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POSTS BY TAG | Reimbursement



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.

Piggybank and stethoscope

Since we posted our Guide to Telehealth Reimbursement, CMS has made a few major changes in regards to billing for telehealth. 

On March 30th, CMS issued a new rule affecting telehealth billing. More than 80 additional services, including inpatient visits, can now be performed remotely via telehealth and will be reimbursed.

Codes to Use When Billing For Telehealth During COVID-19


To bill for telehealth that's being specially permitted during this emergency, you should now use modifier code -95 and the facility and place of service code that you would have used if the visit had taken place face-to-face. This is retroactively effective as of March 1, 2020.

More details about the changes can be found on the CMS website.

Get Started With pMD Telehealth Today

pMD® Secure Messaging™ telemedicine capabilities allow practices to connect, triage, and follow up with patients through secure, HIPAA-compliant text, video, and voice calling. Easily invite patients to download the app at no cost to facilitate timely communication when it matters most.

pMD Telehealth Platform Customizable to Fit Your Needs

No matter the specialty, pMD is highly customizable to fit your practices’ needs and workflows. View additional information, resources, and FAQs about setting up and providing telehealth services with pMD and how to get started now.   

For help setting up patient communication or to contact pMD customer support, please give us a call at 800-587-4989, x1 or email support@pmd.com.

Stay safe, everyone!

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.


Telemedicine has been pushed into the spotlight in recent weeks in light of the COVID-19 coronavirus pandemic. Due to historically variable and restrictive reimbursement policies, many practices are not currently set up to provide virtual care. In light of the profound disruption caused by the pandemic, we are hearing from practices around the country that need to consider offering telehealth and scrambling to do so. Often, they have to consider tomorrow's appointments and wonder will we get paid for these visits? Well, here is what we know:


MEDICARE WILL COVER ALL TELEHEALTH SERVICES

CMS recently announced a major change to its telehealth reimbursement policy. During this crisis, Medicare will pay for telehealth services regardless of the originating site dating back to March 6, 2020. As long as visits are conducted via video, those visits that would normally be provided in an office, hospital, clinics or other settings, can now be done virtually, even from a patient's home. These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.

The codes that can be billed for what Medicare defines as “telehealth services” are typically evaluation and management (E/M) codes, such as 99213, combined with a telehealth Place of Service (POS) and potentially a modifier if required by the commercial payor.

PLACE OF SERVICE 02:

According to CMS, POS 02 is defined as “the location where health services and health-related services are provided or received, through a telecommunication system.” CMS has replaced the GT modifier with POS 02 and can be used when billing CMS claims for synchronous telemedicine visits. 

GT MODIFIER:

Although it has been widely replaced by the 02 POS location, some private payors still recognize and prefer the GT modifier to indicate a service was rendered via synchronous telecommunication.

MODIFIER 95:

Modifier 95 is a fairly new modifier and used only when billing to private payers to indicate services were rendered via synchronous telecommunication. It is important to note that Medicare and Medicaid do not recognize modifier 95. As with the GT modifier, not all payers recognize modifier 95. 

WHAT ABOUT MEDICAID AND COMMERCIAL PAYERS?

At this point, commercial and Medicaid coverage is still much less consistent. While U.S. Representatives have recommended CMS to encourage states to cover all telemedicine services and work with them to expand their capability to do so, reimbursement remains subject to state-specific requirements. In a similar vein, private health insurers, including Aetna, Cigna, Humana, United Healthcare will also cover telehealth for the next 90 days in some states, but the coverage also varies state by state. We encourage practices to always confirm local guidelines.

GET STARTED WITH pMD TELEHEALTH TODAY

pMD® Secure Messaging™ telemedicine capabilities allow practices to connect, triage, and follow up with patients through secure, HIPAA-compliant text, video, and voice calling. Easily invite patients to download the app at no cost to facilitate timely communication when it matters most:

* provide health safety guidelines and recommendations
* share important practice updates and announcements
* outreach to your most vulnerable patient population
* perform telehealth visits with patients advised not to leave their homes

No matter the specialty, pMD is highly customizable to fit your practices’ needs and workflows. View additional information, resources, and FAQs about setting up and providing telehealth services with pMD and how to get started now.   

For help setting up patient communication or to contact pMD customer support, please give us a call at 800-587-4989, x1 or email support@pmd.com.

Stay safe, everyone!

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.
Patient care doesn’t stop because it’s the weekend. Many providers share rounds and on-call activity for the 365 days that make a year. Visiting hospitals and practices on weekdays, I regularly wonder if their work ever slows down on the weekends, and if so by how much?

At pMD we have access to a lot of interesting data. Through the pMD charge capture app, providers record detailed descriptions of their encounters with patients. This data not only facilitates billing and reimbursements for a practice, but also serves as critical communication between providers. Looking at this data, we can get a rough measure of the volume of patients seen by our doctors and mid-levels throughout an average week.

Looking at visit counts for two full years (2012 & 2013) and across all of our specialties around the country, we get the chart below:

 

So it looks like work slows down in sheer volume, but still more than 20% of patient encounters occur on the weekend, and most likely among fewer covering providers.