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Medical Billing Resource CenterHave questions on how to prepare for ICD-10?

Wonder how your practice denial rate and collection rates compare with other practices?

Whether you need some help with improving your bottom line or getting started with ICD-10, we can now offer you an online resource center to help. Our Resource Center is now open, featuring:

White papers on improving your bottom line, how to evaluate medical billing services, ICD-10 and more

– All issues of our monthly enewsletter, Monitor, filled with medical billing and coding news and tips

Infographics including our popular infographic on avoiding CMS penalties for eRX & PQRS

– A Practice Revenue Analysis Tool that will help you compare your results to industry standards

– And of course, links to this blog

We‘«÷ve had many requests for these useful tools, so we wanted to gather them in one place where they‘«÷d be easy to access. They‘«÷re now available to you 24/7, to help bring more to your medical practice bottom line.

Take a moment now to review the Resource Center and tell us what you‘«÷d like us to add. We want this Resource Center to meet your medical billing and coding needs.

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This month we have a number of useful articles on coding that will help you avoid errors and code more precisely.

The G-Codes Are Here for Payment Claims – Ready Or Not
Effective July 1, the Centers for Medicare & Medicaid Services will begin rejecting claims received for Medicare Part B patients that do not include the new requirement of G-coding.

G-coding is a claims-based coding system that CMS plans to “collect and analyze”?ō the data to better understand patient outcomes. It also is meant to be used towards the various conversations surrounding the healthcare reform options floating around…?ŠRead More

CMS Releases Clarification on Reporting External Cause Codes and Unspecified Codes
On May 17, 2013, the Centers for Medicare & Medicaid Services (CMS) released several important clarifications in their ICD-10 Industry Update email. There has been some confusion and frustration regarding the codes in Chapter 20, External Causes of Morbidity (V, W, X, and Y codes), which will replace the current ICD-9-CM E-Code section. Read More

In Sync With ICD-10
In the race to prepare for the new codes, will providers and payers be able to successfully cross the finish line together?

It’s been said that a chain is only as strong as its weakest link. As the timeline for the health care industry’s mammoth ICD-10 implementation marches forward, industry professionals are becoming increasingly aware that if all stakeholders are not ready for the October 1, 2014, deadline, calamity could ensue.

“Everyone is wondering about everyone else…”?ō Read More

2013 OIG Work Plan: HHS Targets Three Areas
From a coding perspective, mechanical ventilation, cancelled surgeries, and Medicare’s transfer policy take top billing.

Last October, the Office of Inspector General (OIG) released its work plan for fiscal year (FY) 2013, an event that sometimes can trigger anxiety among health care organizations. Published annually, the work plan outlines the OIG’s enforcement priorities, enabling health care facilities to better identify compliance risks and more accurately gauge their chances of meeting the requirements…?ŠRead More

Coding for Acute Coronary Syndrome
Acute coronary syndrome (ACS) is classified to ICD-9-CM code 411.1, which is the same code assigned for unstable angina. It is vital to review the entire medical record to make sure the information presented supports the final code assignment. Therefore, if the record contains evidence that the patient may have experienced an AMI but only ACS is documented, then it may be appropriate to query the physician for clarification of the final diagnosis. Final code assignment always is based on physician documentation…?ŠRead More

Dual Coding: An ICD-10 Jump-Starter?Š
By adopting this tactic, health care organizations can accelerate the transition process.

There has been a palpable shift in the conversation surrounding the transition to ICD-10. No longer is it focused on whether the Centers for Medicare & Medicaid Services (CMS) will extend the deadline yet again (it won’t). Instead, it centers on just how soon organizations should start coding in ICD-10 to minimize operational and financial impacts once the October 1, 2014, deadline hits.

For early adopters, the opportunity to code in a dual ICD-9/ICD-10 environment can generate benefits that outweigh negatives such as productivity declines and revenue cycle slowdowns…?ŠRead More

Read Between the Lines: Saving Your Physicians from Copy-and-Paste Problems
Identifying harmful copy-and-paste documentation can help curb serious coding errors.

Like any good story, a medical record should be consistent and relatively easy for the reader to follow, presenting events in a logical sequence. However, as physicians begin to document in the EHR, the patient’s story–the crucial element necessary for coding–can become jumbled and sometimes even unreadable. Coders may begin to see nonsequential dates on progress notes…?ŠRead More

The Coding Corner: Avoid Common Place-of-Service Coding Errors
Place of Service (POS) codes identify where a health care service is provided, which directly affects payment. As explained in MLN Matters?ę Number: SE1104, “To account for the increased practice expense that physicians generally incur by performing services in their offices and other non-facility locations, Medicare reimburses physicians at a higher rate for certain services…?ŠRead More

Appending Modifiers 58, 78, and 79
Modifiers identify procedures that have been altered in some way without changing the fundamental components. In this article, we will examine the modifiers that can be appended to procedure codes for services performed within the global period…?ŠRead More

Updated Codes for Claims Adjustment, Remittance Advice Under HIPAA Released
The Council for Affordable and Quality Healthcare has released updated code combinations for its CORE 360 rule, which is a part of the operating rules for electronic transfer of healthcare funds and remittance advice under HIPAA, according to an AHA News Now report…?ŠRead More

HCPCS Update: Prepare for Medicare’s July Coverage Changes to Zometa and Doxil Codes
Add 2 new Q codes to your system to keep your coding compliant.

The July 2013 HCPCS update has coding changes in store for both liposomal doxorubicin HCl and zoledronic acid. Pay attention both to the new codes available and the coverage changes Medicare will make to existing codes…?ŠRead More

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Medical practice profitability survey reveals less than 9% of physicians are very confident in their medical billing.Two very interesting pieces of news caught my eye this week, and the implications for medical practices from each of these pieces of news is rather staggering, in my opinion.

1. A survey on physician profitability just released by social learning and collaboration platform ?ŠQuantiaMD and EHR/PMS company CareCloud found that only 9% of physicians are ‘«£very confident‘«ō in their current staff, tech and processes for getting paid.

2. A recent blog post on Healthcare IT News discussed the fact that payers are changing their systems from a ‘«£pay-and-chase‘«ō post-payment recovery model to efforts to prevent overpayments. ‘«£Some are implementing analytical technologies to identify possible claim discrepancies at the time a claim is adjudicated. These tools combine predictive, data-driven, integrated code edits and clinical aberrancy rules to identify claim outliers. Unlike rules-based systems, data-driven analytical solutions examine hundreds of variables, and can detect previously unknown and emerging patterns that rules-based analytics may not recognize,‘«ō the article says.

The article goes on to say that ‘«£An additional layer that can deliver savings to a multi-faceted payment integrity program is to reduce billing overpayments that result from improper coding. This can be achieved by supplementing analytics with clinical code edit technologies backed by nationally recognized coding guidelines as they are designed to find coding errors, unbundled treatments, unusual and inconsistent treatment patterns, and inappropriate diagnoses.‘«ō

What these two pieces of news mean to me is that while 91% of physicians are less than ‘«£very confident‘«ō about their billing processes, they are about to face increased scrutiny from payers with finely tuned analytics software, which means that every coding error, unbundled treatment, unusual and inconsistent treatment pattern and inappropriate diagnosis could cause their claim reimbursements to, at best, be delayed, and at worst, to be denied.

This is a recipe for disaster for many practices.

In addition, when asked in the survey how much of their time was spent on ‘«£coding, documentation and administration,‘«ō rather than patient care, the majority of physicians?Š(59%)?Šsaid they sacrificed more than?Š(20%)?Šof their time this way. This is the equivalent of one day per week for a full-time physician spent at a desk rather than in an exam room. About?Š(30%)?Šof physicians spend one-third of their time ‘«Ű or more ‘«Ű on administrative tasks.

So what this picture reveals is that physicians are spending way more time than they want to‘«Ųor should‘«Ųtrying to oversee billing processes they were never trained to manage, with staff who have varying levels of training and experience.

No wonder 91% of them are less than ‘«£very confident‘«ō about their billing‘«ŲI‘«÷m sure an even higher percentage are less than ‘«£very happy‘«ō about this situation!

Plus, a key finding of the PPI survey was that the 5,012 physician participants were two-thirds more likely to foresee a downward trend in profitability for the year ahead than a positive one (36% negative vs. 22% positive). That means it‘«÷s even more hazardous to have billing processes that they‘«÷re not confident in‘«Ųthey need every dollar they can get on the bottom line.

Add all of this together, and it becomes more clear than ever that now is the time for medical practices to change their approach to billing and entrust it to trained professionals who have the technology, processes and experience to handle the current requirements and challenges that lie ahead.

Medical billing is an exceptionally complicated and convoluted process, and only becoming more so. Why would you want less than expert help to manage the lifeblood of your practice?

Find out today how you can have full confidence in your billing processes and bring more to your bottom line. Contact at 800-966-9270 for a complimentary review of your billing.

“Medical Billing made all the difference for my practice. They eliminated all the frustrations associated with insurance reimbursements and increased my revenues by 100%.” ?Š–Janice

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Review these articles from a variety of sources to insure your coding is up to date on E/M, LCD, and other techniques.

Wolves at the Door: E/M Coding Now

Barbara Aubry, a regulatory analyst for 3M Health Information Systems, reports that in the last few weeks, she has read some startling news:

1. The University of Illinois Hospital and Health Sciences System and Mount Sinai Hospital in Chicago owe CMS $145 million in disproportionate share Medicaid overpayments “because they had overcharged poor patients,” according to a FierceHealthFinance news report Feb. 27. What’s even more startling is the alleged overcharges took place 13 years ago.

2. Another stunning article reported Feb. 14 by HealthLeaders Media discussed the case of a respected surgeon who was found guilty of fraudulent coding on claims submitted between August 2002 and October 2003. The doctor was “acquitted of two counts of Medicare fraud but convicted of two counts of making false statements in connection with surgical (CPT) codes submitted” on old claims. He is now serving a 10-month prison sentence.

The Association of American Physicians and Surgeons (AAPS) warns, according to the article, “physicians will now need to practice ‘defensive documentation,’ taking more time away from patient care in order to double and triple check operative notes.” Barbara prefers to call it clinical documentation improvement (CDI), but agrees with the AAPS: Documentation is more important than ever. Read More


Modifier Minute: Modifier 32

Modifier 32?ŠMandated services?Šapplies when a third party, such as an insurer or government agency, specifically requests/requires a service on a patient‘«÷s behalf. For instance‘«™ Read More


Follow New CMS Guidelines ?Što Keep Record Amendments Updated

No practice ‘«Ű or physician ‘«Ű is immune to documentation that needs to be updated; maybe the physician left out an important piece of information, such as the amount of time spent counseling the patient, or the patient‘«÷s diagnosis. When records need to be amended, advises The Coding Institute, be sure your practice follows the latest CMS rules, which were revised on Dec. 7, 2012, in Transmittal 442.

When adding, correcting, or entering information after the date of service, you should identify it as an amendment, and the physician should sign and date it. Never delete the original entry‘«Ųinstead, ensure that all original content is identifiable. You can do this on a paper record by using a single strike line through the original content. For electronic records, you must ‘«£provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification of the record,‘«ō CMS says in the transmittal.

If an auditor ever reviews your files, CMS directs them to consider your amended entries‘«Ųbut only if you follow the rules. Auditors ‘«£shall not consider undated or unsigned entries handwritten in the margin of the document,‘«ō for instance, the Transmittal advises.

CMS advises MACs and auditors that see potential fraud in the documentation to refer those cases to the ZPIC auditors. To read the complete transmittal, visit


CMS corrects edit 84, deletes modifiers reports in an April 30 article that CMS corrected edit 84, added five APCs to the I/OCE, deleted two APCs, and changed the description of another as part of the April updates to the I/OCE. In addition, CMS deleted all of the genetic testing modifiers, retroactive to January 1‘«™ Read More


Denials Management: With MUE Claim Denials, Appeal, and Appeal Again
If you receive a claim denial due to MUEs, you can appeal, according to a recent article by The Coding Institute.

You should follow three steps during the appeals process:

Step 1: Determine the reason for the denial. First, figure out if you made a coding or billing error. If you find a coding error

‘«Ų?Š?Š?Š such as the wrong number of units entered in the units box

‘«Ų?Š submit a corrected claim. If you don‘«÷t find a coding or billing error, move on to the next step.

Step 2: Decide if you have a legitimate reason to appeal. If you believe there is medical necessity for the services over and above the allowable under the MUE, you should appeal to the contractor. ‘«£If there is no medical necessity, take a look

again at coding,‘«ō Harrington says. ‘«£Make sure service is coded properly, and appropriate modifiers have been assigned.‘«ō

Step 3: Appeal the claim. File an initial appeal with your carrier and follow the standard five-level Medicare appeals process. ‘«£If appealing the claim due to a clinical reason, you may wish to employ clinical expertise when putting together your appeal letter,‘«ō Harrington suggests.


Healthcare News: CMS Adds Codes to Conditionally Bilateral List

Also from CMS added seven CPT codes to the conditionally bilateral list as part of the April update to the Integrated Outpatient Code Editor. When a provider performs a conditionally bilateral service bilaterally, coders must append modifier -50 (bilateral procedure) to the code. Read More


Local Coverage Determinations Provide the Missing Link to Complement Coding Guidelines

The missing link to correct coding, according to an article in, is coder knowledge and practical application of Local Coverage Determinations (LCDs). LCDs are integral to complete documentation governing accurate ICD-9 diagnoses coding. LCDs in essence complement official coding guidelines and Coding Clinic advice. Few coding staff actually know and apply?Šofficial LCDs in their region to complement official coding guidelines and policies. Read More


Observation Services: Many Shades of Gray

This recent article in For the Record states that unique challenges give hospitals and physicians little room for error when it comes to correctly documenting these encounters. According to Betsy Nicoletti, MS, CPC, coauthor of, one complicating factor is that while a hospital ultimately determines the category of a patient‘«÷s admission status, the rules are clear that a patient‘«÷s observation stay begins and ends with a physician‘«÷s order‘«™ Read More

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I don‘«÷t know if you‘«÷ve noticed this, but it seems to me that people are finally starting to take ICD-10 seriously and are getting started with their transition planning. I‘«÷ve talked to some consultants who find their phones are suddenly ringing off the hook, and there‘«÷s quite a bit of chatter about it in social media.

And it‘«÷s about time.

CMS has now assured us that there won‘«÷t be another reprieve, which means healthcare entities do need to get on this.

If that idea scares you, then we‘«÷ve got good news: There are plenty of resources out there to help you.

And, as Carl Natale pointed out in a blog post on ICD-10Watch last week, ‘«£If there’s an upside to procrastinating on your ICD-10 planning, it’s that you can learn a thing or two from the healthcare organizations that started early.‘«ō

Key Resources You Can Use

The ICD-10Watch site is just one of multiple resources you can use to get your practice up to speed on the new coding. Here is a list of others that you should check out and watch on a regular basis for news and updates:


I know it seems obvious, but some people seem to skip right over the CMS site‘«Ųwhich is a shame, because it is offering some excellent resources including:

Latest News

CMS ICD-10 Industry Email Updates

ICD-10 Implementation Timelines

CMS Implementation Planning

Provider Resources

The timelines are especially useful, as there are different timelines for small and medium practices, large practices, small hospitals, etc. You can also sign up for CMS ICD-10 Industry Email Updates and follow them on Twitter‘«Ųand they announce new resources and news through their Twitter account.

ICD-10 Watch

This excellent site has been on top of ICD-10 from the start, and in my opinion you won‘«÷t find a better resource for news on the subject. Just a few of their recent posts have included:

Why emotions will be a part of your ICD-10 transitions
We are at the point when it’s time to get serious about ICD-10 implementation planning. Read More
Date: Apr 05, 2013

6 takeaways from ICD-10 end-to-end testing
If there’s an upside to procrastinating on your ICD-10 planning, it’s that you can learn a thing or two from the healthcare organizations that started early. Read More
Date: Apr 04, 2013

How to help physicians prepare for the ICD-10 transition
Physicians will be a key part of making the the ICD-10 transition successful. There are some steps that can help them become more comfortable with the new code sets. Read More
Date: Apr 02, 2013

ICD-10 Monitor

ICD-10 Monitor is another site that has been covering this transition from early on and providing a good overview of the issues involved. Much of their content is not free, but they offer a good news section, and have launched a weekly podcast called Talk Ten Tuesday ‘«Ų a half-hour news and information service featuring interviews with industry experts and case studies by successful providers, all produced live every Tuesday and airing at 10 a.m. ET.

HIMSS, the leading healthcare IT association, offers an ‘«£ICD-10 PlayBook‘«ō which features a variety of resources including:
ICD-10-CM/PCS Transition: Planning and Preparation Checklist (7/31/2012)

Role Based Training for Your ICD-10 Conversion 06/4/2012


AHIMA, another respected healthcare IT association, also offers the latest ICD-10 news and provides an ICD-10 e-newsletter you can sign up for.

Finally, we are pleased to say that has developed a free white paper on how to prepare for ICD-10, written by coding expert Betsy Nicoletti. You can download the white paper now and get a headstart on understanding and preparing for ICD-10.

And if you are concerned that your medical billing team will not be able to convert successfully to ICD-10, contact us for help in transitioning your medical billing to a team that will keep you up to date with coding changes and technology, and bring more to your bottom line.

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Sure, you‘«÷ve seen lots of advice on how to improve your practice bottom line. But how do you run a medical practice into the ground quickly and easily? Now there‘«÷s a different subject. Here are five easy ways to accomplish that goal:

1.?Š?Š?Š?Š?Š?Š Don‘«÷t Worry About Denials

If you want to lose money in a hurry, just ignore your denials. Don‘«÷t track them to see where the problems are, don‘«÷t address procedural or training issues. Denials are never the result of small problems that are easily fixed once identified. You‘«÷ve trained your staff well and things never change, so what‘«÷s the point of process improvement?

2.?Š?Š?Š?Š?Š?Š Assume Appeals Aren‘«÷t Worth the Time They Take

Next best: Don‘«÷t bother appealing denied claims. After all, if they could be paid, they‘«÷d be paid the first time they‘«÷re submitted. It‘«÷s too much trouble to submit additional documentation, and it can‘«÷t be that much money. And they probably won‘«÷t reverse the initial decision (even though studies show appeals result in overturning the initial denial 75% of the time).

3.?Š?Š?Š?Š?Š?Š Don‘«÷t Bother Monitoring Your Payer Contracts

You signed an agreement with your payers as to the amounts you should be paid, so that is settled. You don‘«÷t need to audit payments to insure that you‘«÷re being paid the agreed amount. Even though the AMA‘«÷s study shows some payers pay correctly as little as 86% of the time, which over the course of a year could result in substantial losses, you‘«÷re confident that you‘«÷re being paid correctly.

4.?Š?Š?Š?Š?Š?Š Don‘«÷t Be Too Diligent in Collecting Patient Payments

You don‘«÷t want to annoy your patients by requesting payments due at time of service, although patient due balances now account for 30% of receivables in many physician offices, and the proportion of patient due balances is growing as patients have higher deductible plans. ?ŠAnd you just don‘«÷t believe that you won‘«÷t be able to collect the same amount later, although according to Sara M. Larch, MSHA, FACMPE, you can only expect to collect 50-70% of an insured patient‘«÷s balance after treatment.

5.?Š?Š?Š?Š?Š?Š Stick with the Wrong Medical Billing Team

Even when it‘«÷s clear that the medical billing team you‘«÷re using is no longer right for your practice, don‘«÷t consider changing. After all, it‘«÷s such a headache to find and transfer your revenue cycle management to another team‘«™surely it‘«÷s not costing you that much. Ignore the declining key performance indicators such as Days in Receivables Outstanding (DRO), Days in Accounts Receivable Over 120 Days, and Net Collectable Percentage. You don‘«÷t need to worry about cash flow‘«Ųyou can cover your expenses indefinitely, can‘«÷t you? And even if you‘«÷re not certain your billing team is handling your appeals as they should, or that they will be able to transition to ICD-10 smoothly‘«™your goal here is to drive your medical practice into the ground, so it‘«÷s all good.

But if your goal is NOT to run your practice into the ground, and you want to bring more to the bottom line‘«™now is the time to evaluate whether your medical billing is being handled optimally. Why not talk to a practice revenue consultant‘«Ųfree‘«Ųnow to find out if you could improve your revenue cycle management?

With local branches nationwide and management experience totaling more than 50 years,‘«÷s experts are able to help you find revenue leakages and bring that profit to the bottom line.

For help evaluating your KPIs, denials, appeals and improving your bottom line, contact today at 800-966-9270, or email?Š We‘«÷ll help you keep your practice above ground.

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If you‘«÷re setting up a new medical practice, whether you‘«÷re leaving another practice or fresh out of school, you probably have a lot of questions about how to manage the financial aspects of your practice. After all, you didn‘«÷t go to medical school to learn revenue cycle management.

To help you with this vital process, we asked expert Owen Dahl to outline the basics of revenue cycle management, which he did in our new white paper, Starting Your Medical Practice: Medical Billing, Key Performance Indicators, and More.

The Revenue Cycle

The revenue cycle (RC) consists of three major areas of emphasis. This workload is like an assembly line. The front desk must complete its tasks of account set up before the encounter form can be generated by the clinical staff, which all needs to be completed prior to the insurance claim being submitted. Even though each step is necessary, the volume of work involved in the RC is heavier on the processing side than any other, and all parts must work together. In Figure 1 below, please note the approximate percentage of work effort required to manage the RC by the key areas. The chart is an estimate of the ‘«£normal‘«ō relationship between these major areas. There is no real scale that indicates which is more important: all are absolutely necessary.

Approximate % of Work Effort to Manage Revenue Cycle by Key Areas

In order to meet the demands of proper management of the RC, it is necessary to address it as a complete process and not to look at just one part. One part cannot be fixed and assume that things will improve across the board. Too often fixes are a result of a quick look at one part of the RC, and changes are made that realistically won‘«÷t solve the problem.?ŠIn fact, greater issues often surface in this scenario. For example, a denial report states that patient demographics are the reason for most of the denials. Although it looks like the problem lies with the receptionist, in reality, there may be many issues that caused the denials and not just the capability of the staff. Staff training, lack of delineation of tasks and proper staffing at the front desk could all have contributed to the number of denials. But the issue would not have surfaced if there was not a report from the processing section indicating that there were errors in that area. All component parts of the RC must work together.


Model Revenue Cycle for a Medical Practice



















Following are the basic duties that reside in each of the three sections of the RC:

Front desk

  • Patient scheduling
  • Patient demographics
  • Insurance information
  • Verify insurance coverage
  • Collection of co-pay, deductible and previous balances
  • Obtain authorization for services if necessary


  • Complete encounter form
  • Identify level of service, diagnostic and/or treatments performed with description or CPT code and diagnosis code
  • Charge entry through connected electronic health record


  • Charge entry from completed (encounter form if charge form not done by the physician or clinic staff)
  • Code review
  • Submit claims through clearinghouse
  • Review unclean claims, repair and resubmit
  • Receive explanation of benefits (EOB) and funds
  • Process payment
  • Identify denial and appeal needs from the EOB
  • Appeal claims as necessary
  • Re-file claims for underpayment
  • Process patient statements
  • Update patient account on status of payment
  • Process patient account to final disposition, e.g., payments complete, write off or turn to outside agency for assistance

Thus, we can see the complexity and potential for errors throughout the process. The ‘«£assembly line‘«ō must work like a well-oiled machine to eliminate errors and to achieve the desired bottom line.

Learn more about effectively managing your medical billing‘«Ųrequest our free white paper now and you‘«÷ll get more information on developing financial and collections policies that work for your practice, the key performance indicators you must track to maintain and improve profitability, and more.

And when you are looking for an expert team to help you manage your medical billing, contact at?Š800-966-9270. Our billing management team has more than 50 years of combined experience in medical billing and coding and is ready to help you make sure you are bringing the maximum to your bottom line.


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With extensive changes in E/M coding, the addition of TCM coding and multiple other changes in various specialties, many practices have asked for additional resources to help with transitioning to the new coding and code corrections. Following are some resources and tips you may find helpful:

Your HPI Should Be Longer than a?ŠTweet
Betsy Nicoletti, Nicoletti Notes

Too often, the HPI in EMR notes is shorter than a tweet.?Š And less informative.?Š The history of the present illness describes the reason for the visit and the patient complaints related to the reason.

The problem is, the HPI is one of the most important parts of a medical note for that physician who sees the patient at a later date or for a covering physician.?Š?Š Failing to document it in sufficient detail, copying it word for word from a previous visit or using single words instead of complete sentences: none of those are helpful.?Š Read More

Do You Understand the New Medicare Transitional Care Management Service Codes?
Mary Pat Whaley,

Effective January 1, 2013, Medicare and other payers will pay for two new CPT codes (99495?Šand?Š99496) that are used to report physician or qualifying non-physician practitioner transitional care management (TCM) service for patients, following‘«™ Read More

AAN Tips on How Neurologists Can Navigate 2013 Coding Changes

AAN advised neurologists on ‘«£Five Things You Should Do‘«ō to navigate coding changes in 2013, including:

1. Use new nerve study codes 95907‘«Ű95913 for all payers in 2013.

2. Always perform testing in the best interest of patients.

3. Keep in mind that performing NCS is still an efficient means to generate income.

4. It is acceptable to bill E/M services with EMG/NCS when there is the medical necessity to support the office or hospital visit (this may require a modifier 25).

5. Review and negotiate payment rates for all of your payers, and determine which contracts make the best economic sense for your practice

Read the full advisory for more information.


2013 CPT?ę Code Corrections Include E/M Changes in Multiple Specialties

CPT?ę code corrections issued by the AMA include changes to coding for E/M, cardiography, psychotherapy and more. Find the full list at

New Coding Paradigm for PCI, Other CPT?ę Code Changes in Cardiology Outlined in Presentation

Find slides detailing the 2013 CPT?ę coding changes in cardiology at

2013 CPT?ę Code Changes in Psychotherapy: Provider Frequently Asked Questions

This payer has provided some useful FAQs for questions regarding psychotherapy billing in 2013:

Overview of the?Š2013 Medicare Physician Fee Schedule

The CMS Physician Fee Schedule look-up website was updated on Feb. 14, 2013, and can be reviewed at

For more information on 2013 CPT Coding Tips, see our recent posts:
2013 CPT Coding Changes Overview and Coding Tips
2013 Primary Care CPT Coding Changes
OB/GYN Coding Changes and Tips for 2013
2013 Psychiatry/Mental Health/Neurology CPT Coding Changes
2013 Cardiology CPT Coding Changes: PCI, Pacemaker and Ablation Codes and More
2013 Coding Changes: Radiology, Orthopedics, Gastroenterology, Podiatry
2013 CPT Codes, Fee Changes, Tips for Ophthalmologists

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E/M coding raises many questions for billers. Here is a selection of guidance from experts on the latest twists and turns in E/M coding.

Don‘«÷t Let Your EHR, Changes in E/M Terminology or the New TCM Codes Confuse Your E/M Coding

The Coding Institute

How to Avoid 3 EHR Myths that Can Compromise Your E/M Coding
An EHR can be a helpful tool to save physicians time and ensure that documentation is thorough and neat. But there can be a downside to EHRs if you aren‘«÷t careful: They can mislead you into creating documentation you don‘«÷t really need or that is not pertinent to the evaluation of the presenting problem(s)‘«Ų and in some cases, cause you to fail to document items required to support your code choices.

Consider these three EHR myths to show exactly where your EHR system could be compromising your coding:

Myth 1: Exam Documentation Will Carry Over for Follow-Up Visits
If your EHR is producing documentation that is robust in one section (such as History) and thin in another (such as the Physical Examination), you may be trusting the system to do too much.

A subscriber recently told Ob-gyn Coding Alert that an auditor down-coded most of her E/M claims due to an empty ‘«£Physical Exam‘«ō section in the documentation. However, the practice argued that the EHR vendor had told them that patients being seen for established problems already have physical examination documentation on file, and that the EHR will carry it over from one visit to the next.

Caution: This may be true for past medical, family, and social history (PMFSH), but not for a physical examination. In addition, as the patient‘«÷s condition changes, so might physical findings. A medically indicated examination due to the patient‘«÷s complaints must be done at each separate visit.

E/M guidelines state that if a patient‘«÷s PMFSH has not changed since a prior visit, your ob-gyn does not need to document the information again. He does, however, need to document that he reviewed the previous information to be sure it‘«÷s up to date and also note in the present encounter‘«÷s documentation the date of acquisition and location of the initial earlier PMFSH. Some payers will give no PMFSH credit if you overlook one of these two criteria.

Best practices: As an example, you can note in the record, ‘«£I reviewed the past, family, social history with the patient taken from today‘«÷s patient questionnaire and our previous visit of June 1, 2012. She reports that nothing has changed since that date.‘«ō However, there is no substitute for recording your physical exam information on each visit.

Myth 2: EHR‘«÷s Calculation of Time Spent Qualifies You to Code Based on Time
Many EHRs record a summary of the time spent on the record at the bottom of each visit‘«÷s documentation and give a total, such as ‘«£Total time: 26 minutes, 15 seconds.‘«ō Some practices have reported that they have used this time calculation to select an E/M code based on time alone. For example, if the EHR says that the time spent is 25 minutes, these practices are automatically reporting 99214 for the visits, using the rationale that CPT?ę and Medicare guidelines allow you to code E/M services based on time alone.

Important: The key to billing based on time is that counseling and/or coordination of care must dominate the visit. Therefore, you can only select an E/M code using time as the controlling factor if you meet the rules, and an EHR‘«÷s notation of time spent in the record will not meet those guidelines. Instead, to bill on time alone, the provider‘«÷s documentation must contain the following three elements:

?? Notation of the total time spent on the encounter,

?? Notation of the total time spent on counseling and/or coordination of care or the percentage of the visit spent on counseling/care coordination

?? The reason for/topic of the counseling/care coordination

Remember that the content of the counseling must also be in evidence in the documentation. Simply stating time in the correct format is not enough to bypass the key elements and select the E/M code based on its typical time.

Myth 3: You Should Use the EHR‘«÷s Code Selection in Every Case
Your electronic health record probably offers an E/M code suggestion at the end of each visit–but that doesn‘«÷t mean you should use that to justify all high-level codes.

Several practices have reported that their providers ‘«£thoroughly document‘«ō the History and Physical Exam elements for all conditions, leading to high-level codes, even if the medical decision-making (MDM) does not support 99214 or 99215. They justify this by pointing out that established patient office visits only require two out of three key components (History, Exam, MDM).

Important: CMS indicates in its Carriers Manual that ‘«£Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT?ę code.‘«ō In addition, the 1995 E/M Guidelines state, ‘«£The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.‘«ō

Use your EHR‘«÷s code selection only as a suggestion, leaving the final code choice up to the clinician, and it should be based on medical necessity and the nature of the presenting problem.

Don‘«÷t Let Changes in E/M Terminology and the New TCM Codes?ŠConfuse You
Advice on applying E/M with new ‘«£provider-neutral‘«ō language, new TCM codes and other tips was provided by speakers at the American Medical Association‘«÷s (AMA) annual CPT?ę and RBRVS Symposium.

Most importantly, CPT?ę 2013 has introduced two new codes for transitional care management (TCM) services:

?? 99495 ‘«Ų Transitional care management services with the following required elements: communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit, within 14 calendar days of discharge

?? 99496 ‘«Ų … medical decision making of high complexity during the service period; face-to-face visit, within 7 calendar days of discharge.

Fortunately, as reported in our last newsletter, these codes can help increase revenue for primary care practices. The codes are meant to represent situations when a physician oversees an established patient whose medical/psychosocial issues require moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient‘«÷s community (home) setting. Another key to determining whether to report 99495 or 99496 hinges on timely follow-up ‘«Ų how many days pass between the patient‘«÷s discharge and when the physician is able to see the patient.

Change to Non-Physician Language in Coding
The most widespread changes throughout CPT?ę 2013 ‘«Ų the switch to more inclusive or provider-neutral language ‘«Ų shouldn‘«÷t be difficult for most practices to put into place.

Key Change: Hundreds of codes were revised for 2013 to include ‘«£provider neutral language.‘«ō Codes throughout the book have replaced designations of ‘«£physician‘«ō with ‘«£individual‘«ō or ‘«£qualified health care provider.‘«ō

Note: A few codes retained the ‘«£physician‘«ō language, such as those related to skilled nursing facility admissions, because regulations require that a physician admit the patient.

CMS Providing Some Help on Vaccine-Related E/M Coding Change

Kent Moore, AAFP Getting Paid Blog

The Centers for Medicare & Medicaid Services (CMS) is providing some limited relief to physicians dealing with recent changes to how they’re paid for vaccinations.

The Jan. 1 round of Correct Coding Initiative (CCI) edits required that providers append modifier 25 to evaluation and management (E/M) services performed in connection with immunization administration services (90460-90474) provided on the same date to the same patient or only get paid for the immunization administration‘«™ Read More

For more expert assistance with insuring your E/M coding‘«Ųand all your billing‘«Ųis correct, contact at 800-966-9270. Our billing management team has more than 50 years combined experience in medical billing and coding and is ready to help you make sure you are bringing the maximum to your bottom line.

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A recent survey of 810 participants by leading claims clearinghouse Gateway EDI revealed that the majority of respondents had not yet begun to prepare for ICD-10.

The results revealed that:

– 75.88% of?Šrespondents had not begun their ICD-10 implementation plans

– 58.12%?Šhave not inquired with their practice management software vendor about?ŠICD-10 readiness

The high percentage who have not yet begun is eye-opening‘«Ųand yet it actually does show some improvement from a survey conducted a year ago by WEDI, which said that:

– “Nearly 1/2 of the provider respondents indicated?Šthat they did not know when they would complete their impact assessment”

-“Although 1/3 of providers expected to begin?Šexternal testing in 2013, another 1/2 responded that they did not know ?Š?Š?Š?Š when testing would occur”

– “About 1/2 of vendors are less than halfway?Šcomplete with product development”

WEDI has just concluded their 2013 survey, and we should see results soon. However, what this tells us is that the majority of practices have not yet begun their ICD-10 planning.

As I have written before, when it comes to ICD-10, ‘«£Failure to plan really is planning to fail.‘«ō

And, since I‘«÷m on a roll with homilies: ‘«£The journey of a thousand miles begins with a single step.‘«ō It‘«÷s vital to take that first step now.

Of course medical practices are bombarded right now: EHRs, everyday tasks, marketing, etc., all take up staff time.

But while it‘«÷s easy to postpone ICD-10 prep, that is the worst possible idea‘«Ųbecause it will make your life so much harder when you actually do get to the point where you start implementation.

CMS has recognized this and has issued checklists and timelines you can use in your practice right now to start the process and make sure you‘«÷re moving along as you should.

For example, the CMS timeline indicates that these tasks should have been accomplished by now to prepare for testing:

– Review ICD-10 resources from CMS, trade associations,?Špayers, and vendors

– Apprise your staff and colleagues of upcoming changes?Š(1 month)

– Assemble an ICD-10 project team (1 month): This?Šmulti-disciplinary team will provide the cooperative environment necessary?Što address your organization’s needs

?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š – Appoint a project manager to be responsible for establishing accountability?Šacross the ICD-10 implementation team and making business, policy, and?Štechnical decisions.

?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š – Establish regular check-in meetings to discuss progress and address any issues.

?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š – Conduct an ICD-10 impact assessment to help you determine how the transition to ICD-10?Šwill affect your organization, and allow you to schedule and budget for?Šall ICD-10 activities.

?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š – Plan a comprehensive and realistic budget. This should include costs such as software upgrades?Šand training needs.

?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š – Identify and ensure involvement and commitment of all?Šinternal and external stakeholders. Contact?Švendors, physicians, affiliated hospitals, clearinghouses, and others to?Šdetermine their plans for ICD-10 transition.

?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š – Develop and adhere to a well-defined implementation?Štimeline that makes sense for your?Šorganization.

?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š?Š – Communicate regularly with the?Š entire ICD-10 project team

– Develop ICD-10 project plan for your organization (1?Šmonth)

– Identify each task, including deadline and who is?Šresponsible

– Establish a timeline and share with staff and business?Špartners

– Estimate and secure budget for ICD-10 transition ?Ś

– Develop plan for communicating with staff and business?Špartners about ICD-10

– Work with vendors and internal IT staff to integrate?ŠICD-10 into all systems that currently use ICD-9

You can read more about where you should be at this point in your ICD-10 implementation on

You can find the CMS resource section with checklists and timelines, designed by practice size, at

Finally, we‘«÷re pleased to offer a white paper on how to prepare for ICD-10 complete with checklists and tips, written by coding expert Betsy Nicoletti, available for download to help you plan your ICD-10 transition.

Please take advantage of these resources now to get your practice started on an ICD-10 implementation plan. It‘«÷s a?Šrelatively easy first step on a thousand mile journey.

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