps one of the easiest ways to improve medical coding accuracy. The more detail a provider includes in his or her documentation, the higher the reimbursement. When documenting your visit with the patient, it is important to remember that reimbursement is based on what exists in the medical record. If your practice struggles with documentation, consulting with a Clinical Documentation Improvement (CDI) Specialist could be insightful and helpful. The CDI Specialist can review your process and guide your practice through proper documentation to help improve coding as well as obtain maximum (and compliant) reimbursement. 

PARTNER WITH SUPERSTAR CODERS


Coding rules and regulations change frequently to adapt to the needs of health care. Medical coders spend years perfecting their expertise by gaining experience and obtaining certifications, hence why partnering with coding experts is certainly one way to improve coding accuracy and maximize reimbursement. Coders can help to fill documentation gaps and provide valuable feedback and education to providers. When hiring or partnering with a medical coding company, consider the following:

1) Resources to meet your staffing needs
2) Certifications - there are many types, including specialty-specific ones 
3) Number of years of experience
4) Proven track record of success including case studies and testimonials from former and current clients or employers

While there are many solutions that exist, it is important to find the right strategy for your team and implement best practices to avoid adverse effects of inaccurate coding. pMD’s team of billing experts is here to help you every step of the way so that you can focus on what matters most. Leave the rest to us!

Related Articles:

Custom Medical Coding & Billing Solutions – Let pMD Be Your Coding Assistant

3 Ways to Increase Medical Practice Revenue

Common Physician Billing & Documentation Questions Answered 




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


Claim denials cost providers millions of dollars each year; hard-earned money that could be allocated to more deserving services. We find that many practices do not have the time or resources to work through these denials and therefore those charges are written off and the practice loses out on revenue. The good news is we’re here to help mitigate that lost revenue, which starts by identifying what those common denials are.

Service Not Covered


These are words a provider never wants to hear but is a common denial that practices often receive. This denial occurs when the service is rendered prior to verifying the patient’s benefits and cross-referencing those benefits with the payer’s LCDs (Local Coverage Documents / Determinations) and Articles. These documents outline whether or not a particular item or service is covered on an intermediary or carrier-wide basis. Additionally, each governmental payer and private health plan do not share the same policies and also do not necessarily publish those guidelines where they are easily accessible. With a little extra time and research as well as implementing a process that will keep everyone up-to-date with the ever-changing guidelines, practices can easily avoid such a denial.

Missing Information


If a claim lacks even the slightest piece of pertinent information, you’ll find yourself with a denial. These denials can range from missing data in the fundamental fields such as date of birth, address, policy number, date of the accident or admission, lack of explanation of benefits from the primary payer, as well as failing to code to the highest level of specificity. These denials can be avoided by utilizing smart software that verifies all the information necessary to a claim prior to it being submitted to the payer.

Coding Errors


Providers are not trained to be coders so why is it that they pay the price for coding errors? Payers expect all submitted charges to have been scrubbed appropriately and follow all coding guidelines. Minor errors such as an ICD-10 code with too few digits, services that fail to include all applicable codes, and codes that do not align with the correct place of service can all trigger a denial from the payer. The idea of memorizing coding guidelines sounds like one more laborious task but leveraging a coding team and integrating National Correct Coding Initiative (NCCI) triggers within your practice's software provides a proactive approach in preventing these denials.

Duplicate Claim or Service


A service that is resubmitted for an encounter on the same date, by the same provider, for the same beneficiary, or for the same service will be denied as a duplicate. Sounds reasonable enough but the key to these denials is determining if the charge is in fact a duplicate claim or if the intent was to submit a corrected claim for another denial. It’s easy to disregard a duplicate denial as it suggests that the claim has already been adjudicated but you’ll find yourself leaving money on the table if you do not closely monitor these denials for accuracy. Each payer has particular protocols for which they are willing to accept corrected claims. If you fail to follow these guidelines, it will result in a denial for a duplicate claim in addition to the original denial. You’ll want to be sure that the true denial is addressed accordingly and you have received payment before you file away the duplicate denial. 

Limit For Timely Filing Has Expired


Each denial that you receive will ultimately result in a payment turnaround lag. It also can lead to a lack of payment if not addressed within a timely manner. By ensuring you submit your claims within the payer’s timely filing guidelines, you can easily avoid this denial. That sounds simple enough but it would also require you to be aware of every single one of those guidelines. Unfortunately, there is not a universal policy and can vary from payer to payer. Some accept charges up to 365 days from the date of service and others as little as 90 days post-service date. Submitting claims electronically can help expedite your submission and also provide you with acknowledgment reports should you find yourself having to produce supporting documentation that the claim was filed within the payer’s requirements. 

Additional Ways to Prevent Common Denials in Medical Billing


Let’s face it, some denials are inevitable. Why not leverage the denials that you’ve already received to create predictive logic in your software that can flag potential denials in the future. By analyzing denial trends and also collecting supporting documentation in advance, you can eliminate denials altogether!

Once you have identified the denial trend and implemented a process to avoid future denials, take it to the next level. After you have established that your documentation has substantiated your historical billing, initiate a contract with the payer to eliminate future requirements to have to provide supporting medical records. An expert team can help support that negotiation and also facilitate the management of tracking, analyzing, and reporting on these trends to get ahead of them. 

With all that said, how do medical denials impact your patients? Your top priority is maintaining a good relationship with your patients, and you can still do so while preventing revenue loss. It helps to have an expert on your side that is conversant with the provisions of these payers. They can navigate those denials, advocate on behalf of the patient, and alleviate the burden on both the patient and the practice. 

Our experienced team of medical billing and RCM experts is here to support you through all these challenges. Let us take on reducing your claim denials and increasing your practice revenue so that you can focus on what truly matters most - your patients.

Related Articles:


To find out more about pMD's suite of products, which includes our charge capture and MIPS registrybilling servicestelehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.
Ensuring a clean claim to avoid denial


If you were to Google, “What is RCM?” you’re not going to find an easy answer. At its most basic level, Revenue Cycle Management is defined as the financial process that health care practices and providers use to track patient care episodes. However, the search will spit out a myriad of definitions, and a laundry list of vendors, advertisements for new medical billing software, and companies promising to help improve your revenue cycle. Let us break it down for you. 

When does the revenue cycle begin?


Many vendors may say the revenue cycle begins when a provider renders a service to a patient. At pMD, we think of it a little bit differently. We believe the revenue cycle begins long before the patient even steps foot in the office or onto a video call. A successful revenue cycle starts at the point of patient registration and appointment scheduling. Making sure a patient is set up, ready to go, has paid their co-pay, and insurance has been verified prior to their appointment is crucial to ensuring the patient has a successful visit, and the provider is reimbursed in a timely fashion. In fact, one of the most common reasons for claim denials is due to “missing information,” such as the patient’s insurance or demographic information is not accurate, up to date, or incomplete. Finding a solution that helps you gather and verify correct patient information upfront, prior to an appointment, pays huge dividends in a practice’s eventual collections and overhead costs.

When does the revenue cycle end?


Some may argue that the revenue cycle ends when reimbursement from a patient and/or payer hits your bank account. Others might say that the revenue cycle never really ends, since the lifecycle of a patient relationship can be long and complex, with one episode of care bleeding into the next. Here at pMD, we believe that it’s all about consistently finding ways to simplify and shorten this cycle. Additionally, carrier relationships can be complex and iterative, meaning there is always room for improvement. One piece is clear though - the ultimate goal of an RCM partnership is to reduce the amount of time it takes for a practice or provider to get reimbursed for services, while also maximizing those reimbursements. As the saying goes, your dollar today is worth more than your dollar tomorrow. 

How do you measure the health of your revenue cycle? 


There are various metrics used to measure the efficiency of one’s revenue cycle, and the importance of each is going to depend on the individual practice and their unique priorities. The most commonly used measurement technique is known as days in AR, or accounts receivable. Days in AR is a measurement of the average time it takes to collect payments owed to the practice. Days in AR gives you a snapshot idea of how quickly you are getting reimbursed for your services, and by extension, how effective your revenue cycle is. Another common way to measure one’s revenue cycle is through overall collections, which can be drilled down further, to examine collection trends by payer or even by charge code. The appropriate metric used may depend on an individual organization’s specific needs or goals. 

What can I do to improve my revenue cycle?


Ask an expert! Here at pMD, our mission is to streamline and optimize as many areas of the patient care episode and the revenue cycle as possible. Through our integrated RCM software and services, we’re able to help practices consolidate vendors, reduce costs, streamline workflows, improve patient care and satisfaction, and collect your maximum reimbursement quicker. Not sure what a vendor could do to improve your financial metrics? Contact pMD for a no-commitment financial impact analysis by our team of RCM experts FREE of charge! 

If you are interested in learning more about pMD’s Billing & Revenue Cycle Management Services, please contact us here or give us a call at 800-587-4989 x2. 

 

Related Articles:

What are Comparative Billing Reports? 
Reduce Claim Denials with Real-Time Eligibility 
Is your revenue cycle vendor a true strategic partner?


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

 

In 2010 the Centers for Medicare and Medicaid Services (CMS) began to release Comparative Billing Reports (CBRs). A CBR compares provider to provider billing practices, both regionally and nationally, to determine if a provider is an “outlier”, or billing outside of the expected pattern. If a provider is found to be an outlier, they will receive a notification detailing the analysis and erroneous billing, while offering education on the topic. CBRs review many areas of billing, and even topics outside of billing. Some common topics include; evaluation and management, modifier utilization, and groups of specific codes, for example, radiation modality treatments for oncology providers or dialysis visits for nephrology providers. It's also important to note that CMS is not the only one reviewing billing practices in this manner. Other large commercial payers have similar programs, such as UnitedHealthcare’s Peer Comparison Reports, which functions much like the CBR.

What is a CBR used for?


CMS and other payers perform CBRs and similar reports with the goal of providing educational resources and outreach. This outreach ensures compliance with coding and billing standards and reduces potential fraud, waste, and abuse. CBRs can also ultimately help patients. Most patients are unaware of the many coding and billing rules that exist and therefore have a difficult time identifying when they have been overcharged. This can lead to costly out-of-pocket expenses toward co-insurance and deductibles. Educating providers can offer a real impact on reducing a patient’s financial burden.

What should I do if I received a CBR?


While CMS says “receiving a CBR is not an indication of or precursor to an audit” the receipt of a CBR can still be a stressor, especially if a provider or practice does not have the right tools to internally investigate the CBR findings, or worse, does not know where to begin to address a CBR. The risk of removing focus from the patient care to address these billing practices is high. Additionally, ignoring the report altogether could place the provider and practice at risk for more CBRs in the future and even potential audits. CBRs should be promptly reviewed and addressed by taking the following steps:

* Examine the issue identified in the report closely
* Evaluate the organizations or individuals billing patterns as they relate  to the CBR subject
* Perform a root cause analysis and address or correct any errors with education
* Continue to monitor the situation closely

How do I avoid a CBR?


One of the best defenses for CBRs and other billing challenges is to practice proactive risk analysis, or regular and consistent monitoring to identify potential billing issues before they begin. Proactive risk analysis can easily be achieved by utilizing the data that already exists within your billing software. Reports that visually display information such as charge capture counts or evaluation and management level distribution can be particularly useful. The same reports can then be combined with CMS benchmarking data, allowing a provider or practice to easily identify any variance from expected billing patterns.

These reports should paint a clear and visible picture, providing valuable insight. In the event a CBR is received the reporting can be used as part of the examination and subsequent monitoring following education on the error. Reports can also be supplied to coding/auditing or Clinical Documentation Improvement Departments as a resource to begin analysis for targeted internal education.

Taking a proactive approach to billing patterns can effectively decrease billing errors, support operational excellence and allow providers to spend more time focusing on patient care, which is the heart of pMD’s mission.

If you are interested in learning more about pMD’s Billing & 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.

 


Claim denied. Ugh! These are two words that make all those involved in the health care revenue cycle cringe. Unfortunately, claim denials are very common, costly, and time-consuming to correct. However, there are strategies to avoid them, with the potential to significantly increase your bottom line and decrease your revenue-related headaches. We’re going to talk about one of those strategies here — real-time eligibility. 

Why Are My Claims Being Denied?


Eligibility verification is one of the first phases in the revenue cycle and by far the most significant. Did you know eligibility issues are one of the top five reasons claims deny? In fact,  nearly 24% of claims submitted are denied for eligibility and registration issues, such as the patient not being eligible for medical benefits on the date of service, or having incorrect demographic information, like date of birth or a misspelled name. 

The eligibility verification process is directly linked to claim denials which can have a variety of unwanted consequences. This includes a hike in the number of days in A/R, an escalation in write-off rates, a standstill of cash flow, inflated costs to collect, and most importantly, delays in a patients' access to treatment. The process of verifying eligibility needs to be both efficient and accurate in order to determine the responsibilities of both the payer and the patient.

How Do I Make Sure My Claims Aren’t Denied?


Most claim denials are avoidable, in fact, 90% of them could be avoided. Research also shows that of those denied claims, approximately 60% of claims are recoverable, meaning they can be corrected and resubmitted for reimbursement. 

This sounds pretty good, right? Well, the reality is that a whopping 65% of denied claims are never reworked, which translates to a huge loss in revenue. The remaining claims that are reworked can be a drain on resources when factoring in both time and overhead costs. The average cost to correct and resubmit a denied claim can range anywhere from $30 - $125 per claim.

By implementing the right tools and processes, such as checking real-time eligibility, the likelihood of having your claims denied decreases significantly. By simply using real-time eligibility tools, you’ll be able to increase the number of  “clean” or error-free claims submitted,  tackling a number of the top reasons claims are denied, such as eligibility, no authorization, or being covered by another insurance plan.

What Is Real-Time Eligibility?


But what exactly is real-time eligibility, and how do I use it to my advantage?

Real-time eligibility is a software tool that allows medical staff to electronically confirm a patient’s insurance coverage by interfacing directly with the insurance carriers. This instant eligibility check provides an up-to-date overview of the patient’s coverage and plan benefits. Real-time eligibility can answer important questions such as if the insurance policy is active, the start and end dates of a policy, deductible amounts, copay coverage, and if prior authorization is required. Verification checks can be done at the time of the patient’s appointment, or even prior, which not only saves both the staff and patient time during check-in but also provides a clear understanding of both the provider and patients’ responsibilities.

Real-time eligibility benefits all those involved in the revenue cycle management process. For example, the amount of time staff spends checking and verifying a patient’s coverage is reduced significantly, as it eliminates back and forth phone calls, and the need to check multiple systems in order to verify coverage. Additionally, verifications are saved to the patient’s record, which provides an audit trail and proof of insurance coverage. Plus, it makes it much easier to submit clean, error-free claims, which facilitates faster payment and improves cash flow, which leads to increased provider satisfaction. Let’s not forget about the most important part of the revenue cycle, the patient. Being able to communicate to the patient their financial responsibility prior to, or at the time of service, makes for a much-improved patient experience.

Claim denials are preventable when identified and addressed early in the revenue cycle process. By implementing real-time eligibility, you can decrease the burden of claim denials, and in turn, enhance revenue, improve the overall patient experience, and let the provider focus on what matters most — patient care.

Learn About pMD Medical Billing & RCM Tools & Services


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.

Related Articles:
* Collecting Patient Payments & Solving the Patient Payment Equation
* When to Consider Breaking Up with Your Medical Billing Company
* Investing in Partnerships Pays Dividends


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.

Interfacing health care IT systems


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.


Related Articles:
* Healthcare Interface Implementation: 2 to Tango, 3 to Interface
* Interoperability in Health Care IT: The New Norm… Eventually
* Investing in Partnerships Pays Dividends

I’ve worked in health care for many years, and while providers face their fair share of challenges, there’s one question that I’ve noticed almost always bubbles to the top - who do I ask about coding questions? This can be especially distracting as they attempt to focus their efforts on providing the best medical care.

Why Coding is So Difficult

Coding appears to be a thorn in everyone’s side. Why is that? Well, imagine having to enter codes on patients 30+ times a day! Currently, to determine whether you’ve made the correct E&M (evaluation and management) code selection, providers must successfully meet each criterion of the 1997 Documentation Guidelines for E&M Services. Yes, you read that correctly, 1997! 

Let’s take a look at charge code 99213 as an example. While this may seem like a straight-forward, low-level subsequent visit, think again! To correctly select this code, you need to meet two of the following three requirements: 1) an expanded problem-focused history; 2) an expanded problem-focused examination; and/or 3) medical decision-making of low complexity. But, that’s not all. Now answer the following question; how do you define and determine expanded and low complexity? Each of the previously required components is broken down even further into several categories and elements that need to be considered.

As you can see there are many variables that go into selecting the correct code. The question many providers are left with is: who has time to reference the various guides and available resources when trying to complete a patient visit? Unfortunately, inaccurate coding can lead to significant penalties and lost revenue.

The Consequences of Medical Coding Errors

The good news is that changes are coming. Starting in 2021, time-based billing will be available for applicable services, dramatically reducing the complexity associated with code selection. CMS alone has reported a 9.2% monetary loss due to incorrect coding and 55.2% loss due to insufficient documentation in the CY of 2019. If you were to submit an incorrect claim to the government, this would violate the Federal Civil False Claims Act (FCA). Penalties may include substantial fines and even possible imprisonment. As frightening as those repercussions are, the most common consequence of medical coding errors is not receiving reimbursement from the insurance carriers. 

It’s about time we actually apply the infamous motto “patients over paperwork” and remove the providers’ burden of having to recite coding guidelines. Thus, eliminating the fear of possible sanctions due to inaccurate coding.

pMD Helps Solve Coding Problems & Meet Medical Billing Needs

At pMD, we can create customized edits designed to prompt providers to select accurate codes based on specific parameters and requirements, such as charge code or diagnosis criteria, NCCI edits, patient demographics, and much more. This is a quick, seamless process that enables the provider and biller to feel confident in their code selection. Just a few extra clicks based on prompts can assist with accurate and timely claims submission. Additionally, it can result in quicker payment turnaround as well as the appropriate utilization of E&M codes. 

pMD is continuously evolving to serve the medical billing needs of practices. Contact us to learn more about how pMD can best assist you and your practice!

Related Articles:
Standardized Code Sets, Their Impact on Providers & the Solutions
Investing in Partnerships Pays Dividends
Electronic Health Records Don’t Reduce Administrative Costs - Mobile Charge Capture Does!

 

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.


From a financial perspective, one of the benefits of mobile charge capture software is a tremendous reduction in charge entry lag. This is the length of the time between when the patient is seen and when the charge is captured electronically - not on a piece of paper where it could be misplaced or accidentally used as a napkin.

Providers who see patients in an office or clinic setting typically have low charge entry lag. Patients come to them and the provider is always in front of a computer, so they can capture billing information at the same time as they're doing other documentation.

Everything changes the moment the provider heads over to see patients at an outside facility such as a hospital or nursing home. Suddenly they are walking from room to room, and they need to improvise a system (typically a paper system) to track what happens as they go along - or they have to reconstruct it from memory later, when they're in front of a computer. Then they have to figure out how get the paper or spreadsheet back to their billing office. This administrative burden can create a cycle of procrastination that leads to weeks of charge entry lag as busy providers struggle to stay on top of their paperwork.

The statistics tell the story. If you're looking for a mobile charge capture solution, you should ask each vendor what their median charge lag is across their entire customer base for these places of service: Hospital Inpatient, Hospital Outpatient / Surgical Center, and Skilled Nursing Facility. If a vendor tracks these statistics, the answers may reveal whether their charge capture solution is usable in real time. If they don't track these statistics, why not? Charge entry lag is one of the key metrics for charge capture software, and you should choose a vendor that helps its customers measure and improve it.

In February 2017, the median (typical) pMD customer had a charge entry lag of 0.06 days at these remote facilities. In fact, 84.9 percent of pMD’s customers had a charge entry lag of less than one day outside of the clinic setting. Of providers who used pMD to capture charges in February, 90.8 percent used the pMD mobile app to do so, and 91.2 percent of all February charges were created on mobile. These numbers prove that practices are living the dream of real-time mobile charge capture. The fast, intuitive mobile app that works offline is key to achieving this.

What does all this mean for a medical practice? If you start out with a charge entry lag of one week at your remote facilities, and you become a typical pMD customer with a charge entry lag of less than one day, then you immediately recover a full week of revenue that had been floating out there somewhere in paper form. You could bill 372 days worth of revenue in a single calendar year of 365 days.
Finally, and as expected, the announcement medical practices have been waiting for since spring came today. The U.S. Department of Health and Human Services issued a rule this afternoon to finalize the new ICD-10 deadline for October 1, 2015. Shortly after, CMS stated in a press release that this change “allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015.”

The deadline was pushed back on March 31 of this year when the U.S. Senate voted on legislation that included a one-year delay to ICD-10. This delay came as a relief to many medical practices that required additional time and resources to implement an effective ICD-10 plan by the mandatory transition date. Even with the one year extension now formally in effect, medical practices are continuing to press on with their ICD-10 implementation strategies. With a good mobile charge capture system in place the ICD-10 transition is smoother and easier, making the countdown to the new disease classification system less daunting.

Marilyn Tanner, Administrator of CMS, contends that the "ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics.”

Source: CMS.gov