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We write quite a bit about the benefits of outsourcing your medical billing to a highly-qualified third party medical billing service. But we‘«÷re not the only ones; if you search on Google, you‘«÷ll find quite a number of articles on the benefits of outsourcing.

Here are a few of the greatest hits, which we think you‘«÷ll find useful.

As early as 1999, the American College of Physicians-American Society of Internal Medicine wrote about comparing inhouse and outsourced medical billing, citing the example of one doctor in Pennsylvania who began outsourcing the practice’s billing. Since then, he said, he was getting more money‘«Ųcollections had increased more than 30%‘«Ųand getting paid faster. ‘«£Those are the benefits of outsourcing billing operations that third-party billing companies like to tout: higher collection rates and fewer staff headaches,‘«ō the author states.

The article goes on to explain that the solution isn‘«÷t so simple for every practice, and that ‘«£mom and pop‘«ō medical billing services provide mixed results. We couldn‘«÷t agree more, and have written about that in several blog posts. That‘«÷s why we argue that a nationwide, multi-branch medical billing service is the best bet for improved revenue.

Next, medical billing software resource?ŠSoftware Advice published a popular article?Šon its blog,?ŠThe Profitable Practice. This article actually included a study done by the site, which came up with the following results comparing annual costs for both approaches:


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


Eye-opening, isn‘«÷t it? To think that you could reduce your collections costs and still collect more on an annual basis‘«Ųthat additional $254,000 to the bottom line is nice to have, in our opinion. Of course, that is once again predicated on the idea that you see an increase in your collections, which requires a medical billing service with experience and trained staff.

The article also provided some recommendations on factors that would spur a provider to consider outsourcing their billing, including:

– Your billing process is inefficient.

– You have high staff turnover.

– You’re not tech savvy.

– You’re a new provider.

– You have different priorities.

All good points‘«Ųwe agree that these are good reasons to consider outsourcing your medical billing.

Most recently, we have seen two articles published by Med City News on why outsourced medical billing may be the best option for many practices. In the first article, the author points out that ‘«£More than 10% of debts for a majority of providers go over four months and are unfortunately written off as bad debts. Medical billing services, on the other hand, are much feistier in their attempt to recover debts, often turning out to be successful in cases where in-house billing teams tend to fail. Therefore, providers facing outstanding debts for longer times have much to gain by outsourcing their billing to a renowned medical billing company to experience higher revenues and much shorter billing cycles.‘«ō

In the second article, the same author points out that ‘«£Your medical billing company will be contractually bound to perform some services, such as appealing denials which will eventually result in shorter billing cycles‘«™

‘«£Outsourcing medical billing services also results in a much lower claim rejection rate such that a medical practice can expect between 5% to 15% increase in the amount they are able to collect by opting for a billing service.‘«ō

We strongly agree with these statements, as we have seen these types of improvements repeatedly with our own clients. But we also agree with the idea above that it‘«÷s important to evaluate whether outsourcing your medical billing is right for your practice; only you can make that decision.

If you‘«÷d like to learn more about choosing the right medical billing service for your practice, download our free white paper, When and to How Select the Right Medical Billing Service. It‘«÷s full of checklists you can use to determine whether outsourcing your medical billing is right for you, and how to find the medical billing service that will provide the results you want.

You can also call us today at 800-966-9270 to talk with one of our expert practice revenue consultants, and they‘«÷ll be happy to discuss your needs and how we can help bring more to your bottom line.

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As of today, the new HIPAA requirements go into effect in less than 3 weeks. Are you ready?

If not, you have 20 days to get ready. That‘«÷s DAYS.

Time to prepare, folks.

As we have noted in previous blog posts, there are several steps that you need to take in order to protect your practice. In case you missed them, here are the highlights:

There are three relatively small changes that just about all offices will encounter:

Patients can now ask for copies of their electronic medical information in electronic format. Also, with both paper and electronic record requests, the office has only 30 days to produce the information. There‘«÷s no more 30-day extension for records that are inaccessible or kept off site.

When patients pay for services personally and in full, they can require that the office not share information about the treatment with their health plans.

The office can give immunization information to a school if the school is required by law to have it and if the parent or guardian gives written permission.

A larger change that practices will encounter involves business associates, which are now required to comply with HIPAA just as providers are. They have to have safeguards and policies and procedures for keeping data secure. They are required to have business associate agreements with their own subcontractors. And they can get hit with penalties if they don‘«÷t.

What you need to do

Steps that providers need to take before the September deadline to protect their practices, provided by Holly Carnell, JD, and Meggan Bushee, JD, Attorneys at McGuireWoods on?ŠBecker‘«÷s ASC Review, include:

1. Update your internal policies.

Key changes that a practice will need to make to its internal privacy policies include (See the full list):

A. Breach standard response– the Omnibus Rule changed the standard for determining whether a breach of unsecured PHI has occurred; the new breach standard should be included in providers‘«÷ internal policies on responding to a potential breach. Who must be notified has remained unchanged.

B. Marketing and sale of PHI – marketing of third party products and services and sale of PHI is generally prohibited, unless the provider has received valid authorization from the patient.

C. Decedents‘«÷ PHI – providers may disclose only PHI that is relevant to the family member, relative or friend‘«÷s involvement in the deceased‘«÷s care, and cannot disclose PHI if the provider is aware that the deceased person expressed a prior preference for it not to be disclosed to the person in question.

D. Disclosures to schools?Š- providers may disclose proof of immunization to schools if the school is required by state, or other, law to have proof of immunization prior to admitting the individual, and the provider obtains and documents the oral agreement to the disclosure by either a parent, guardian, or other person acting in loco parentis of the individual, or from the individual if he or she is an adult or emancipated minor.

E. Patient rights to limit disclosures?Š- a provider must comply with a patient‘«÷s request that PHI regarding a specific healthcare item or service not be disclosed to a health plan for purposes of payment or healthcare operations if the patient paid out-of-pocket, in full, for that item or service.

F. Provision of electronic copies of medical records?Š- providers complying with a patient‘«÷s request for an electronic copy of his or her PHI are required to provide access to such records in the electronic format requested by the patient if the records are maintained by the provider in an electronic designated record set and are readily producible in the requested format.

2. Provide staff training.

Make sure that your policies are both updated and implemented. Once your practice has updated your privacy policies, staff members should receive training on any new and revised policies.

3. Offer notice of privacy practices.

After you have updated your NPP, your practice must make the NPP readily available to existing patients who request a copy on or after the effective date of the revisions; must post the revised notice on its website, if applicable; and must post the notice in a prominent location on its premises.

4. Revise your business associate agreements.

Providers should revise their business associate agreement forms to reflect the new requirements under the Omnibus Rule. The deadline for this is September 23, 2013. However, existing BAAs that were entered into on or before January 25, 2013 and have not been modified after March 26, 2013 do not have to be updated until September 23, 2014.

You should note that the Final Rule broadened the definition of a business associate to include subcontractors, health information organizations, entities that offer a personal health record to individuals on behalf of a covered entity, and other entities that provide data transmission services for covered entities and that require access on a routine basis.

The Final Rule also provides a list of HIPAA Privacy and Security Rule requirements that apply directly to business associates, including requirements to:

A.?Š?Š?ŠMaintain detailed records?Šof uses or disclosures of protected health information (‘«£PHI‘«ō) to be produced upon request;

B.?Š?Š?ŠProvide an electronic copy of PHI?Što covered entities or individuals upon request;

C.?Š?Š?Š?ŠSign business associate agreements?Šwith subcontractors that?Šcreate or receive PHI on their behalf; and

D. ?Š?ŠMake reasonable efforts to limit release or use of PHI?Što the minimum necessary to accomplish the intended purpose of the use or disclosure.

Many of these new requirements were not previously believed to apply to business associates, so business associate agreements will need to be amended to comply with the new provisions.?Š For more information on your business associate agreements and what entities are covered under this definition, see this recent post on?ŠJD Supra Law News, which provided the BAA items above.

Once your practice has updated its BAA form, attorneys recommend conducting an inventory of all current BAAs (including BAAs in which the provider is the covered entity and BAAs in which the provider is a business associate or subcontractor). Each of these BAAs will need to be modified by an amendment or replaced with the practice‘«÷s revised BAA form. This may also be a good opportunity to consider whether the protections and restrictions in the form agreement go far enough in protecting patients and the practice.

You should review all your business relationships to ensure you have a BAA in place where one is required under HIPAA. Providers may have relationships that did not previously require a BAA, but which do now under the Omnibus Rule‘«÷s expansion of the definition of ‘«£business associate.‘«ō One key change to the definition of business associate is the inclusion of subcontractors of business associates that deal with PHI.?Š However, covered entities are not required to enter into BAAs with downstream subcontractors. Rather, the business associate who contracts with the subcontractor must enter into a BAA with the subcontractor.

Remember that ‘«£business associate‘«ō includes such partners as:

– Medical billing service

– Attorney

– Marketing group

– IT support

– Etc.

If you‘«÷re unclear on whether a vendor is a ‘«£business associate‘«ō there are several good?Šdecision trees?Šonline developed by other groups that help define the term.

The penalties get higher

Finally, lest you think you can ignore these changes, remember that the penalties for noncompliance have gone up ‘«Ű significantly.

The amount depends on the level of negligence. Previously, the limit was $25,000 per violation; now it‘«÷s $50,000, with an annual limit of $1.5 million.

And the Office of Civil Rights, which enforces HIPAA, cautions that it‘«÷s looking hard for violations and plans to enforce HIPAA ‘«£vigorously.‘«ō

If you‘«÷re concerned about whether your medical billing service will be HIPAA compliant under the new rules, contact?ŠŠat?Š800-966-9270. maintains strict HIPAA compliance at each of its 5 nationwide branches, and we will help you bring more to the bottom line while keeping you in compliance.


Additional Resources

HIPAA: What Your Medical Practice Needs to Do for the September 23, 2013 Deadline

HIPAA: Why Your Practice Needs to Worry About the September 23, 2013 Deadline

Be Prepared for the New HIPAA Rules ‘«Ų Coming Soon to Your Practice

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ICD-10 is just over 400 days away, yet many practices have not yet begun to plan for it. Here‘«÷s a review of the latest news and tips on preparing for this change that‘«÷s being called ‘«£the Y2K of healthcare.‘«ō

ICD-10 Could Cause Healthcare Reimbursements to Take a Hit
Becker‘«÷s ASC Review

Providers who are not prepared for the ICD-10 transition may see their bottom lines suffer, according to aMediGainreport. The?ŠHealthcare Billing and Management Association?Šrecently stressed the importance of being prepared for the change to ICD-10’s more granular code set. Holly Louie, chair of the organization’s ICD-10/5010 committee, testified before Congress that the economic stability of the country’s healthcare reimbursement system is hinging upon this successful switch‘«™ Read More

ICD-10 Budgeting: Do You Know How Much the Transition Will Cost?
ICD-10 Watch

The true cost of the ICD-10 transition may not be as easy to calculate as you think. Sure you can call healthcare vendors to get quotes on modifications to software and hardware, upgrades and purchases of new software, systems and equipment.

But that’s not the whole price. You need to get your best estimates of the following elements‘«™ Read More

61% of Providers Say ICD-10 Testing Will Take 9 to 12 Months
Becker‘«÷s ASC Review

A new?Šreport?Šfrom Qualitest Group shows that around 75 percent of healthcare organizations have not begun testing for ICD-10 despite the looming deadline for a full transition next year‘«™ Read More

ICD-10 Transition: Maybe It’s Time to Panic a Little
ICD-10 Watch

We are about 14 months away from the ICD-10 implementation deadline. Surveys report that healthcare providers are in various states of readiness. QualiTest Group?Šsurveyed more than 300 professionals?Šabout their ICD-10 testing plans. The two major findings are:

– Most respondents have either completed ICD-10 assessments or are in the process of assessments.

– 75 percent of respondents have not yet begun ICD-10 testing.

While starting sooner than later is important, this survey doesn’t raise too many alarm bells. It does report a great deal of planning and progress in the ICD-10 transition. Other surveys released in the past few months have found less preparation.

Perhaps a more troubling indicator is the amount of newly released literature that suggests there is an audience that hasn’t heard of ICD-10 implementation. If the healthcare industry is on its way to a smooth ICD-10 transition, we wouldn’t need so many guides to planning ICD-10 implementation. Read More

Physician Practice Costs for ICD-10: Clinical Documentation
ICD-10 Monitor

Physician offices are inching slowly toward ICD-10 ‘«Ų very slowly. A recent survey of 1,200 practices conducted by MGMA reveals that loss of physician productivity, staff efficiency, and changes to clinical documentation are still major concerns.

While MGMA and the physician community at large are reluctant to implement ICD-10 (and have raised many roadblocks to its progress), the organization‘«÷s May 16, 2012, letter to CMS provides valuable guidance regarding the six key areas of cost impact to watch.

MGMA advises ICD-10 will add significant costs for physician practices and clinical laboratories in these six areas:

  • – Staff education and training
  • – Business-process analysis
  • – Changes to ‘«£superbills‘«ō
  • – IT system changes
  • – Increased documentation costs
  • – Cash flow disruption

Read More

ICD-10 Transition: What It Takes to Work with Healthcare Payers
ICD-10 Watch

You could put off communicating with your healthcare payers until you submit your first ICD-10 coded claim Oct. 1, 2014. What could go wrong?

Early communication will help healthcare providers test the ICD-10 claims process and gain insight into how reimbursements will be affected after Oct. 1, 2014. That second part will help prepare for DRG shifts. This puts a price tag on procrastination. Read More

Fast Tracking ICD-10: Building the Action Plan
ICD-10 Monitor

It‘«÷s time to get geared up for ICD-10 by building an action plan. We just finished developing a budget for a large hospital system and found that the bulk of the budget will go to software applications, hardware upgrades, and education and training. These also happen to be three high-risk areas as it pertains to compliance.

Now we have to turn the impact assessment and gap analysis into the action plan. I am finding that working with hospital systems that have large steering committees with several sub-committees helps distribute the action items evenly. For example, every department will need education, whether in the form of simple awareness, fundamental instruction, documentation courses or in-depth training. By assigning this task to the education subcommittee, an organization can map out an education plan listed front and center in the action plan. I find that, for large health systems and hospitals, it is helpful to map out action items and milestones in an Intranet portal so every steering committee member and subcommittee chair can track progress along the way‘«™ Read More

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Big changes are occurring in health care, and to help you stay abreast of them, we‘«÷ve gathered the latest news that can affect your practice revenue. Below you‘«÷ll find articles on health insurance exchanges, collaborating with other practices to save money, getting tax breaks for your practice, online patient payments, and much more.

5 Ways Health Insurance Exchanges Could Impact Physician Income
Becker‘«÷s ASC Review

The Patient Protection and Affordable Care Act’s health insurance exchanges will open on Jan. 1, 2014, and likely have an impact on physician income, according to a?ŠMedscape News?Šreport.

The exchanges will be open online Oct. 1, 2013, designed to allow uninsured people to choose coverage for the next year. According to the report, primary care physicians and specialists could see:

‘«ů?Š?Š ?ŠLower reimbursement rates from insurance companies participating in the exchange
‘«ů?Š?Š ?ŠLess control over the number of patients from exchanges they see
‘«ů?Š?Š ?ŠProblems collecting out-of-pocket from exchange patients
‘«ů?Š?Š ?ŠPatients who aren’t familiar with following treatment regimens
‘«ů?Š?Š ?ŠFormation of narrow networks for insurers, which begin with hospitals and then decide how physicians are included with the potential for “cost profiling”

Read More

Collaboration Can Save Medical Practices Time, Money and Effort

Physicians can share front office staff and an electronic health record system. However, they need to prove integration efforts are legal to avoid antitrust violations‘«™
Read More

Patients More Willing to Pay Healthcare Bills Online
Becker‘«÷s ASC Review

In 2012, around 13 percent of the gross dollar volume of all patient payments was made online, according to “Trends in Healthcare Payments Annual Report: 2012,” a recent report by vendor Instamed. The figure is up from around 8 percent in 2010‘«™ Read More

How to Get Tax Breaks for Your Medical Practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them‘«™ Read More

Waste Not, Want Not: Billing Unused Drug Supplies

Physicians sometimes must discard an unused portion of a drug. If the physician (rather than the patient and/or facility) supplies the drug, Medicare may allow compensation for this ‘«£wasted‘«ō portion.

As instructed by the National Medicare guidelines for reporting drug waste found in the?ŠClaims Processing Manual, chapter 17, ?ļ 40.0, drug waste is reported?Šin addition to?Šthe drug administered‘«™ Read More

A Quick Guide to ‘«£Separate Procedures‘«ō

CPT?ę codes designated as ‘«£separate procedures‘«ō are considered to be incidental and bundled with any related comprehensive/major procedure when performed during the same session, through the same incision, and/or at same anatomic site. A separate procedure may be reported only if:

1. It is the only procedure performed,?Šor

2. It is unrelated to or distinct from other procedures performed during the same operative session (e.g., separate incision or site, performed on the ipsilateral/contralateral side, etc.).

Read More

For Some Post-Op Care, a Phone Call May Be All That’s Needed

Scheduling a call instead of an in-person visit could reduce patient no-shows, which would help physicians better manage patient loads and follow-up care‘«™ Read More

The Top Five Essential Tips for Successful Appeals
California Medical Association

How you present appeals to your carrier can make the difference between success and failure. AAPC‘«÷s Managing Editor?ŠG. John Verhovshek, MA, CPC,?Šrecently offered five tips for successful appeals in an article published by?ŠCalifornia Medical Association.

  1. – Be prepared
  2. – Write a proper appeal letter
  3. – Correct the claim before you appeal
  4. – Code only what documentation supports
  5. – Avoid obvious mistakes

Read More

Prompt Proper Assistant-at-surgery Payment

Successful coding and billing for surgical assistants depends on three principal factors:

  1. – Does the payer allow additional reimbursement for surgical assistance for the reported procedure?
  2. – Has the surgeon sufficiently documented the need for and role of the surgical assistant?
  3. – Has the proper modifier been appended to the claim?

Here are some tips and techniques for ensuring your assistant-at-surgery claims prompt proper payment‘«™ Read More

Advance: Appending Modifiers 50, 51, and 59
AAPC News/Advance

Modifiers are crucial to telling the story of a claim by identifying procedures that have been altered, without changing the core meaning of the code(s) submitted. AAPC‘«÷s National Advisory Board Member Relations Officer Nancy Clark, CPC, CPB, CPMA, CPC-I,?Š recently published an article in?ŠAdvance for Health Information Professionals, in which she expounded on the proper application of modifiers 50, 51, and 59. Ms. Clark provided examples, tables, and even comparisons between modifiers.

1. Modifier 50?ŠBilateral procedure?Šdescribes procedures or services that take place on identical, opposing structures (e.g., shoulder joints, breasts, eyes).

2. Use modifier 51?ŠMultiple procedures?Što show that the same provider performed multiple procedures (other than E/M services) during the same session.

3. Modifier 59?ŠDistinct procedural service?Šindicates a:

– Different encounter or session;

– Different procedure;

– Different site; or

– Separate incision, excision, injury, lesion, or body part.

Read More

15 Statistics on Surgery Center Accounts Receivable Days
Becker‘«÷s ASC Review

In all ASCs:
1. 0 to 30 days: 53.4 percent
2. 31 to 60 days: 17.2 percent
3. 61 to 90 days: 8.2 percent
4. 91 to 120 days: 5.4 percent
5. Over 120 days: 15.9 percent

The article also provides data on AR days In ASCs with fewer than 3,000 cases and ASCs with at least 6,000 cases. Read More

Posted on August 8, 2013 by · Leave a Comment
Filed under: Medical Billing, Physician billing, Resources, Tips and Tricks  

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Earlier this week, we shared a post entitled, ‘«£Physicians‘«÷ Top Concerns Include Financial Management: 5 Ways to Relieve Those Concerns,‘«ō which discussed several ways your practice can improve profitability, including expanding your schedule. We recommended adding hours before and after ‘«£normal‘«ō practice hours, as well as adding Saturday hours, in order to increase availability for patients and add revenue.

By coincidence, Physicians Practice published a related article just yesterday entitled, ‘«£How to Code, Negotiate After-Hours Reimbursement at Your Practice‘«ō which you will find extremely useful if you are considering expanding your schedule.

Among the useful tips the article provides:

– When negotiating with payers which are reluctant to pay additional reimbursement for after-hours services, you may succeed if you use savings potential as leverage. The author suggests that you ‘«£make it clear that you‘«÷ll willingly send patients to the emergency department instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than‘«ō comparable services you would provide. That‘«÷s a pretty powerful argument!

-To further demonstrate cost savings, the author advises that you could also start billing all applicable after-hours codes for your practice. Over time, he says, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Coding Correctly is Key

Another consideration, of course, is how to code and bill services in these added hours. We found useful information on this subject in an article on Supercoder Bolt (formerly Coding News), where the author detailed the differences between coding for services provided during your regularly scheduled expanded office hours and what is considered ‘«£after hours‘«ō (after your posted office hours).

The article advises that when your physician provides E/M service in your practice during regularly scheduled ‘«£evening, weekend, or holiday office hours,‘«ō you should bill 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service), according to AMA guidelines outlined in the?ŠCPT Assistant?Š(Vol. 13, Issue 6, June 2003).

However, if you should decide not to expand your office hours, keep in mind that you can still receive additional reimbursement for patients seen after your normally posted office hours. If your physician sees a patient in the office during hours when the practice would normally be closed, such as on weekends or after 6 p.m., CPT guidelines allow you to bill 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed [e.g., holidays, Saturday or Sunday], in addition to basic service) as long as the documentation supports the after hours service, according to?ŠJetton Torix, CCS-P, CPC-H,?Šcourse director of Knowledge Source Seminars in Star, Idaho, in the article.

An important note in the article:?ŠA patient is considered an after-hours patient only if they come to your office after your normal office hours end ‘«Ų not when they visit during normal office hours and the appointment runs past closing time.

Remember:?ŠThe article also cautions that whether you select 99050 or 99051, you would report the after-hours code in addition to the appropriate E/M service code for the visit.

We hope you will consider some of these methods for improving your practice profitability. And remember, you don‘«÷t have to expand your hours necessarily; by hiring a part-time physician or non-physician, you can provide additional access to medical care for your patients when they need it.

If you are interested in improving your practice bottom line, a great way to start is to review your medical billing and insure that you are being reimbursed for all of your care, and getting paid in a timely fashion. will be happy to review your current levels of reimbursement and speed of payment and advise if there are ways they can be improved. Just contact us today at 800-966-9270 or at

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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.

Posted on July 23, 2013 by · Leave a Comment
Filed under: Medical Billing, News, Physician billing, Tips and Tricks  

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‘«£Well, either you’re closing your eyes

To a situation you do not wish to acknowledge

Or you are not aware of the caliber of disaster indicated

By the presence of a retail clinic in your community.

Ya got trouble, my friend‘«™‘«ō

This, of course, is a paraphrase of the lyrics to a song from one of my favorite musicals, The Music Man. In the film, the main character incites the townpeople by talking about the problems sure to be caused by a pool table in their small town.

I‘«÷m not trying to start a boys‘«÷ band (his solution), but I do think physicians need to pay attention to the challenges presented by the rapid proliferation of retail clinics. These challenges include:

– Loss of patients

– Interruption of continuity of care

– Loss of revenue

A recent Medscape article cited a study by JAMA Pediatrics that found ‘«£almost 1 in 4 parents who had a relationship with a pediatrician took their children to retail clinics for minor problems, mostly because of the convenience.‘«ō

And lest you think the problem is primarily for pediatricians, remember that many patients who would ordinarily see primary care physicians, allergists and other specialists may instead opt to visit the local retail clinic. Why would they go to an unknown physician or even a PA or NP instead of seeing you, their trusted doctor?


It‘«÷s all about convenience these days, and if you think that doesn‘«÷t apply in healthcare, think again. The very fact that these clinics are growing as quickly as they are indicates that convenience is a major factor for patients.

How fast are they growing?

In the coming years, the number of walk-in medical clinics at big box retail stores is expected to increase by an annual rate of 25% to 30%, according to a new Accenture report.

According to?ŠAccenture?Šresearchers, the growth rate of in-store health clinics was between 50% and 150% from 2001 to 2008, with the exception of 2005 when the growth rate shot up to 442%. In 2009 and 2010, the growth rate fell sharply to between just 1% and 3%. However, the rate has picked up in the past couple of years, reaching 14.7% in 2011 and 2012, the researchers found.

‘«£Most of my patients will never leave me for one of these places,‘«ō you‘«÷d like to think. But why take a chance?

There are steps you can take to maintain‘«Ųand grow‘«Ųyour patient base. Without having to be at your practice 24/7 yourself. Here are some ideas from consultant Rochelle Glassman, who has successfully advised multiple practices on these issues:

1. Extend your hours. Fight fire with fire‘«Ųextend your hours so that you‘«÷re open before and after work/school hours. Your patients need options for when they can see you.

2. Consider Saturday hours. Many of your patients would appreciate the opportunity to get medical care on Saturdays so they don‘«÷t have to be away from their jobs. Due to the down economy, many people were afraid to take time off work even for medical care, and that unfortunately has not changed yet.

Wait, you say‘«ŲI don‘«÷t want to work 20 hours a day and give up my Saturdays. You don‘«÷t have to. Hire another provider, either a physician or non-physician provider, to handle those extra hours. Chances are they can handle most of the problems that will come in during those hours, and you can make arrangements for those patients who need to see you.

This idea, according to Glassman, has the added benefit of opening up your schedule during your current office hours for walk-in and same day appointments.

To survive the coming changes in healthcare, you need to evaluate your practice and see where you need to make changes. Don‘«÷t wait until your revenue has dropped due to the competition from either these clinics or other practices that have adjusted; get ahead of the wave.

And if you also need to reevaluate your revenue cycle management and make sure you‘«÷re being reimbursed for every claim, contact On average, our physician clients get paid faster than 75% of multi-specialty group practices nationwide as surveyed by the Medical Group Management Association and Healthcare Billing Management Association for Days Revenue in AR.

We‘«÷d like to help you get paid faster and more completely.

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2013 OIG Work Plan: HHS Targets Three Areas
For The Record

From a coding perspective, mechanical ventilation, cancelled surgeries, and Medicare’s transfer policy take top billing in the OIG work plan for 2013.

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.

According to the OIG, the work plan is part of “a dynamic process, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. We assess relative risks in the programs for which we have oversight authority to identify the areas most in need of attention and, accordingly, to set priorities for the sequence and proportion of resources to be allocated.”

In creating the work plan, the OIG evaluates several factors, including mandatory requirements by law, regulation, or directive; congressional, Health and Human Services (HHS), or Office of Management and Budget requests and concerns; management and performance challenges facing HHS; collaborative work performed with partner organizations; and management’s responsiveness to results from previous reviews. Among OIG’s areas of focus for 2013 are coding related to payments for mechanical ventilation and cancelled surgeries as well as Medicare’s transfer policy.

Read More:


Cardiology: 93010 Is Sometimes the Right Choice on Cardiac ?ť?ŠCath ?ť?ŠDay

The Coding Institute

ECGs are bundled into cardiac catheterizations. But if you overlook opportunities to report ECGs on cardiac catheterization days, you could be shortchanging your practice. ?ť?ŠMedicare offers rules for reporting ECGs on the same date as cardiac catheterizations. The gist is that routine ECGs performed during cardiac caths are not billable in addition to the cardiac cath. But you may bill separately for diagnostic ECGs performed before or after the cardiac cath service. Here’s a closer look.

During cath: Medicare’s Correct Coding Initiative (CCI) manual, Chapter 11, Section I.4, indicates that because ECG monitoring is routinely used during cardiac catheterization, ECG codes aren’t reportable in addition to cardiac cath codes.

(The manual is available from the Downloads section at Coding/NationalCorrectCodInitEd/index.html.)

Note the Diagnostic Exception

Although ECGs that are an integral part of the cardiac cath aren’t separately payable, the patient may have diagnostic ECGs before or after the cath session. Those diagnostic ECGs are separately payable by Medicare when you append modifier 59 (Distinct procedural service) to the ECG code.

The CCI manual, Chapter 11, Section I.16, supports this by stating, “Cardiac catheterization procedures or a percutaneous coronary artery interventional procedure may require ECG tracings to assess chest pain during the procedure. These ECG tracings are not separately reportable. Diagnostic ECGs performed prior to or after the procedure may be separately reportable with modifier 59.”

Note: Don’t confuse standardized patient care with diagnostic ECGs. Some physicians will routinely order an ECG before and after a cardiac catheterization and/or interventional procedure. This is considered standardized patient care.

Helpful: If you’re having trouble determining whether the service performed meets the definition of diagnostic, consider the requirements listed in the National Coverage Determination (NCD) for Electrocardiographic Services (Section 20.15). The NCD manual is available by clicking the link for Publication 100-03 at Regulations-and-Guidance/Guidance/Manuals/Internet- Only-Manuals-IOMs.html.

Use the Appropriate Code for Diagnostic ECG

Once you’ve determined that a patient had a reportable ECG on the same date as a cardiac cath, you need to choose the correct code. For interpretation and report of a typical 12-lead diagnostic ECG performed in a facility, the appropriate code is 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). Recall that to override the cardiac cath/ECG edit, you must append a modifier to the ECG code.

Tip: The code definition refers to “at least 12 leads.”?ō For proper coding, you should know that a “lead”?ō and an “electrode”?ō are not the same thing. For instance, providers may refer to 10 electrodes placed on a patient for a 12-lead ECG. To simplify, think of a lead as an electrical view or snapshot of the heart from a particular perspective, creating what the provider sees on the graphic representation. A combination of electrodes can provide a single lead.

The use of “at least”?ō in the 93010 code definition is also important because it means the code is appropriate for 12 or more leads. ?ť?ŠConsequently, 93010 is correct when documentation shows 10 electrodes for a 12-lead ECG or 14 electrodes for a 15- lead ECG because in both cases there are 12 or more leads.

Bottom line: On cardiac cath days, experts advise only coding ECGs ordered/documented as diagnostic and performed before or after the cardiac cath. Baseline screenings or monitoring ECGs are not considered diagnostic.


Gastroenterology: How to Have Stress-Free GI Pressure, Transit Measurement Reporting

The Coding Institute

You can improve your CPT?ę 2013 code 91112 claims success if you focus on whether or not the procedure was complete and concentrate on who owns the equipment for the procedure. These codes replaced the former Category III codes 0242T.

Check Payer Rules for 91112

When your gastroenterologist performs a wireless capsule test for GI pressure and transit measurement, you will report the procedure and the interpretation of results using 91112 (Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report).

Note: Many payers still consider the procedure of using a wireless capsule to measure GI pressure and transit as investigational and might not provide coverage for the procedure. Many payers also mention that this procedure needs pre-authorization, so check with payers’ coverage policies to avoid the risk of denials.

Append Suitable Modifiers for Discontinued Procedures

Your gastroenterologist may attempt a capsule study for pressure and transit measurement but may need to discontinue the procedure. One such scenario is when the patient has difficulty swallowing the capsule. In such a situation, you will have to append modifier 53 (Discontinued procedure) to 91112 to indicate the incomplete work. Another situation that warrants you to report this modifier is when the capsule gets retained in the stomach.

If your gastroenterologist repeats the procedure by placing the capsule endoscopically in the duodenum for the repeat procedure, then you need to report the procedure using 91112 and the modifier 52 (Reduced services) to the code to indicate that your gastroenterologist used the wireless capsule to measure pressure and transit in the areas beyond the stomach.

Reminder: Don’t forget to report the endoscopy that your gastroenterologist performed to place the capsule. You will have to report it with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Separate Components When Appropriate

When reporting 91112 for GI transit and pressure measurements, you will have to check who owns the equipment that is being used. If your gastroenterologist owns the recording device and provides the capsule for the procedure, you will just have to report the entire procedure and the interpretations along with the report using 91112.

However, if your gastroenterologist is only providing interpretations and prepares the report for the GI transit and pressure measurements, and the hospital owns the equipment, you will have to report components of 91112 separately. In such a scenario, you will have to report the services of your gastroenterologist using 91112 with the modifier 26 (Professional component) and the hospital will report its part using 91112 with the modifier TC (Technical component).


Internal Medicine: Injection Administration Coding Edits–New?ŠBundling Policies

The Coding Institute

The latest update from the Correct Coding Initiative (CCI) brings some limited–but good–news for internal medicine physicians: approximately 30 edits involving immunization administration and evaluation and management (E/M) services now have a modifier indicator of 9, meaning that the previous bundles have been deleted and are no longer valid. The changes took place April 1, 2013, when CCI 19.1 became effective, and the deletion date is January 1, 2013, indicating the change is retroactive to the first of the year.

The explanation for the changes falls under “CPT?ę manual or CMS manual coding instructions.”?ō

Six immunization administration codes are part of the reversed edits:

– ?ť?Š90460 –?ŠImmunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

– ?ť?Š+90461–?Š?Š…each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

– ?ť?Š90471 –?ŠImmunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

– ?ť?Š+90472?Š1–?Š?Š…each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

– ?ť?Š90473 –?Š?ŠImmunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

– ?ť?Š+90474 –?Š?Š…each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure).

You can now report these administration codes in conjunction with any level of inpatient consultation without the necessity of appending a modifier to the inpatient consultation code to get both services paid, according to specialists. The affected codes are:

“Unfortunately, the other edits bundling office, outpatient, and preventive E/M services with vaccine administration codes in the absence of a valid modifier remain in place,”?ō a coding specialist notes. “That means you’ll need to continue appending a modifier, such as 25, to an affected E/M code provided at the same encounter as a vaccine administration to get paid for both services under the CCI edits.”

Exception: The one exception is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services.). Code 99211 is bundled with a vaccine administration code, regardless of whether you include a modifier.

Recoup: The deletion date for these edits is January 1, 2013, which suggests that the change is retroactive to that date. If you had any services denied on the basis of these particular edits for dates of service between January 1 and April 1, 2013, you may want to consider appealing the denials on the basis of CCI release 19.1.


Neurology: 4 Tips for Conquering Carpal Tunnel Coding Challenges

The Coding Institute

A lack of definitive results from diagnostic tests can complicate carpal tunnel coding. Take care not to jump to a definitive diagnosis code. But this does not mean you will compromise on payment. Follow these tips to ensure you earn what you should for carpal tunnel cases.

1. Don’t Jump to a Diagnosis Too Soon

When your neurologist treats carpal tunnel syndrome (CTS), you usually report diagnosis code 354.0 (Carpal tunnel syndrome).

Note: Your neurologist may document “suspected”?ō CTS in the clinical record. If so, don’t report the definitive diagnosis code 354.0 just yet. While your neurologist is waiting for test results, you should report the patient’s symptoms in support of any services your physician provides.

Reason: ICD-9 official guidelines instruct you to use signs and symptoms codes in the office setting when your neurologist documents an uncertain diagnosis. According to ICD-9, “Do not code diagnoses documented as ‘probable,’?ō ‘suspected,’ ‘questionable,’ ‘rule out,’?ō or ‘working diagnosis,’?ō or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

You may find the ICD-9 guidelines on the CDC website: icd/icd9cm_addenda_guidelines.htm#guidelines

2. Check for Diagnostic Testing

To establish a diagnosis of CTS, your neurologist may perform nerve conduction studies (NCS) and/or electromyography (EMG). Each one has its own diagnostic significance.

You report 95860 or 95861 only when no NCS is performed. If both NCS & EMG are performed, then you need to look at either add-on code +95885 (Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited [List separately in addition to code for primary procedure]) or +95886 (Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels [List separately in addition to code for primary procedure]).

Watch for the complete limb EMG. Additionally, the 95860 (Needle electromyography; 1 extremity with or without related paraspinal areas) — 95864 (Needle electromyography; 4 extremities with or without related paraspinal areas) codes, as well as the 95886 code is ONLY billed when a complete limb EMG study has been performed — testing performed on five or more muscles studied, innervated by three or more nerves or four or more spinal levels’ otherwise the code would be 95870 (Needle electromyography; limited study of muscles in 1 extremity or non- limb [axial] muscles [unilateral or bilateral], other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters) if no NCS are performed.

Count nerves for NCS: You select from codes 95907 (Nerve conduction studies; 1-2 studies) — 95913 (Nerve conduction studies; 13 or more studies) depending upon the total number of separate nerves that are tested.

3. Submit Single Code Once Diagnosis Is Established

When your neurologist has established the diagnosis of CTS, focus on code 354.0. In this case, you do not report the codes for the signs or symptoms, such as numbness, tingling or finger pain. According to ICD-9, “Signs and symptoms that are integral to a disease process should not be assigned as additional codes.”

Reason: Your neurologist may be doing nerve conduction studies and/or electromyography to confirm the diagnosis of CTS. In this case, do not report the signs and symptoms as secondary diagnoses as these are integral to the primary definitive diagnosis.

4. Code for the Treatment Provided

Your neurologist may begin with noninvasive, conservative treatments in the early stages of CTS and include injections in later stages of the disease.

Initial treatment may include pain-relieving medications and a wrist brace or splint.

When pain-killers, splints, and physical therapy have failed or cannot be used for one or more reasons, your neurologist may administer injections into the carpal tunnel to perform a nerve block and relieve the symptoms. If so, submit 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid]; carpal tunnel). Depending upon what option your payer prefers, you report either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side) when your neurologist injects both carpal tunnels.

If the symptoms still persist, your neurologist may refer the patient for surgical treatment to relieve the pressure on the median nerve.

Note: Ensure all treatment steps are documented in the treatment plan, or payers may reject your claim based on lack of medical necessity.


Obstetrics: Troubleshoot Your Pregnant Patient Transfer Claims by Counting Visits

The Coding Institute

Prepare for coding your OB-GYN’s services up to the date of the patient’s move depending on how many antepartum visits the physician provides — here are tips for one to three and four to six visits:

1-3 Visits Mean Office E/M Codes

If your OB-GYN sees a pregnant patient for only one to three antepartum visits, how should you report it?

Answer: You need to report the appropriate E/M codes for payment. You won’t have a set E/M code for the patient’s first visit. Your patient could be new to the practice, or the first visit may meet the criteria for a level-five established visit. Therefore you should look to the entire code series (99201-99205 for new patients, 99211-99215 for established patients) as possible options.

Second and third visits: Now your coding options are more limited.

When Medicare and ACOG were developing the relative value units for antepartum care, the follow-up visit was estimated to be a 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), so this code is your best bet for each of these visits in the absence of documented problems.

Note: In some rare circumstances, such as when the patient has absolutely no problems during the visit, however, the documentation might support reporting only 99212 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 10 minutes face-to-face with the patient and/or family) for each visit.

If the patient’s pregnancy is without complication, your diagnosis would be either V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy).

Watch out: Because you do not have a specific antepartum code for one to three visits and have to report E/M codes, payers sometimes will deny these claims and tell you to “include in the global.”?ō You are forced to appeal these decisions. Explain to the payer that you cannot report a global code because you are no longer the patient’s OB care provider.

4-6 Visits Mean Antepartum Code

Your ob-gyn sees a pregnant patient for four to six antepartum visits. How should you report this?

Answer: Four to six visits means you?ů‘ťľ‘šůll be flipping through your book to the maternity care and delivery section — particularly the antepartum codes. You should report 59425 (Antepartum care only; 4-6 visits), which represents the total services rendered by your ob-gyn. This means that you’ll report only one unit of this code.


Opthalmology: Focus Your Cataract Coding With This Tip

The Coding Institute

With several possible surgical treatments for cataract procedures, which you probably code more often than any other surgery, there’s a lot of room for error — with over $800 at stake for complex cataract procedures in 2013.

Use this tricky scenario as a guide:

Document Necessity for Planned Vitrectomy

Scenario: During the course of a cataract removal, the vitreous collapses and the ophthalmologist finds it necessary to perform a vitrectomy.

Question: Can you code separately for the vitrectomy?

Answer: The answer depends on whether the vitreous collapse was an iatrogenic (inadvertently introduced) complication. Ophthalmologists often have to perform a vitrectomy during cataract surgery due to vitreous collapse in the course of removing a dense, senile cataract. In these cases, Medicare considers the vitrectomy a component of the cataract surgery, and thus not separately payable.

The National Correct Coding Initiative bundles vitrectomy codes 67005 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; partial removal) and 67010 (…subtotal removal with mechanical vitrectomy) into cataract surgery ?Šcodes 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification], complex …) and 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]).

Rationale: When procedures are performed together that are basically the same, or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is included in the more extensive procedure. The column 1 code generally represents the comprehensive service, and the column 2 code is the component that is part of the more extensive column 1 procedure.

Exception: If a prolapsed vitreous exists and is known in advance — and documented in the patient medical record — it is not considered a complication of the cataract surgery. Therefore, the physician who plans to perform a vitrectomy during the same operative session of cataract surgery could code separately for the vitrectomy using modifier 59 (Distinct procedural service): 67005-59 or 67010-59.

Key: Use 379.26 (Vitreous prolapse) for the vitrectomy and the appropriate cataract diagnosis (366.x, Cataract) for the cataract removal.

Be prepared to provide documentation in case you receive denials when using the cataract and vitrectomy codes together, despite using modifier 59. Payers are aware of the potential for abuse of 59 and may want you to go through the review process to prove you’ve met the definition of “distinct procedural service.”?ō

Provide the chart notes to show that you knew about the vitreous collapse in advance and that you made plans to repair it prior to the surgical session of another service. Also, you should provide the operative report with clear documentation showing that there was another condition, besides the cataract surgery, that made the vitrectomy medically necessary.

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