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Survey reveals top challenges for medical practices include financial management, increasing practice efficiencyYet another recently released survey shows that physicians in the U.S. are struggling with financial management‘«Ų90% report this as a concern, and it‘«÷s second in the list of top challenges second only to shifting reimbursement models (91%). The survey, conducted by Wolters Kluwer Health, revealed that the financial management challenges are coming from increased costs, healthcare IT adoption and the Affordable Care Act/increasing legislation.

When asked about their top focus areas for the next three to five years, physicians cite increasing their practice‘«÷s efficiency (48 percent), exploring different business models such as mergers, becoming part of a hospital system or patient-centered medical homes (34 percent) and adopting technology to improve clinical decision making or support evidence-based decision making (31 percent).

For those of us in the revenue cycle management field, the first item is key: increasing a practice‘«÷s efficiency.

This is something we have always encouraged, and continue to do so. Here are some things you should consider in terms of making your practice more efficient:

1. Make sure you‘«÷re getting paid for all of your care. I recently heard of a practice that hadn‘«÷t looked at their missed encounter reports for a year. When the reports were reviewed, the practice discovered that they had 15 missed encounter reports for just one code. That meant thousands of dollars of revenue lost! Don‘«÷t let this happen to your practice‘«Ųmissed encounter and other reports should be reviewed on a regular basis‘«Ųweekly reviews are recommended.

2. Are you maximizing your schedule? Look at your no-show rate, and if you have a no-show rate of 25%, you should be double-booking 1 of 4 appointments. If you don‘«÷t, you could be losing up to $1.2 million per year, according to practice management consultant Rochelle Glassman. You should also keep a waiting list as many dentists do, says Glassman. That way when your schedule opens up, your staff can fill it quickly with patients who want to be seen‘«Ųand will rarely be no-shows.

3. Are you expanding your schedule? As we mentioned in a recent blog post entitled Physicians: Are You Prepared to Compete with Retail Clinics?, ?Šyou need to be aware that your competition now includes the Minute Clinics and Urgent Care Centers opening on nearly every corner. These centers are popular because many patients are no longer comfortable taking time off work, or they want to get help for their screaming baby first thing with a walk-in or same-day appointment. In order to compete, you need to take two steps according to Glassman:

A. Offer expanded hours before and after your current normal office hours, on Saturdays and during the lunch hours. You don‘«÷t have to cover these hours yourself; consider bringing on a part-time physician or non-physician provider to see these patients.

B. Review your schedule and arrange it to offer walk-in and same-day appointments. How can you do this while double-booking? Set specific times, and use your wait list to fill the appointments if needed. Don‘«÷t lose your long-time and new patients to the retail clinics.

4. Consider how you‘«÷re using your office space. Are you using valuable office footage for administrative functions when you could be using it to see patients? Functions like medical record storage and medical billing do not need to‘«Ųand shouldn‘«÷t be‘«Ųhoused in your office when that office space could be generating revenue.

5. Is your medical billing team the right one for your practice today? The medical field is changing rapidly, and methods that once worked are no longer optimal for today‘«÷s medical practices. Hiring a front office person and teaching her to handle your medical billing is no longer sufficient with today‘«÷s more stringent‘«Ųand complicated‘«Ųrequirements. Similarly, a one-person medical billing company is no longer the best choice to insure you are receiving maximum reimbursement.

In these challenging times, you need to choose the best, most cost-efficient means for insuring your practice profitability. That means the right medical billing team, and with the challenging reimbursement environment today, you need a top-notch team.

That‘«÷s why you should talk to a nationwide medical billing company with offices across the country. is proud to say that we have experienced teams in cities across the country, providing a depth of experience and resources unmatched by most internal billing teams or medical billing companies.

To find out how we can help you improve your practice profitability, contact us today at 800-966-9270 or by email at

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That‘«÷s right‘«Ųmy medical billing service beats your inhouse billing staff. Well, not literally‘«Ųbut in the things that matter, yes, our third party billing service can beat inhouse staff hands down on most points.

Here‘«÷s why I say that:

1. You only pay for our billing services when you‘«÷re actually using them. You don‘«÷t have to pay us whether or not you have claims to bill, whether or not we are sick or on vacation. And you only pay us when you get paid. That‘«÷s a pretty efficient way to run your medical billing.

2. Our medical billers are highly trained and expert in medical billing. Medical billing is what our billers do, every day, all day. We hire only highly trained billers, and we make sure they stay up to date on their training. Plus, they learn from each other‘«Ųtheir colleagues in our offices across the country who are handling just about every specialty.

3. Our medical billers are up to speed on all the latest requirements and software. We make sure they‘«÷re up to date on HIPAA, CPT coding changes and other important legal issues. And they are trained on multiple software platforms. Because if we don‘«÷t, we are out of business.

4. Our medical billing staff will provide you with reports you can trust, and that have been proven to work for hundreds of other practices. We follow best practices across our multiple locations, and learn from what our experience managers throughout the company are doing. Reports are developed and refined to insure they are providing you with the information you need to manage your practice. And if you need different reports, tell us‘«Ųwe‘«÷ll work with you to get you what you need.

5. We save you all the hidden costs of hiring and maintaining a billing staff inhouse. ?ŠHiring and maintaining a billing staff has multiple hidden costs you probably don‘«÷t think about:

A. Medical Billing Specialist’s Employee salary

B. Medical Billing Specialist’s Employee benefits

C. Worker’s compensation


E. Healthcare insurance

F. Vacation, sick leave, etc.

G. Performance bonus

H. Computer hardware purchase & maintenance

I. Software purchase & renewal

Do what you do best. Let us handle the rest.

You didn‘«÷t go to medical school to learn how to manage medical billing staff; you wanted to treat patients. Why waste your valuable time on administrative details better outsourced and left to the experts?

Here‘«÷s what one of our customers said about making the change:

‘«£ made all the difference for my practice. They eliminated all the frustrations associated with insurance reimbursements and increased my revenues by 100%.‘«ō

Why not find out how you can reduce your headaches and increase your bottom line? Contact today at 800-966-9270 and talk to one of our practice revenue consultants about how we can improve your practice profitability.

We‘«÷d love to show you how we can beat the results your inhouse medical billing staff is getting.

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Medical billing service adsWhen you search for ‘«£medical billing services‘«ō on Google, it may seem like you‘«÷re being deluged with information‘«Ųand you may feel like you have no way to sort through what you‘«÷re seeing.

There are quite a few medical billing companies listed for any search‘«Ųso how do you find the right one for your practice? Here are a couple of tips for looking at Google ads:

1. Look for reviews. As you can see from our listing, we have more than 30 reviews from customers linked to our Google listing. These reviews give you a good idea of how well we‘«÷ve performed for practices like yours.

2. Notice what the ad says.?ŠOur ad plainly states, ‘«£Every Claim Paid. Guaranteed.‘«ō We put our guarantee in print, right at the top of our ad, because we mean it. And we stand by it.

3. Placement matters. Being one of the top ads on the left side of the page says that the company is large enough to commit some significant dollars to advertising‘«Ųand that‘«÷s a good thing if you want a medical billing service that will be around for a while (and you do). Having a medical billing service with resources and a commitment to the field will serve you in the long run.

Once you‘«÷ve called the number in the Google ad, notice a couple of things:

A. Does the representative on the phone seem to understand medical billing? If not, how can they match you with the service you need? If it‘«÷s a call center or the person just wants to close a sale without understanding your needs, beware. You want to deal with a medical billing service that understands and works to meet your requirements, and that starts with the first contact.

B. Does the representative give you a proposal in writing? Percentages and service level promises mean nothing unless they‘«÷re written down. Make sure you get all of your specified needs in writing in the proposal, so you know what the pricing includes.

C. Will the representative quote you real prices? In the beginning, of course, the rep needs to understand exactly what your needs are and how the medical billing service can meet them. But at some point the rep needs to be willing to quote you a price that includes what you‘«÷re looking for. And once you have a written proposal, you can compare that with what the services and price you are currently receiving. Otherwise, you don‘«÷t know what you‘«÷re comparing.

D. Can the representative answer your questions about denial rates, appeal success and other key performance indicators? Make sure you‘«÷ll be receiving the level of service that you need‘«Ųa high denial rate and low appeals success rate will slow down your revenue stream significantly. And how soon after claims are received by the medical billing service are they submitted? Data will help you choose the best revenue cycle management partner for your practice.

When you‘«÷re looking for the best medical billing service for your practice, be sure to consider these questions.

And for more tips on when and how to select the right medical billing service for your practice, download our white paper with checklists and useful advice now.

Or, call now at 800-966-9270 and we‘«÷ll be happy to answer your questions on improving your practice profitability.

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Do you know the top 3 reasons medical claims are denied? Want to find out how well you know the world of denial management‘«Ųa key part of medical billing? Let‘«÷s have a little fun during this holiday week: Take our easy quiz now, and see how you score!

1. The top 3 reasons claims are denied are:

A. Coverage terminated, Incorrect and/or incomplete patient identifier information, Incorrect provider information

B. Incorrect and/or incomplete patient identifier information, Coverage terminated, Services non-covered/Require prior authorization or precertification

C. Incorrect?Šdiagnosis and procedure codes, Coverage terminated, Incorrect provider information

D. None of the above


2. The Medical Group Management Association (MGMA) found that better-performing medical groups average aclaims denial rate of:

A. 10%

B. 2%

C. 4%

D. 6%

E. They found it was a waste of time to track it


3. The best way to avoid denials is:

A. To undercode so it‘«÷s obvious the claim should be paid

B. To code the diagnosis to the absolute?Šhighest level for that code, meaning the maximum number of digits for the code being used

C. To make friends with as many people at the insurance companies as possible.

D. Don‘«÷t provide too much documentation so that the insurance company can‘«÷t determine if you‘«÷ve coded correctly or not


4. When developing a process for improving your practice‘«÷s denial rate, the first step in the process is:

A. To contact all your payers and ask them for the top reasons your claims are denied

B. To contact your specialty society and get statistics from them for your specialty

C. To measure the practice‘«÷s baseline denial rate, and then determine and categorize the reason for each denial

D. Look in your medical billing software for a report



1. B; The top 3 reasons claims are denied are Incorrect and/or incomplete patient identifier information, Coverage terminated, Services non-covered/Require prior authorization or precertification

i) Incorrect and/or incomplete patient identifier information?Š(e.g., name spelled incorrectly; date of birth or SSN; subscriber number missing or invalid; insured group number missing or invalid)

Solution:?ŠVerify patient demographic and insurance information before EVERY visit. Ask permission to photocopy the patient‘«÷s state-issued identification (passport, driver‘«÷s license, etc.) and insurance card, so that you are sure to have the proper spelling, group numbers, etc., on hand.

ii) Coverage terminated

Solution:?ŠVerify insurance benefits?Šbefore?Šservices are rendered.

iii) Services non-covered/Require prior authorization or precertification

Solution:?ŠAgain, contact the patient‘«÷s insurance and confirm coverage before services are rendered. You‘«÷ll end up with angry customers if you bill a patient for non-covered charges without making them aware that they may be responsible for the charges before their procedure.

Read More


2. C; The Medical Group Management Association (MGMA) found that better-performing medical groups average just a?Š4% claims denial rate.

Here are some average denial rates by specialty (note that these are for all practices, not better-performing groups):

2011 Denial Rates by Specialty
Category Denial Rate
Primary Care 7%
Cardiology 8%
Surgeons/Ambulatory Surgical Centers 8%
Radiology 9%
Physical Therapy 10%
Chiropractors 13%
Durable Medical Equipment 14%


3. B; The best way to avoid denials is to code the diagnosis to the absolute?Šhighest level for that code, meaning the maximum number of digits for the code being used.


4. C; When developing a process for improving your practice‘«÷s denial rate, the first step in the process is to measure the practice‘«÷s baseline denial rate, and then determine and categorize the reason for each denial. Although if you can get a report from your medical billing software on the most common denial reasons, that will certainly help speed the process.


How Have You Scored in Part 1?

4 Correct: You‘«÷re a Denial Management Champ!

3 Correct: You‘«÷re doing well, but take note of the explanations above to improve your score.

2 Correct: Keep learning!

1 Correct: Hmm‘«™you may want to read up on our blog. Here are some other articles we‘«÷ve published on denial management:

Reduce Denials in Your Medical Practice for an Improved Bottom Line

Fast Billing/Practice Management Tips to Improve Profitability

Medical Billing Reporting: Don‘«÷t be Kept in the Dark About Your Practice

Join us tomorrow for Part 2 of our Denial Management Quiz!

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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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Specialists, take note of these valuable tips for improving your coding, for cardiologists, neurologists, OB/GYNs, ophthalmologists and others.



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


The Coding Corner: Coding for an Incomplete Colonoscopy

Medicare rules for coding colonoscopy differ from American Medical Association (AMA) rules, particularly with regard to “incomplete”?ō colonoscopies. For a Medicare patient undergoing a screening colonoscopy, if the surgeon is able to advance the scope past the splenic flexure, consider the colonoscopy “complete”?ō and report the appropriate code…?ŠRead More


Modifier Indicators: Keys to Success for 64615 Edit Pairs

The Coding Institute

The latest Correct Coding Initiative (CCI) edits–version19.1, effective April 1, 2013–introduced a number of edits for new chemodenervation code 64615 (Chemodenervation of muscle[s]; muscle[s] innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral [e.g., for chronic?Šmigraine]). Read on for the rundown of how the changes could affect your pain management coding.

Check Whether a Bypass Is Possible
Some of the edits involving 64615 can be “bypassed”?ō by appending a modifier in order to report both procedure codes. You can’t slip past the edit for other pairs, however, so pay attention to the assigned modifier indicators.

Bypass option: Approximately 20 other edits involving 64615 are classified with modifier indicator “1”which means you can sometimes append a modifier to break the edit and report both services. The most appropriate modifier will depend on the situation, but coders often turn to modifier 59 (Distinct procedural service).

Some of the edits in these pairs that you might be able to unbundle and report with 64615 include:

– 92585 -?ŠAuditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive
– 95822 -?ŠElectroencephalogram (EEG); recording in coma or sleep only
– 95907-95913 -?ŠNerve conduction studies
– 95925 -?ŠShort-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs
– 95928 -?ŠCentral motor evoked potential study (transcranial motor stimulation); upper limbs
– 95938 … –?Šin upper and lower limbs.


How to Avoid Making Modifier 22 Mistakes

The Coding Institute

Appending modifier 22 (Increased procedural services) may be something you think you’ve got down pat, but that doesn’t mean your coding will always be error-proof.

The following three modifier 22 tips will clarify how much longer a procedure should take to append modifier 22, if you can use an unlisted procedure code instead, and whether you have regular CPT?ę code alternatives.

1. Some experts suggest that you shouldn’t use modifier 22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor when deciding to use this modifier. The additional time and work must be significant. Rule: A procedure should take at least 25 percent more time and effort than usual.

2. Using an unlisted-procedure code instead of modifier 22 is a big mistake. Some coders go this route because they think the payer will manually review such claims and the carrier’s computer cannot automatically deny them. But you could be setting your practice up for missed reimbursement, because quite a few insurers will deny the service on first submission–which will lead to appeals. Conversely, all claims that go in with a modifier 22 will be reviewed.

3. Instead of attaching modifier 22 when a procedure is above and beyond its normal scope, you should consider reporting a CPT?ę code that more specifically explains why the procedure was prolonged or unusual. In other words, before you use modifier 22, you should always look to see if there’s another CPT?ę code that more accurately reflect the work the OB/GYN did.


Include Lens Fitting In These Cornea Codes

The Coding Institute

If your ophthalmologist is using a relatively new code for the fitting of a therapeutic contact lens, you will need to know the new CCI rules.

According to the new set of CCI edits, CPT?ę code 92071 (Fitting of contact lens for treatment of ocular surface disease), introduced in 2012, is now bundled into:

– 65220-65222 -?ŠRemoval of foreign body, external eye …
– 65275-65286 -?ŠRepair of laceration …
– 65400 -?ŠExcision of lesion, cornea (keratectomy, lamellar, partial), except?Špterygium
– 65410 -?ŠBiopsy of cornea
– 65420 -?ŠExcision or transposition of pterygium; without graft
– 65426 -?ŠExcision or transposition of pterygium; with graft
– 65430-65600 -?ŠRemoval or destruction procedures on the cornea
– 65710-65757 -?ŠKeratoplasty procedures on the cornea
– 65760-65782 -?ŠOther procedures on the cornea.

These edits all carry a modifier indicator of “1”,?ō meaning that you can use a modifier to break the bundle under the appropriate clinical circumstances, and report the two bundled codes separately.

For more information on the Correct Coding Initiative, visit


3 Steps to Sharpen Your Skills for Strapping Codes

The Coding Institute

A simple treatment like strapping could really tie you in knots–if you’re not clear on some coding fundamentals. Take these three steps to strapping coding success.

1: Understand Unna Boot, Buddy Tape Definitions

Before you go ahead and assign a code for strapping, you’ll need to understand how your payer defines strapping. Strapping may be done to support and/or restrict movement of ligament structures by exerting pressure upon the extremity or other area of the body.

Unna boot?Šapplication is one method of strapping. An Unna boot is a type of paste bandage.

The Unna boot bandage restricts the volume of the distal lower extremity, controls edema, and promotes venous blood return. You report Unna boot application with (29580, Strapping; Unna boot).

A common mistake is to overlook the removal of an Unna boot. Check if the removal was done by same or another provider. Removal of an Unna boot applied by another provider outside the practice may be reported using CPT?ę code 29700 (Removal or bivalving; gauntlet, boot or body cast).

Remember: Confirm with your payer specific reporting guidelines for Unna boot removal.

Another example of strapping is buddy tape or “buddy splint.” Buddy straps are prefabricated straps made of canvas or foam and Velcro and are reported with codes 29280 (Strapping; hand or finger) or 29550 (Strapping; toes).

Step 2: Look to Body Area for Code Selection
CPT?ę arranges strapping codes by body area. Begin with code family 29000-29799 (Application of casts and strapping), then narrow your code choices by anatomic area (body, upper extremity, or lower extremity). Each anatomic section has options for splints, casts, and strapping. In particular, the strapping codes are in ranges 29200-29280 (body and upper extremity) and 29520- 29590 (lower extremity).

Step 3: Keep Up With Payers’ Supplies Guidelines

Payers support strapping when the physician has stabilized a joint with non-rigid materials allowing the patient to retain some range of motion, such as tape, web rolls and possibly an elastic (e.g., ACE) bandage. But the sole use of elastic bandages as strapping may be controversial among certain payers. Check with your payer to see if specific codes are applicable.


Avoid Separate Imaging with Thoracentesis

Thoracentesis is a puncture made between the ribs into the pleural cavity to aspirate or remove accumulated fluid (pleural effusion) from the chest cavity. A needle attached to a syringe is introduced through the skin and chest wall until it penetrates the pleura.

For 2013, CPT?ę deleted 32421 and 32422, previously used to describe thoracentesis, and replaced them with two new codes…?ŠRead More

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The Coding Institute
Here are some excellent tips from a leading resource for coding training and information.

CMS Clarifies 99495 and 99496 Use: Answers to Place and Date of Service Questions

CMS offered some new insights into how Medicare payers expect you to use 2013‘«÷s new transitional care management (TCM) codes during the agency‘«÷s March 12 Open Door Forum, noting several important points about the TCM codes to keep in mind when completing your claims.

The new TCM codes are:

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

99496, Transitional care management services?Š with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge, medical decision-making of high complexity during the service period, and face-to- face visit within seven calendar days of discharge.

The codes are intended to apply when a physician oversees a patient whose health issues necessitate moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient‘«÷s community (home) setting.

‘«£A face-to-face visit is required within a specific time frame after the patient‘«÷s discharge, depending on which code you‘«÷re reporting,‘«ō said David A. Ellington, MD, an AMA CPT?ę Editorial Panel member who presented E/M changes at the CPT?ę and RBRVS 2013 Annual Symposium ( ‘«£The initial interactive contact ‘«Ų face-to-face, phone call, or email ‘«Ų should be within two business days of discharge. If you make two attempts to contact the patient or caregiver within that time but are unsuccessful, CPT?ę states that you can still report transitional services if the other criteria are met.‘«ō

Additional Pointers
During the March 12 CMS forum, CMS‘«÷ Ryan Howe emphasized the following areas:

– When determining which place of service (POS) code to use on your TCM claim, you should use the location that ‘«£required the face-to-face visit.‘«ō

– The 30-day TCM period begins on the date of discharge and continues for the next 29 days. Your date of service should be the thirtieth day of care‘«Ų not the first, Howe said during the CMS call.

– CMS will reject any claims with dates of service prior to Jan. 30, 2013, because the codes became effective on Jan. 1 and only cover 30-day periods.

– You can report TCM codes for both new and established patients, Howe said, which is a departure from CPT?ę rules. ‘«£CPT?ę guidance suggests that the codes are only for established patients, but for Medicare purposes, they can be reported for new patients as well,‘«ō he said.

– If 30 days pass between discharge and the initial communication with the TCM practitioner, you cannot report TCM codes, Howe said during the call.

– Medicare will pay only the first TCM claim received per beneficiary in one 30-day period beginning on the date of discharge, so if more than one practitioner reports the code for the same patient, only the doctor whose claim is received first will get paid.

– If the patient dies before the thirtieth day of TCM, you cannot report the TCM codes because they cover a full 30 days. Instead, you‘«÷d report the appropriate E/M code.

For more on the TCM codes, read the FAQs at


Reduce ‘«£Ordering/Referring‘«ō Edit Losses with These Quick Steps

Key: Double check physician NPI is individual and not group practice NPI.

If you have been postponing updating your ordering/referring physician info, take action or you may have begun seeing losses starting in May.

Phase 2 of the ‘«£ordering/referring‘«ō edits hit May 1 and CMS indicated they would issue costly denials as opposed to less burdensome returned claims when practices have invalid ordering/referring physician information. The system will deny claims when the doctor isn‘«÷t in the Provider Enrollment, Chain, and Ownership System (PECOS) file or when the name doesn‘«÷t match.

Smart practices will take these six steps to minimize cash flow delays and financial losses due to ‘«£ordering/referring‘«ō edit denials:

1. Check and recheck. CMS posts a ‘«£Medicare Ordering and Referring File‘«ō on its website with the full list of ‘«£the National Provider Identifier (NPI) and legal name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS),‘«ō CMS explains on the site. The website is at CMS updates the report weekly, it says in newly?Šrevised MLN Matters article SE1305.

Now is the time to step up PECOS file checking. Pay attention to which physicians are sending referrals and ordering services and verify that those physicians are eligible to do so and are currently enrolled in PECOS.

2. Spur enrollment. If you find your docs don‘«÷t have a record in PECOS, you‘«÷ll need to get them to enroll in it or you won‘«÷t be able to get paid.

Resource: Links to educational Medicare articles about enrolling in PECOS are in the ‘«£Additional Information‘«ō section at the end of the MLN Matters article at

3. Match the PECOS file exactly. If your claim calls a physician ‘«£Jack‘«ō and he‘«÷s listed as ‘«£John‘«ō in the PECOS file, it will get shot down. Also, don‘«÷t use credentials such as ‘«£Dr.‘«ō in the name field, CMS advises.

Key: On paper claims, be sure to list first name first and last name last in item 17.

Don‘«÷t let software differences trigger unnecessary edits. Make sure that the physician information that is on file in the providers‘«÷ software systems and is being coded on the claim for enrolled physicians matches the PECOS information, including both the NPI and physician name.

4. Use the right NPI. ‘«£Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to an individual physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral,‘«ō CMS instructs.

5. Know the rules for exceptions. Use the teaching physician‘«÷s information for interns and residents, CMS directs. The exception is for docs in states that license their residents. State-licensed residents may enroll in PECOS on their own to order and/or refer and may be listed on claims.


Separate Problem Can Be Billed During a Well Check Visit

When a patient comes to your office for a preventive wellness visit, if the patient mentions a health problem or other concern during the preventive visit, the encounter might qualify for two codes.

Checkpoint: If the problem ranks as ‘«£significant,‘«ō you can report your work to address it in addition to the preventive care. This may take the form of a problem- oriented E/M code (e.g. 99201-99215), a procedural service, or both.

Key: Although poorly covered in the past, many payers now recognize and pay for these separate, significantly identifiable services addressed during preventive medicine visits. Of course, those additional services, if covered, may also result in a patient financial obligation (e.g. deductible, copay, or coinsurance) that would not accrue with a simple preventive visit. ?ŠManaging patient expectations in this situation is important.

3 Tips: If you‘«÷re still unsure whether you‘«÷re justified in billing a problem- based E/M code along with the preventive visit, keep a few criteria in mind:

1. If the problem is significant enough that it would require or justify the patient to come back for another visit if the internal medicine physician doesn‘«÷t address it, that could be a clue that you‘«÷re dealing with a problem-based E/M situation.

2. Check whether the problem has its own ICD-9 diagnosis code. If so, that means addressing the issue could be a stand-alone (and separately reportable) service.

3. Look for additional evaluation and treatment options, such as X-ray or lab tests, or written prescriptions. These can be other signs that the physician is addressing a significant problem.


Penalties Could Be Coming Your Way for Illegible Documentation

If your physician‘«÷s handwriting is really difficult to read, you should be worried–because payers are getting stricter about illegible documentation and he may face penalties, advises The Coding Institute.

Physicians could actually have problems with payers in the future if the payers cannot read their notes. Billers should stress the importance of legible notes to their providers and may even want to suggest that they print, use dictation, or invest in an electronic medical record (EMR) system to ensure legibility.

Many coders shake their heads when they hear that some physicians maintain incomplete notes, and that auditors ask those physicians for money back since their documentation didn‘«÷t support the codes they billed. But have you ever thought that writing illegibly could make you qualify for CMS‘«÷s interpretation of incomplete notes?

‘«£When determining the medical necessity of an item or service billed, Medicare‘«÷s review contractors must rely on the medical documentation submitted by the provider in support of a given claim,‘«ō CMS says in MLN Matters article SE1237. ‘«£Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS [fee-for-service] claim payment denials.‘«ō

To read the MLN Matters article, visit

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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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Some excellent articles on protecting and improving your practice profitability have been published recently; here‘«÷s a selection of some we thought would be useful to you.

The Top 3 Reasons Your Claims Get Denied
There are plenty of reasons an insurer might deny your claims, but the most common billing errors are also the simplest and easiest to correct. Here are the top 3‘«™ Read More

Protect Your Practice from Reimbursement Rates and Abusive Payment Tactics
Financial challenges are the top concern in practices today. One of these challenges lies in the obligations defined through physician contracts. If you are one of those practices hard pressed to find a file drawer with all of the original agreements, addenda, and rates associated with reimbursement, you may end up with rates that do not even cover the cost of bringing patients through the door‘«™ Read More

Keep Your Patients Safe from Banned Healthcare Workers
The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) wants to be sure you don‘«÷t employ excluded individuals to care for government-insurance patients. They are cracking down‘«™ Read More

Don‘«÷t Overlook an Opportunity for Loss
Every practice has its opportunity for loss.?ŠKeeping track of your money is a big job, and who is going to make sure it‘«÷s handled honestly? You can hope for employees with the highest integrity and for those who would do anything to make sure your office is as successful financially as it can be.

Still, theft happens‘«™ Read More

Fighting For Provider Revenue
In this insightful article, author Ken Congdon discusses the fact that healthcare reform, reimbursement cuts, sequestration, and RAC and Meaningful Use audits are new financial challenges cutting into provider revenue. He looks at ways to cope, advising physicians that:

1. Lean management is essential to reshaping financial processes
2. Focus on perfecting front end collection

He writes that ‘«£Of all the financial pressures currently facing healthcare providers, it seems like the biggest concern among many is effectively addressing the expected rise in patient financial responsibility.‘«ō

Read the full article now at

Stop Losing Revenue From 5 Common ASC Billing Mistakes
Here are five common mistakes made in ambulatory surgery centers (many applicable to other specialties as well) that result in increased denials and decreased revenue:

1. Mismatching fee/service invoices.
2. How to bill hardware or implant removals.
3. Not knowing coding changes, such as for excision of skin and soft tissue lesions.
4. Not filing claims on time.
5. “Defaulting” to 100 percent in-network participation.

Read the full article at

CMS: Clearinghouses Can Provide Limited ICD-10 Assistance
CMS released information to clarify the role of clearinghouses in assisting the transition to ICD-10, saying that clearinghouses should not be expected to provide the same level of support for ICD-10 as they did for the HIPAA Version 5010 upgrade‘«™ Read More

4 Reasons ICD-10 is Important to Healthcare
As the burden of the ICD-10 transition wears on, CMS reminds providers of the new code set’s importance to medicine, offering four reasons why ICD-10 matters:

1. It advances healthcare and eHealth initiatives. ICD-10, along with other federal programs, aims to provide greater interoperability, data sharing, quality measurements and clinical outcomes.
2. It captures medical advances.
3. It improves data for quality reporting. The more detailed code set naturally provides better data to measure outcomes and quality.
4. It improves public health research, reporting and surveillance.


5 Tips to Negotiate More Beneficial ASC Payor Contracts for Ophthalmology
Stephen Rothenberg, JD, a consultant with Numerof & Associates, Inc., discusses how ambulatory surgery center leaders can negotiate more beneficial payor contracts for ophthalmology procedures and the outlook for eye surgery as a specialty in the future‘«™ Read More

Is Your A/R Costing You More Than You Realize?
As more employers adopt insurance plans with higher deductibles as a way to better manage and save on employee healthcare cost ‘«Ų patients seeking surgical procedures are facing higher out-of-pocket costs, including increased co-pays and deductibles. Although billing patients and maintaining accounts receivable has been a widely used and accepted method of helping patients manage fees, it can cost your ambulatory surgical center more than you may realize‘«™ Read More

4 Tips for Finding Overlooked Revenue Sources in Healthcare
At the Becker’s Hospital Review Annual Meeting in Chicago May 10, Vince Pryor, CFO of Edward Hospital in Naperville, Ill., and Bruce Shapiro, senior vice president of operations at The CCS Companies, parent company of CCS Revenue Cycle Management, discussed commonly overlooked revenue sources.

“I don’t think you can go into a revenue cycle and not find at least 1 or 2 percent,” Mr. Pryor said. “There’s always something you can work on.” Read More

37 Statistics on What Providers Think About Bundled Payments
The majority of physicians and hospitals say bundled payments have the most potential to improve healthcare affordability rather than patient-centered medical homes or accountable care organizations, according to survey results from Booz & Company. ?ŠRead More

6 Biggest Reasons Provider Business Strategy Will Fail
Scott Regan, Founder and CEO of AchieveIT, gave a presentation at the Becker’s Hospital Review Annual Meeting in Chicago on May 10, 2013, titled “The 6 Biggest Reasons Your Strategy Will Fail.” Review those reasons now‘«™ Read More

Are Your Vendors Violating HIPAA? Why Internal HIPAA Compliance May Not Be Enough
We have recently assisted several healthcare provider clients that have discovered that their business associates had allowed protected health information of the provider’s patients to be improperly disclosed in violation of the Health Insurance Portability and Accountability Act of 1996. Specifically, the providers entrusted their patients’ PHI to a business associate, and the business associate did not appropriately protect it‘«™ Read More

Get Your 10 Electronic Prescriptions (eRx) Done Before June 30th to Avoid a 2% Cut in Medicare Payments in 2014
The deadline is fast approaching for both individual eligible professionals (EPs) and group practices participating in the Group Practice Reporting Option (GPRO) to complete their required number of electronic prescriptions. If you are an EP or an eRx GPRO participant, you must successfully report as an electronic prescriber before June 30, 2013 or you will experience a payment adjustment in 2014 for professional services covered under Medicare Part B‘«÷s Physician Fee Schedule (PFS.) Read More

Credit Card on File in Action: Changes for Patients and Employees
At Manage My Practice, we are big proponents of the credit card on file system as a road to financial viability. This program changes your patient collections from a back-end collection program to a front-end collection program, effectively collecting 95% of the patient responsibility within 45 days of the service. Read More

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Is your practice ready for the influx of patients expected with the launch of healthcare insurance exchanges mandated by ACA for Jan. 1, 2014??ŠFourteen million U.S. residents will join the ranks of the newly insured on Jan. 1, 2014, according to the Congressional Budget Office.

‘«£Definitely!‘«ō you might think‘«Ų‘«£I‘«÷m ready for more revenue.‘«ō

Yes, but what about your practice: your staff and your processes? Are they ready?

Right now your office probably chugs along fairly well (or maybe not‘«Ųyou decide). But if the volume of patients you‘«÷re seeing increases rapidly, what will happen to your systems?

– Will no shows go through the roof because staff doesn‘«÷t have time to make reminder calls?

– Will patients wait interminably because check-in isn‘«÷t smooth (and meanwhile, your Yelp ratings plummet)?

– Will you be seeing patients whose coverage isn‘«÷t confirmed because staff didn‘«÷t have time to verify eligibility? (And not everyone will be covered, in spite of the mandate.)

– Will your denial rates rise and your appeal success drop because billing staff are simply overwhelmed?

These are all possibilities‘«Ųif you don‘«÷t review your office processes now, tighten up where needed and plan ahead for the increase.

Here are some steps you should take now:

1. Do an audit of your office. Where are the bottlenecks? How can they be eliminated?

2. Verify eligibility electronically. If you‘«÷re not already verifying eligibility electronically, there will never be a better time to make that change. You can‘«÷t afford having staff spend hours on the phone or even an hour visiting different insurers‘«÷ websites‘«Ųthey need a one-stop method of checking. Many billing software solutions offer this now, and your staff will need it.

3. Take patient histories electronically. By taking patient histories electronically via a patient portal or a tablet in the office, you‘«÷ll reduce wait times for patients (a major source of dissatisfaction) and eliminate the need for a staff member to enter the data into the EHR. This is vital with an increased patient flow; if you have patients sitting, filling in patient histories by hand, your scheduling is going to be shot within the first 2 hours. And you know many of them will forget to fill in the patient history ahead of time or forget to bring it if they do fill it in.

4. Use electronic check-in. Either through a patient portal or in-office kiosks, you need to have patients check themselves in. This will save your front office staff a great deal of time and reduce waiting time. It also offers patients the opportunity to cancel and reschedule easily in advance‘«Ųwhich means you won‘«÷t have holes in your schedule you have to juggle at the last minute.

5. Evaluate your billing processes. With more patients to bill and file claims for, your billing staff could easily be overwhelmed. Then think about the denial management and appeals‘«Ųwill your staff be able to handle the increased volume? Plus get ready for ICD-10?

Even if your billing staff is able to handle the volume of billing your practice currently sees, with the increased number of patients, they may soon be overwhelmed. Plus, they may be seeing new types of denials and problems as payers sort out how they‘«÷ll handle the new coverage.

That‘«÷s why now may be the time to consider turning to a medical billing service‘«Ųan organization that will be up to speed on all of the new regulations and requirements, able to staff up quickly and handle the increase in claim volume. This is what a medical billing service‘«Ųparticularly a nationwide medical billing service like‘«Ųdoes every day.

Find out how we can insure that your medical billing runs smoothly‘«Ųand brings more to your bottom line‘«Ųeven in the face of changes such as the health insurance exchanges and ICD-10.

We‘«÷re ready; we‘«÷ll make sure you‘«÷re ready.

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