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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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Yesterday we posted the first part of our Denial Management Quiz so that you could see how well you scored on your knowledge of techniques for improving your denial rates. Now let‘«÷s move on to Part 2 with some more sophisticated techniques. Ready? (Missed Part 1? Read it here.)

1. Now that we‘«÷ve established that you should track denials, what exactly should you track?

A.?Š Total claims denied for your practice; Total claims filed to a payer; Number and dollar value (charge) of denied line items;

B.?Š Total claims filed to a payer; Number and dollar value (charge) of denied line items; Calculate percentage denied (B divided by A)

C.?Š B above, plus calculate these percentages for your entire medical practice and also by payer, reason, provider, specialty, and location (if you have more than one office)

D. A, B & C


2. When you‘«÷re notified that a claim has been denied, what is your next action?

A. Refile the claim as is; the insurer clearly didn‘«÷t review it

B. Write it off and move on to other claims; if the claim could have been approved, it would have been the first time

C. Investigate; approximately 75% of denials can be resolved without an appeal

D. Appeal; the insurer may need additional information to approve the claim

E. C and D


3. In order to prevent future denials, you should:

A. Fire the person responsible immediately

B. Return denials to their origin (for example, registration errors to front office)

C. Establish a feedback loop with providers by listing top denials at provider meetings; attach EOB examples

D. Educate billing staff on denials, but don‘«÷t bother the providers with the details

E. B and C


4. Your practice should appeal:

A. Every claim, every time

B. Establish a minimum amount for claims to be appealed across the board

C. Different types of denials at different amounts. Establish a protocol for different types of denials and different amounts



1. C; To correctly track the number of claims that are denied for your practice, you‘«÷ll want to measure the following:

i)?Š Total claims filed to a payer (number and total charge amount)

ii)?Š Number and dollar value (charge) of denied line items

iii)?Š Calculate percentage denied (B divided by A)

iv)?Š And calculate these percentages for your entire medical practice and also by payer, reason, provider, specialty, and location (if you have more than one office)


2. E; When a claim is denied, you want to investigate to see if the denial can be resolved without an appeal, but if not, then APPEAL! 75% of appeals result in denied claims being overturned and paid.


3. E; In order to prevent future denials, you should return denials to their origin and establish a feedback loop with providers.


4. C; Your practice should appeal different types of denials at different amounts. Establish a protocol for different types of?Šdenials and different amounts, and test the results. There are ‘«£soft‘«ō denials that can be easily corrected, and ‘«£hard‘«ō denials that require more effort. A $20 ‘«£hard‘«ō denial may not be worth the $25-30 it costs most practices to appeal.


How Have You Scored in Part 2?

4 Correct: You‘«÷re a Denial 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 need some help with your medical billing. Consider hiring a medical billing service like, which allocates over 50% of its billing costs to the successful collection of the last 20-30% of charges that typically do not get paid on first submission. These are the claims your staff probably doesn‘«÷t have either the time or expertise to collect on‘«Ųbut we do, and we do it every day.

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.

Contact us today to find out how we can help improve your medical billing results and free your staff to focus on patient care.

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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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Believe it or not, 2013 is just about half over. That means it‘«÷s time to assess your fiscal year and see what you want to do to finish the year with the best possible bottom line.

I know it‘«÷s difficult to find time in the midst of a busy practice, but this is something you don‘«÷t want to skip. Here are a few items you need to review:

1. Are you ready for the eRX incentives/penalty? Now is the time to qualify for eRx incentives and avoid the 2% Medicare penalty that will start in 2014. June 30 is the end of the 6-month reporting period for 2013 to avoid the 2014 adjustment‘«Űgiving you only 7 more business days. To prevent the adjustment to your Medicare payments, you have to submit 10 G codes by June 30 and they must be processed into the National Claims History by July 26.

2. Have you made a decision on how your practice will handle PQRS reporting? As we mentioned in a previous blog post, while the PQRS will remain voluntary, starting with the 2013 reporting year, it will include both incentives for 2013 (+0.5%) and penalties for non-participation in 2015 (-1.5%).?Š 2015 penalties may also be avoided by electing to participate in the ‘«£administrative claims-based reporting mechanism‘«ō by October 15, 2013.?ŠRead More

3. Have you reviewed your denial rates and reasons for this year? As expert Elizabeth Woodcock, MBA, FACMPE, CPC, advises, you should develop a systematic process for managing and tracking denials so you can monitor them by type, frequency and payer to reveal new opportunities to make your collections process more efficient. The midpoint of the year is an excellent time to do this, so that you can make sure your denials are reduced and managed effectively for the remainder of the year.

4. How is your ICD-10 plan coming along? If you haven‘«÷t developed a plan for implementing ICD-10, stop waiting. In an interview with Healthcare IT News, Farzad Mostashari, MD, national coordinator for health information technology, said his best advice for providers is to begin prepping for the change now. If you haven‘«÷t already, now is the time to begin assessing the impact on your practice and your training needs. Find more information in our recent blog posts and white paper.

5. Have you evaluated ways to generate additional revenue this year? In our recent blog post entitled ‘«£Healthcare Providers: There are Ways to Make More Money,‘«ō we offered some ideas on how to identify additional revenue in your practice. Make sure you‘«÷re not missing out on some low-hanging fruit this year.

6. Finally, have you evaluated your medical billing to determine if you have the right team for your practice needs now? Sometimes a practice outgrows an inhouse or one-person billing company, and doesn‘«÷t realize it. The mid-year point is a good time to review your revenue cycle to see if you‘«÷re getting paid as quickly as you should, whether your denial rate is as low as it could be, and whether your appeals are being handled effectively.

If you find that your medical billing needs have changed and you are looking for a new solution, or if you would just like to explore how your bottom line could be improved, contact at 800-966-9270. We‘«÷re ready to help you evaluate your options for revenue cycle management.

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

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

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

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

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

This is a recipe for disaster for many practices.

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

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

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

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

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

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

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

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

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

Wolves at the Door: E/M Coding Now

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

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

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

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


Modifier Minute: Modifier 32

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


Follow New CMS Guidelines ?Što Keep Record Amendments Updated

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

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

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

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


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


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

You should follow three steps during the appeals process:

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

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

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

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

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

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


Healthcare News: CMS Adds Codes to Conditionally Bilateral List

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


Local Coverage Determinations Provide the Missing Link to Complement Coding Guidelines

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


Observation Services: Many Shades of Gray

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

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