An Introduction to Mac-based Medical Billing Applications

A piece on medical billing software from Software Advice caught my attention. I wanted to share it with my readers - I thought you might find it useful.

Katie Matlack, the medical software writer for Software Advice, noted that with the rise in popularity of iPhones and iPads, many doctors are looking for the same simplicity and convenience in the computer products they use at work. She also made the point that one area in which doctors are always looking to improve is in medical billing. From there, she went on to discuss options that folks with Mac systems have and provided some medical billing software reviews.

Here’s a quick overview:

There are several things to keep in mind when you are exploring what Mac-compatible medical billing software to get.

• Can the software support a practice of your size?

• Is your software appropriate for the specialty your practice serves?

• Do you want to purchase a web-based solution (also known as a hosted or software-as-a-service option – or a traditional Mac-based software system that’s installed on-site at your office)?

That last point can often make people take a step back and wonder what is the difference between web-based solutions and native-based solutions. Fortunately, Katie talks about the differences in her post, pointing out that web-based solutions are the norm for Mac users in the medical world because the vast majority of medical practices are still based on personal computers (PCs) that run Windows (and so there are very few software solutions built specifically for the Mac). However, she also makes the point that, for offices that run entirely on Apple computers and are looking for a consistent Apple OS look and feel, finding a native Mac solution can be the preferred choice.

Katie includes a list of medical billing software options, covering both native Mac solutions as well as web based ones. Head on over to her blog post for a more detailed discussion of how to choose the right medical billing software for your Mac-based office.  

Posted by Simant Ajmera

How To Correctly Bill Nerve Conduction Studies?

A nerve conduction study (NCS) is a neurological test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. The nerve conduction test provides physicians with information about the functioning of the peripheral nerves including both the type of dysfunction and the likely location of its cause. It is used to help diagnose various diseases that impact the nerves.

Coding and billing these procedures incorrectly could lead to a significant loss in reimbursement. Understanding these codes help gain in proper reimbursement.

The Nerve Conduction Studies include following codes:   

95900: Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study
95903:Nerve conduction, amplitude and latency/velocity study, each nerve; motor,with F-Wave study
95904:Nerve conduction, amplitude and latency/velocity study, each nerve; Sensory
95905:Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report

By definition, CPT 95900 is bundled into CPT 95903 when it is performed on the same motor nerve. However, when multiple nerve conduction studies, with or without F Wave study are conducted on different motor nerves during the same session, they are billable using modifier 59 (Distinct Procedural Service) to indicate that a separate, distinct motor nerve was studied. But if multiples sites on the same nerves are stimulated or recorded then these codes are reported just once.

For example: If a physiatrist performs a test on 3 nerves without F-wave and the same 3 nerves are tested with F-wave, only CPT 95903 is reported X number of nerves. However, if the physiatrist performs motor study on 2 nerves in left arm and 2 sensory nerves in the right arm, then both CPT 95900 and CPT 95904 are reportable. If NCS is performed on two different branches of a given motor or sensory nerve, then again appropriate CPT from 95900-95904 series is reported.

There is however a unit limit on the codes. Codes 95900 and 95904 are listed as exclusions to the 3 unit limit and upto 12 units for CPT 95900 and CPT 95904 can be billed and upto 3 units for CPT 95903 can be billed.

For NCS performed with preconfigured electrodes array(s), CPT 95905 should be reported.

Codes 95900-95904 are modifier-51 exempt, so modifier-51(multiple procedure) should not be reported on these codes.

Documentation for Nerve Conduction Studies is very critical. NCS uses sensors to measure and record nerve functions including conduction, amplitude, and latency/velocity. Per AMA (American Medical Association), Nerve Condution studies are only billable if the provider documents the distance between the stimulation and recording sites, conduction velocity, latency values, amplitude and the nerves studied.

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Posted by SMBS Team

Understanding Burn Codes Just Made Easy

According to the ICD-9 CM officical guidelines for coding and reporting, burns are classified by depth, extent and by agent (E code). So before you assign a diagnosis code, here are a few things to remember.

• Location/anatomic site of the burn
• Extent/severity of the burn
• Percentage of the body surface burnt
• Cause of the burn

Severity of the burn is determined by burned surface and the depth of the burn and this comes from the 941-946 series. Burn depths are classified in three degrees: first is superficial burns (inflammed and painful) involving the epidermis. These include erythema or redness of the skin; second degree invloves the middle layer i.e. dermal. These burns include blisters; third degree invloves full thickness skin loss. These are serious burns invloving all the layers of the skin including the fatty tissue beneath them.

Always sequence the first code that reflects the highest degree of burn (if more than one burn is present).

For example: A 25 yr old presents with a second degree burn of the right forearm and first degree burn of the right index finger and third degree burn of the abdomen. You must sequence your codes as 942.33 (3rd degree burn of the abdomen), 943.21 (2nd degree burn of the forearm), 944.11(1st degree burn of the index finger).

Imp:You should only code for the highest level burn when you assign multiple burns of differing degrees (severity) in the same body area.

Next you need to assign the code that reflects the extent of the burn i.e. how much body surface area is involved and this code comes from the 948 category. The inclusion of codes from 948 series is important as it may affect your reimbursement. To assign a code from 948 series simply ask what percentage of the body has been burnt and what percentage of the body has received 3rd degree burns.

For example: A patient presents with a 10% body surface with third degree burn of the thigh, assign code 948.11. Here the fourth digit of the code indicates the total percentage of the body that has been burnt and the fifth digit indicates the percentage of the body that has received third degree burns.

Lastly you need to assign the E code. E codes suggests as how the burns occured, whether it was accidental or caused by a hot substance or objects. If the burn is accidental, report an E code from E890-E899 (accidents caused by fire and flames) and if occured from hot objects report the code from E924 (accidents caused by hot substance or objects, caustic or corrosive material and steam).

For example: accidental steam burn in factory should be reported as E924.0 (burn by steam), E849.3 (Industrial place and premises).

Case Study: A 24 yr old youngman presents with a third degree burn on the right forearm 2%; first degre burn on right wrist 3%; and second degree burn to the right chest wall 5%. He states that he got burnt by hot steam while working in a restaurant.

Here's how the Codes should be sequenced:

943.31 (3rd degree burn forearm);

942.22 (2nd degree burn chest wall);

944.17 ( 1st degree burn wrist);

948.11 (Percent TBSA - indicates the percentage of body surface with 3rd degree burns);

E924.8 (accidents caused by hot substance or object, caustic or corrosive material & steam)

E849.6 (accident caused in Public building- restaurant).

Posted by SMBS Team

 

 

Importance of RVUs on Reimbursements

Every CPT code has been assigned a relative value unit (RVU) and they are determined on the basis of the resources necessary to the physician's performance of the service. Assigning these services in the proper sequence based on a highest to lowest RVUs can ensure proper payment. When submitting the claims, listing the codes in the wrong order may lower your reimbursements. Here are some examples which illustrates how a change in sequence may affect the way you are reimbursed.

Case 1: During a right eye cataract surgery with IOL, an ophthalmologist also performed fistulization of sclera for glaucoma;trabeculectomy ab externo in absence of previous surgery.The claim was billed as -

Line 1: 66984 RT (RVU 20.85)

Line 2: 66170-59-RT (RVU 32.13)

The payer processed the claim with a 50% reduction on the second line item and made a total payment of $1335.24.

Since CPT 66170 has higher RVU, the claim should have been billed with CPT 66170 -RT on the first line and 66984-59-RT on the second line. Then the reimbursement would have been $1533.19.

A potential loss of $197.95 per case, which could add up significantly if physician is performing multiple such cases.

Case 2: A surgeon performed an anterior discectomy and osteophytectomy at C5-6 and C6-7 with allograft fusion and zephyr plating.The claim was billed as -

Line 1: 22554 (RVU 34.17)

Line 2: 22845 (RVU 20.25)

Line 3: 20931 (RVU 3.06)

Line 4: 63075-51 (RVU 37.04) 50% reduction

Line 5: 63076 (RVU 6.86) X3

The payer processed the claim and made a total payment of  $3910.16.

The RVUs in the above metioned claim suggests that the claim should have been billed like this:

Line 1: 63075 - Full payment

Line 2: 22554-51 (50% reduction)

Line 3: 22845

Line 4: 63076 x 3

Line 5: 20931

The reimbursement would be $3966.22. A potential loss of $56.065 per case, which could add up significantly if physician is performing multiple such cases.

Case 3: An Ob-Gyn performed a left Salpingo-oophorectomy and a right ovarian cystectomy. The claim was billed as

Line 1: CPT 58720 LT (RVU 20.00)

Line 2: CPT 58925-51-RT (RVU 20.51) 50% Reduction on the second line item.

The payer processed the claim with a 50% reduction on the second line item and made the total payment of $1155.73.

Since CPT 58925 has a higher RVU(20.51) then CPT 58720 RVU(20.00), the codes should have been submitted in this order

Line 1: 58925-RT $782.85

Line 2: 58720-51-LT $391.42(after 50% reduction)

Total Amount would be: $1165

A potentioal loss of $9.27 per case which could add up significantly if physician is performing multiple such cases.

When reporting multiple surgery procedures performed on the same day, on the same patient by the same physician, codes should always be listed according to their assigned RVUs.This proper sequencing is very crucial when it comes to reimbursement because if a lower RVU code is billed first, it will be reimbursed fully while the higher RVU code will be paid at a reduced rate thus lowering the overall reimbursement.

When should CPT Modifier-52 be used ?

Modifier-52 is used to describe circumstances in which services provided were reduced in comparison to the full description of the service. When a physician does not complete a procedure in its entirety the procedure must be billed by appending modifier-52 or in other words if a physician elects to partially reduce or discontinue the procedure for reasons other than the patients well being being threatned, modifier-52 may be used. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumsatnces or those that threaten the well being of the patient prior to or after adminsitration of anesthesia, see modifier 73 and 74 (see modifiers approved for ASC hospital outpatient use).

Also note that if you have a Co-surgery situation, where the surgeon did not open and close the procedure, you must report the code and append modifier-52.

Following are the three different scenarios where it would be appropriate to use modifier-52.

Scenario 1: An ophthalmologist performed fluroscein angioscopy in only one eye of the patient. Since only one eye is assessed, use modifier-52 to report reduced services. It would be inappropriate to use modifier-50 here.

Scenario 2: A cardiologist attempted to perform a Percutaneous Transluminal pulmonary artery balloon angioplasty of the totally occluded blood vessel. The surgeon could not complete the procedure because of an anatomical problem which prevented him from performing the catheterization. Hence CPT 92997 with modifier-52 should be coded.

Scenario 3: During an open procedure, an Ob-Gyn  calls a general surgeon to perfom an Appendectomy. Since the general surgeon did not open or close the procedure, he must report the CPT 44950 with modifier-52.

When submitting a claim with modifier-52, attach a brief explanation stating the nature of the reduced services and the reason why and any/or all medical documentation supporting the claim. This will help the payer in assessing the fee value to the service performed.

Posted by SMBS Team

Correct Way to Code and Bill Brain Mapping

Surgically removing brain tumors adjacent to "eloquent" or functional regions of the brain poses significant risks for causing neurological impairments. Brain Mapping is performed for such eloquent cortex identification or to determine where the motor/sensory transition exists. CPT 95961 ( Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance) code should be used for the first hour of attendence.

For any subsequent attendence CPT 95962 (each additional hour of physician attendance) should be used.

Note that the physician must be physically present in the room for these codes to be billed.This cannot be performed or interpreted remotely by a physician.

Also CPT codes 95961- 95962 (functional cortical mapping) are not eligible for the 95920 (intraoperative neurophysiology testing per hour) hourly add on code.

How to handle a denial by an Insurance carrier for Intraoperative Neuromonitoring services?

Once a denial is received, the first step should be to review the policy or LCD(Local Coverage Determination) by the carrier regarding the services in question to determine if the claim has been denied correctly or not. Once that is determined, the next step is to write an effective appeal letter clearly stating the medical necessity for that procedure. Include a copy of the Op Report, Copy of IONM interpretation report and a copy of the LCD/Policy from the insurance carrier highlighting the areas that justify and support your appeal.

If after reviewing the LCD, it is determined that the claim has been denied correctly for not medically necessary reasons, make sure that the ICD-9 codes listed on the claim are definitive and not general. It is also very important to use the appropriate modifiers to capture the complete payment on the code.

How to report EEG during Non Intracranial and Intracranial Surgery?

During non-intracranial surgery i.e carotid endarterectomy or stenting, cardiac surgery, CPT 95955[Electroencephalogram (EEG) during nonintracranial surgery] should be used. This code cannot be billed in conjunction with CPT 95920.

Codes 95812 and 95813 are also used as EEG codes. CPT 95812 [Electroencephalogram (EEG) extended monitoring;41-60 min) and CPT 95813 [greater than 1 hour] can be used for intracranial surgery ( i.e. aneurysm clipping or coiling). These codes should only be billed as one unit regardless of the length of the surgery. Since these codes are not hourly codes, they should not be billed in multiple units like CPT 95920 nor can be billed in conjunction with CPT 95920.

Costly Coding and Billing Errors: Part 1

Often in medical coding and billing , mistakes happens but if they are not addressed immediately or if they are overlooked, it could turn into a costly affair for the provider causing potential loss in revenue. In this series of coding and billing errors, we will try to highlight some of such common errors and their financial impact on the practice.

CASE 1:

A physician performed an arthrocentesis on the acromioclavicular joint bilaterally on a 74 year old female. The biller billed the CPT code 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst ) without the modifier-50. The insurer processed the claim and paid for unilateral service (100%) instead of bilateral service (150%).

Financial Impact:

Medicare allowable for the procedure is $52.41 for unilateral service and $78.61 for bilateral services. In this case,a potential loss of $26.20 for the physician and this could add up if there are multiple cases like this.

CASE 2:

An ophthalmologist performed excision of a pterygium with graft on a patient but failed to document this in the chart. The staff didn't know and used the CPT code 65420 (excision or transposition of a petrygium without a graft) in place of CPT code 65426 (excision or transposition of a petrygium with graft).

Financial Impact:

The difference in the allowable between these codes per Medicare is $117.70. This loss could have been stopped, had the physician documented in the chart that petrygium was done with a graft or if the staff had questioned the physician about the procedure. 

CASE 3:

A Chiropractor provided spinal manipulation on a medicare patient and coded CPT 98940 (1-2 body area) but forgot to put in modifer-AT on the superbill. The billing staff overlooked and submitted the claim without this modifier. Medicare denied the claim stating maintenance therapy.

Financial Impact: The physician lost $25.67 which is the allowable amount for this procedure code. This figure can add up significantly if the chiropractor sees more such patients in a day.

 Posted by SMBS Team

Should You Outsource Your Medical Billing?

One of the many business questions physicians face is whether to outsource their medical billing to third-party medical billing services or do it in-house with medical billing software. Some physicians would assume outsourcing billing to a medical billing service makes the most sense. After all, they're the experts with the resources to properly process your claims, right? Others might want to maintain control of collections and do it all in-house.

Hold on. Don't make a decision before thinking it through. Both methods of revenue cycle management have benefits and drawbacks. It's up to the individual practice to weigh the pros and cons before deciding which approach is best.

Software Advice, a website that reviews medical billing software , has broken down in-house billing and outsourced billing in terms of cost and qualitative factors. You'll need to weigh the differences carefully when assessing the needs of your practice and decide if outsourcing makes sense.

Cost Analysis
For many practices, the outsourcing decision boils down to one factor: cost.

To help compare the costs of in-house billing versus outsourced billing, we've created a hypothetical, three-physician practice. To arrive at these numbers, we've used what we believe to be industry averages. Here are the characteristics of this practice:

• Three primary care physicians;

• Two medical billing specialists;

• 80 insurance claims filed per day (~20,000 per year);

• $125 billed per claim on average (~$2,500,000 per year); and,

• We assume that the billing service has a high collection rate on claims.

So, how much does each billing approach cost? Take a look at the annual costs:

	IN-HOUSE	OUTSOURCED
Billing department costs	$118,000	$4,000
Software and hardware costs	$7,500	$500
Direct claim processing costs	$3,600	$122,500
Software and hardware costs	$5,500	$2,000
% of billings collected	60%	70%
Collections	$1,370,900	$1,623,000
Collections costs	$129,100	$127,000
Collections, net of costs	$1,241,800	$1,496,000

 

 

 

 

 

 

 

 

 

Some background on our cost assumptions follow. 

Billing staff costs. IN-HOUSE: This was calculated by adding up the median salary of two medical billing employees ($80,000), healthcare costs for two employees ($9,000), federal and state taxes for two ($12,000), and training costs to keep the employees updated on the latest industry developments ($2,000). Finally, we've included $15,000 in ancillary costs for statement paper, office space, office hardware and other miscellaneous costs. OUTSOURCED: We factored in five hours of time per week required to manage tasks related to billing at approximately $15 per hour. Even the best medical billing service will require follow up from a practice about particular issues. That adds up to approximately $4,000 per year in administrative costs.

Software and hardware costs. IN-HOUSE: We've factored in an annual cost of approximately $7,000 for practice management software (~$200 per month, per doctor) and another $500 for computer hardware costs. This does not include the upfront cost of a software system. OUTSOURCED: This reflects the computer and printer the practice would still need to interact with the billing service and print documents.

Direct claim processing costs. IN-HOUSE: Clearing house fees for a provider submitting 20,000 claims per year would be approximately $300 per month ($100 per physician), or $3,600 annually. OUTSOURCED: A medical billing service usually charges a percentage of the amount collected as their fee. The industry average varies widely by specialty. We've used 7% for our primary care practice.

Percentage of billing amount collected. IN-HOUSE: The percentage of revenue that a practice collects varies widely by specialty as well. Our hypothetical practice collects 60% of what it actually bills. According to industry experts, this describes an in-house billing department that is average at bill collection. OUTSOURCED: A practice can expect a 5% to 15% increase in the amount they're able to collect by switching to a billing service. We factored in a 10% increase in the amount of money collected by a billing service as an average between the two.

Our cost comparison favors outsourcing billing, mainly based on the ability of a billing service to collect a higher percentage of the billed amount. Of course, this introduces a BIG IF. That is, outsourcing makes more sense IF the billing service improves collections significantly (i.e. on the order of 10%).

But there are other factors - beyond costs - that a provider must consider in its decision making. Let's examine the two approaches to compare advantages and disadvantages.

In-House Process
The in-house procedure for processing insurance claims involves a number of steps that are universal to every practice. First, employees enter information into the medical billing software program from a "superbill," which is gathered during a patient's visit. The superbill contains particular diagnosis and treatment codes, among other patient information, which the insurance company uses to determine if the claim is legitimate.

Via the practice's billing software, the provider then submits the claim to a medical billing clearing house, which verifies the claim and sends it to the payer. The clearing house scrubs the claim for the errors (for a fee) before passing it on to the payer. By not submitting claims directly to a payer, the provider saves time, money and lowers rejection rates. The clearing house also has the ability to format and submit claim data en masse in the various insurance company formats.

Once the claim is rejected/accepted by the payer, notification of the claim's status is sent to the clearinghouse, which updates the provider on the status of a claim. If a claim is rejected, the provider's staff resubmits the claim once additional information has been gathered. The practice will be charge for each claim submission, even if it's a correction.

EHR software- especially those EHRs with a integrated practice management system - has the potential to make in-house billing easier for a practice. EHR software, when integrated with a practice management system, will populate both system's data fields. Diagnosis codes and other information needed for billing doesn't need to be keyed into another system. This eliminates a second round of data entry. This tighter integration may be one factor that helps keep billing in-house.

Outsourced Process
The process for outsourcing billing is more straightforward for practice staff. Superbills and other documents are scanned and electronically sent or mailed to the medical billing service. The medical billing service takes care of the data entry and claim submission on behalf of the provider. Most billing services charge a percentage of the collected claim amount. The industry average is approximately a 7% charge for processing claims through a medical billing service.

The medical billing service takes care of much of the "dirty work" associated with the billing process. It will also follow up on rejected claims, pursues delinquent accounts, and even send invoices directly to patients. The convenience factor is a major reason that providers choose to outsource.

If a practice is using EHR software, then the process is even easier. Information from a patient's superbill is stored in the EHR and electronically transmitted to the billing service. This eliminates the need to send paper records to the billing service. And because the EHR software eliminates an extra round of data entry, accuracy is also improved.

One possible issue here is data integration between the EHR software and the billing service. The type of data being exchanged between the provider and the billing service will need to match, or else the data will need to be converted to a different format. Depending on the billing service, data conversion may be an option.

Should You Outsource Your Billing?
Besides costs, there are other factors that would spur a provider to consider outsourcing their billing.

• Your billing process is inefficient. If you've been watching your collections drop while the time to collect increases, you may have issues in your billing department. Outsourcing to a third-party billing service typically decreases the number of rejected claims and decreases the time it takes to receive payment from a payer.

• You have high staff turnover. Turnover is an issue in any industry but turnover in a provider's billing department is especially damaging. Claim processing is the economic life blood of a practice and a new addition or replacement in the billing department will inevitably lead to slowdown in the processing of claims.

• You're not tech savvy. Keeping your billing in-house will require an investment in practice management software. Add in training for your staff and the significance of this investment becomes clearer. If you don't want to deal with software upgrades and occasional technical issues, outsourcing is probably a good choice.

• You're a new provider. New providers have plenty to learn and worry about aside from their billing. Outsourcing their billing right off the bat can give them much needed relief from the day-to-day stress of launching a new practice, without a trial by fire in hiring, training and managing employees.

• You have different priorities. Many doctors are not strong on the business side of running a practice. They became doctors to help patients - not worry about the administrative/clerical side of the business. Outsourcing the billing process eliminates the hassle and frees doctors to concentrate on patients.

It's important to note that a medical billing service isn't a silver bullet for in-house billing issues. Billing services can vary widely in their efficiency and accuracy when processing claims. If a provider chooses a billing service that is lax and prone to errors, the headaches surrounding billing issues won't get better - they'll get worse.

Which Approach Should I Choose?
It's important for a practice to factor in their individual costs and preferences when deciding whether or not to outsource their medical billing. In an apples-to-apples comparison, we found that outsourcing had the higher net income. However, cost isn't the only issue practices should consider. There are plenty of other factors involved in this business decision that may be as - if not more - important than costs.

Posted by Chris Thorman