Posted on Sun, Apr 25, 2010 @ 09:07 PM
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
Posted on Fri, Apr 02, 2010 @ 04:24 PM
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
Posted on Wed, Mar 24, 2010 @ 11:04 PM
When an opthalmologist performs extracapsular cataract removal 
with IOL insertion, the correct way to code the procedure is by using CPT code 66984 [Extracapsular cataract extraction removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique ( eg, irrigation and aspiration or phacoemulsification)]. However if there are any complications encountered during surgery such as removal of dense cataracts with application of indocyanine green or trypan blue dye, pupillary enlargement, or in pediatric cases amblyogenic development stage, CPT 66982 [Extracapsular cataract extraction removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, endocapsular rings,or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage] can be used.
Note: There is a misconception among surgeons that if a surgery has taken longer than normal time, for example: to remove a dense cataract but it didn't require any extra mechanical devices or any capsular dye for visualization, it can be considered as complex cataract.
Another misconception is that if surgeons are using presbyopia correcting IOL's or Toric IOL's, it qualifies as complex cataract surgery, it doesn't. The type of IOL used during surgery doesn't affect the case as being complex or routine cataract surgery.
Both CPT code 66982 and 66984 has a 90 day global period and if the opthalmologist performs cataract surgery in the other eye during this global period ( for example: lets say first surgery was performed on 3/2/10 in the right eye and the next surgery was performed on 4/15/10 in the left eye) then modifier -79 should be used for the subsequent surgery. Using modifier -79 will initiate a new postoperative period.
Posted by SMBS Team
Posted on Fri, Mar 12, 2010 @ 08:55 PM
Question: How to correctly bill Punctum Plugs?
Answer: CPT code 68761(closure of the lacrimal punctum; by plug,
each) should be used to report the lacrimal procedure. This procedure is based on per puncta, not per eye so in situations where two puncta are treated in the same eye, multiple surgery rules apply. So report each service as a separate line item, adding modifier-51 to the second and any subsequent procedure. If performed in both eyes, bilateral payment rules apply, so report this procedure code with a modifier-50. This code is same whether you used temporary( collagen) or permanent(silicone) plugs. Medicare does not allow separate reimbursement for the supply of the plug(s), however certain commercial payers do. Check with payers if the supply of the plug(s) are covered. If it is covered, report the supply codes with A4262[Temporary, absorbable lacrimal duct implant, each] or A4263[Permanent, long term, nondissolvable lacrimal duct implant, each].
Posted by SMBS Team
Posted on Tue, Mar 09, 2010 @ 08:23 PM
Question: When a patient elects to upgrade his standard frame to a deluxe frame after cataract surgery, can a physician charge the differential even though he accepts assignment of benefits?
Answer: Yes, you can. Medicare covers up to one pair of 
eyeglasses or one set of contact lenses after cataract surgery with IOL implantation. As such Medicare will only pay for the standard frames but if a beneficiary chooses to upgrade to a deluxe frame, the participating provider or supplier (ophthalmologist, optometrist or an optician) may charge the beneficiary the difference between the standard frame and the deluxe frame charges for what he/she may have charged from his/her private pay patients, in addition to 20% coinsurance and/or any applicable deductible on glasses with standard frames, even though the provider accepts assignment if the following conditions are met:
a) Explain the beneficiary the price and difference between standard and deluxe frame and issue an ABN (Advanced Beneficiary Notice) and have it signed.
b) Have a statement signed and dated on patients chart which states :
The beneficiary[name], [Medicare Id#], was fully informed that an extra charge is being made by the physician or supplier for the upgraded frames and that this extra charge is not covered by Medicare, and that the standard frames are available for purchase but beneficiary declined the option to go for standard frames and instead chose the deluxe frames.
_________________Signature ___________Date
c) Once patient choses the deluxe frame, the physician or the supplier is then required to submit claims to medicare indicating the purchase of deluxe frames as 2 separate line items on the claim form; his/her actual charge for the standard frames and his/her charge for the deluxe frame (differential).
For example: On Line 1, V2020 for the cost of standard frames and the Medicare approved amount; and on line 2,V2025 (Deluxe Frame) for the difference between the charges of deluxe frame and standard frame.
Once the claim is processed, Medicare summary notice will reflect Code V2025 as non covered charges.
Posted by SMBS Team
Posted on Sun, Mar 07, 2010 @ 07:59 PM
When you are billing a Workers' Comp/PIP Claim, your success 
depends in part on whether your office captures all the pertinent information up front. When the patient first walks in and fills out the paperwork related to WC/PIP claim, often times it is incomplete, and/or illegible. Result - Confusion and delay in claims processing. By following these simple tips, you can avoid unnecessary delays in claims processing.
1. Obtaining accurate and complete information is not only vital in terms of billing the claims but also in providing the necessary medical care to the patient. This collection of the data begins at the front desk. A little diligence at the initial stage can save a lot of headache afterwards. When dealing with WC/PIP cases, the front office should thoroughly verify the case details. Make sure
- That the patient has completed an Accident Report also known as First Report of Injury [in case of WC to the employer and in case of PIP to the No-Fault carrier].
- Claim has been logged with the insurance carrier and a claim no. has been assigned to the case.
- Patient's questionnaire is filled out and has been received by WC/PIP carriers.
- In case of PIP cases, if the carrier has requested for an affidavit of ‘No Insurance', make sure that it has been received and acknowledged by the PIP carrier.
Often, you will come across a situation where patient, in need of urgent medical treatment has either contacted the provider directly or contacted the attorney who has sent them to providers for treatment and neither the employer (in case of Workers Compensation) nor the No-fault carrier (in case of Motor Vehicle Accidents) have been informed about the injuries. Reporting the accident/injury is very important as sometimes there are limitations placed on the completion of the First Report of Accident/Injury. In such cases, it is very important to contact the Employer/No-fault Carrier and patient must be made aware of this situation.
2. Once this initial process is over and you have received the Accident Report from the patient and/or attorney, review the report to make sure you have all the information needed to file the claim. This part is very important as sometimes things are overlooked. If any of the information is missing or not verified, this could create a lot of agony and pain at the time of filing the claim. Make sure the accident report has following information:
- Name, Address, Telephone Number of Worker's Compensation Insurance/ No-Fault Carrier
- Claim Number assigned to the case
- Name of the Claim Adjuster handling the claim (for in-office use only)
These small but vital piece of information are very important as this goes on your HCFA 1500 or its electronic equivalent and if this information is not filled correctly or missed out completely, chances are your claim will get denied and you will have to rework again.
Note: Claims adjusters usually look for reasons not to pay the claim. Any such minor errors or incomplete submissions leave the door open for them to deny your claim. Also note that Workers Compensation and No-Fault patients usually require Pre-certification/Prior authorization for procedures/treatments to be performed. So it is also advisable to check with the case adjuster if the treatment being provided is a covered or a non covered service.
3. Once you have filed the claim, do not wait for the carrier to send you the status notification. Based on your state laws and insurance guidelines, simply pick up the phone and do a follow up call. You might be surprised that your claim is simply pended for additional documentation or missing some pertinent information. This will enable you to take any appropriate action immediately and promptly.
Addressing these issues on time will speed up the process of claims handling, reduce redundant work associated with WC/PIP claims and will stop the revenue leak.
Posted by SMBS Team
Posted on Tue, Mar 02, 2010 @ 11:02 PM
To bill pachymetry of the cornea, one should use CPT 76514 (corneal
pachymetry, unilateral or bilateral). This code can only be used to report if the procedure is being performed using an Ultrasound technique. Since CPT 76514 is inherently bilateral it should not be reported with any site modifiers (RT or LT). Also it would be inappropriate to use modifier -50 with it. This service includes the interpretation and report, therefore no professional and technical modifiers (-26 or -TC) should be used.
Posted by SMBS Team
Posted on Sun, Feb 28, 2010 @ 03:14 PM
The Center for Medicare and Medicaid Services (CMS) created two modifiers that allows you to distinguish between services that are statutorily not covered or otherwise not a Medicare benefit because Medicare does not consider them "reasonable and necessary".
Modifier -GY: Appending -GY modifier to the CPT code enables 
one to identify an "item or service is statutorily excluded or the service does not meet the definition of Medicare Benefit". This will automatically create a denial and beneficiary may be liable for all charges whether personally or through other insurance, ( for example: when a beneficiary wants new eye glasses and wants to get a denial through Medicare for secondary payer purposes), claim should be submitted with -GY modifier. This way claim may be processed faster than it would be without -GY modifier. ABN's ( Advanced Beneficiary Notices) are not an issue for statutory exclusions.
Modifier -GZ: You should append -GZ modifiers to CPT codes when you think a service will be denied because it does not meet Medicare policy standards for medically necessary care and you didn't get an ABN or patient refused to sign an ABN and you nevertheless, did furnish the sevices. By using -GZ modifier, you are notifying Medicare that you know an ABN should have been signed but was not and that you recognize you made an error. This modifier is a measure of good faith towards Medicare. Note: You cannot bill patient for these services.
Posted by SMBS Team
Posted on Tue, Feb 23, 2010 @ 09:09 PM
Question: A patient with Rheumatoid Arthritis presents for a Remicade Injection(Infliximab) and receives two pushes, one of Benadryl and one of Solumedral. A recommended dose of Inliximab 200 mg was administered for 3 hrs by means of an intravenous infusion. How would you report these services ?
Answer: The correct way to report these services would be:
Dx Code: 714.0 (Rheumatoid Arthritis)
Pre Medication: 96375 X 2 (Total of 2 pushes); J1200 X 1 unit (Benadryl); J2930 X 1 unit (Solumedrol)
Infusion: 96413 ( Infusion first hour); 96415 X 2 ( two additional hours); J1745 X 20 units (Remicade 200 mg). NOTE:This product is billed by 10 mg units so that 10 units are all within a 100 mg vile).
Certain payer policies for IV therapy codes may vary. Some may prefer to use CPT codes:
96365(Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial upto 1 hour)
96366(Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour).
Please consult your local payer for specific coding policies.
Posted by SMBS Team
Posted on Thu, Feb 11, 2010 @ 11:14 PM
Question: How should I code for 95920 during spinal surgeries?
Answer: If during a spinal surgery, the only modality you are using is screw stimulation, you should report 95920 only for the time spent to interpret to collect this data. You should not report 95920 for the duration of the surgical procedure (i.e. skin incision to skin closure). You can report 2 units of CPT 95870(Needle EMG; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other then thoracic paraspinal, cranial nerve supplied muscles or sphincter) if performed in each leg. However, if five or more muscles are stimulated, then CPT 95861 (Needle electromyogrphy;2 extremities with or without related paraspinal areas) should be reported.
Posted by SMBS Team