All Posts in Category: Medical Billing

Medical Claim Denials

How to Deal With Medical Claim Denials and Rejections

We know you hate medical claim denials and rejections. It can be difficult for practitioners to deal with such denials. The job can be complicated, frustrating, and often very time-consuming.

Knowing how to deal with medical claim denials can save you time and improve your cash flow. Here are some basic pointers to remember:

Review all Information That You Have

Rejections are more common than you’d like to think. About 17 percent of all in-network claims were rejected in 2019 and the number was 14 percent in 2018.

To reduce your risk of medical claim denials, review all the information you have including remittance advice and explanation of benefits.

The notification sent by the insurance provider indicates whether the claim was denied, partially paid, delayed, or paid in full. 

Follow the instructions if the claim stands “contested or unclean”. Correct the issues, if any, and resubmit the claim with any missing information. 

Look for reasons why the payment was declined and make sure to follow the steps provided by the insurance company.

Get in touch with the carrier if the notification isn’t clear. Having a conversation with the carrier can help solve small issues such as an administrative error or poor submission procedures.

Waste No Time

Waste no time and submit and resubmit claims as soon as you can. Most companies and statutes put a limit on when claims can be submitted. Being too late can cause you to lose money. 

Apply Again and Again

If your resubmitted claim gets denied and the denial seems improper to you then go ahead and appeal the decision. Make sure to follow all guidelines and submit the required documents to ensure your appeal gets accepted.

Remember that the process varies from provider to provider, hence check with the carrier. Moreover, state laws also come into play. In most cases, you will have to submit an explanation of why you wish to appeal the decision and provide documents to support your claim. 

You may have to submit documents to demonstrate necessity if your claim got rejected due to a lack of “medical necessity”. Be careful about the information you provide.

All practitioners are required to meet the set obligations under the HIPAA and to only provide what’s ‘necessary’. Working with a HIPAA-compliant company like Medical Healthcare Solutions can help reduce the risk.

Filing another appeal or resubmitting your claim may do the trick. Do not give up just because you are asked to submit the claim again and again. Being persistent shows you’re serious about getting paid.

Understand How to Appeal

Since the appeals process changes from company to company, it is important that you ask questions and ensure you’re fully familiar with it. 

Being aware of the policies will put you in a favorable position to respond to medical claim denials.

Keep a Record

Keep a record of everything related to a claim including the name of the person you’ve been corresponding with. A few more things to take note of include: 

  • Why the company chose to deny, partially pay, or delay the claim
  • How your office followed up
  • The outcome of the follow up

You might need this information in the future when you choose to appeal or file a complaint regarding medical claim denials. Moreover, these records can help face similar situations in the future.

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Orthopedic Billing Codes

Orthopedic Billing Codes

Medical coding and billing is one of the most important aspects of any orthopedic practice, because it keeps revenue coming in, and without that the practice would quickly go under. Given its importance, it’s easy to see why there is so much emphasis placed on accurate coding and billing. Claim denials and delays will interrupt cash flow, and that will always create stress for a practice, because monthly bills and expenses have to be paid regardless of whether regular revenues are coming in or not. In order to ensure that such delays and denials are kept to an absolute minimum, here are some guidelines to follow in the preparation of medical billing claims for an orthopedic practice.

Keep abreast of all updates 

Every year there are changes to the Current Procedural Terminology (CPT) code set, and these are ignored at your peril. If your coding and billing is performed in-house, you need to be aware of all changes issued, so you can be sure to use any appropriate new codes. In any given year, there are generally several hundred updates applied to the code set, and your in-house personnel need to be educated about these, whatever they may be.

Avoid the most common reasons for denial 

In order to avoid the most common reasons for denial of a claim, you have to be aware of what those common reasons are. Duplicate claims and services are probably the single biggest reason that claims are denied by a carrier, so each claim should be scrutinized so as to avoid this. It’s important to be familiar with the fee schedule and stay within its guidelines. Make sure that patient information is correct when it’s gathered, and be diligent about verifying insurance information, because these go hand-in-hand with denials when anything is amiss.

Understand how ICD-10 changes have affected orthopedic billing codes 

Orthopedic coding and billing may have been more significantly impacted than any other area of medical practice by the recent ICD-10 updates. For one thing, laterality is fully addressed in ICD-10, whereas it was nowhere to be found in ICD-9. That means physicians must document right, left, and bilateral for all fractures and joint issues. In addition, it will now be necessary to specify the actual site on the body where service is delivered, rather than simply documenting spondylosis or spinal stenosis. Payers will require that a physician submitting a claim document exactly where injuries have occurred and what kind of treatment was delivered. It will also be necessary to identify the type of visit that a patient makes to your office, i.e. an initial consultation, a follow-up procedure, or a continuation visit.

Consider outsourcing 

Depending on the size of your orthopedic practice, it may be highly advantageous for you to consider outsourcing your coding and billing processes. One of the first advantages you should gain is fewer delays and denials of your submitted claims. Billing companies recognize that their reputation depends on accuracy and reliability, so they go to great lengths to make sure their team of coders are well-versed in all the current medical codes, and that they stay abreast of current developments and changes. Any company which doesn’t adhere to high standards of accuracy and reliability simply won’t be in business for very long.

When you outsource your coding and billing operation, you’ll relieve yourself of the necessity of hiring trained staff members to perform that function in-house, so you are likely to save money on monthly expenses due to the lower payroll costs. You will probably also notice an increase in profitability and a more consistent cash flow, because you have fewer denials and delays, and this can be very important in terms of keeping your orthopedic practice running smoothly. Outsourcing may not be right for every single orthopedic practice, but it has proven to be very helpful and very effective for a great many physicians already, and it has removed a great deal of stress from the coding and billing function. It might well be the best way for you to handle all the intricacies and complexities of orthopedic billing.

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Gastroenterology Billing Codes

Gastroenterology Billing Codes

Gastroenterologists provide both surgical and medical services, and that calls for a fairly broad range of billing codes to be used when it comes time make a claim for reimbursement. In gastroenterology, all reimbursement must be based on the principle of Relative Valve Units (RVU’s), which are assigned to every possible service which might be provided to a patient. These services are founded on three individual factors, including practice expense, malpractice cost, and physician work value.

The national physician fee schedule is determined by adding all three of these factors together and then multiplying by a specific conversion factor which is decided by the Centers for Medicare and Medicaid Services (CMS). Whenever claims are submitted, there must be a clear medical necessity demonstrated, otherwise there’s a good chance that a claim will be denied, or at least deferred pending further investigation. In terms of incoming revenue, any deferred or delayed claim is almost the same as a denied claim, since it results in some indefinite period of non-reimbursement.

There are four essential services which gastroenterologists perform routinely, and must choose the correct billing codes for when they wish to be reimbursed for services provided. These four areas are: evaluation and management services (E&M), endoscopy and procedural billing, diagnostic studies, and diagnosis codes. Making a mistake with the billing and coding in any of these areas will very likely result in some kind of delay in being reimbursed, or in an outright claim denial.

Evaluation and management services 

E&M visits are often extremely important, given that they provide the foundation for any medical necessity regarding additional procedures or diagnostic services. These can be crucial for successful treatment of the patient, and that makes them just as important as the actual procedures, which are often deemed more important to a practice, since they generate the most amount of income. For E&M services, there are three criteria which must be met in order to validate an initial patient visit: patient history, the examination, and the treatment plan. 

There are five levels of service for such initial office visits, and there are also three levels for inpatient visits. These levels must all be accurately coded and billed for, and it happens frequently enough that an un-schooled clerk will assign a guessed-at level rather than the most appropriate one. This may go unnoticed for a time, but if an audit ever becomes a reality, these guesses will be discovered and it will result in claim denials or some kind of reconciliation on past claims.

Endoscopy and procedural billing 

Before you can make any kind of claim in this area, it will be necessary to justify medical necessity. Documentation must include the location of any abnormalities or lesions, method of treatment, and the reason for that method of treatment. Any special equipment used during the procedure must be fully documented in the endoscopy report, and this requires close communication between the physician and the billing staff. Ultimately, the physician is responsible for the submission of accurate claims, so it behooves the medical professional to have the billing staff well trained in how to supply appropriate and required documentation, as well as the correct medical billing codes for every possible procedure.

Diagnostic studies 

As always, medical necessity must be demonstrated in order to submit a claim for any kind of diagnostic testing. Abnormal lab tests, unusual symptoms, and signs of illness do warrant the need for continued examination, and these are generally the most important factors signaling the need for further diagnostic testing. It will be necessary to clearly indicate the results of any diagnostic testing, and for any procedures which were necessary. A plan or recommendation for treatment must also be included and indicated by the appropriate billing codes when submitting a claim.

Diagnosis codes 

Codes for diagnosis come directly from ICD-10-CM, and the assignment of these codes is the next most important step after a patient visit, a diagnostic study, or a procedure. These billing codes provide justification for medical necessity of services provided, so it is crucial that the correct codes are used. Since there are nearly 72,000 codes which might be used in this area, it is essential for office personnel to be properly trained in the correct usage of the codes. Getting reimbursed for all services provided requires a good amount of education and training for all staff members, in addition to close communication between physician and office people. 

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2021 Evaluation and Management (E/M) Code Changes

2021 Evaluation and Management (E/M) Code Changes

Each year, a number of Evaluation and Management Code Changes are announced, and these E&M code changes must be adhered to throughout the calendar year and beyond, unless they are superseded by later changes. For calendar year 2021, the E&M code changes described here will be in effect, and must be used by medical personnel when making any kind of medical claims. Excerpts from the code changes document issued by the American Medical Association pertaining to this year’s changes are included below. This kind of uniformity is of course necessary, so as to avoid total chaos in the realm of medical billing

Coding changes regarding time 

It is necessary to include time as a factor in medical claims, so as to determine the most appropriate type of medical service. For some outpatient services, it will be possible to use time by itself as the appropriate code level, for instance using codes 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215. Since most categories of service use time in a different way, it becomes important to review and understand the instructions for each of these categories. It is often difficult to provide precise estimates of the time which is spent on a face-to-face basis with any patient, because it happens fairly often that patient encounters occur on multiple occasions and for varying amounts of time. For those medical codes mentioned above, time should be considered the total face-to-face time on the actual date of any patient encounter.

Additionally, there was a significant change to the Evaluation and Management Code effective January 1, 2021. CPT code 99201 will be deleted. For new patient codes, times begin at 15–29 minutes for CPT code 99202 and then advance in 15-minute increments with 99205 assigned 60–74 minutes. For existing patients, the time element was removed from CPT code 99211.

Separately reported services 

It is allowable to report any specifically identifiable procedure separately, as long as it was performed on the date of the E/M services. For example, any physician-administered diagnostic tests for which CPT codes exist can be reported separately, and it is also allowable to claim the time needed to interpret the results of those diagnostic tests. Any tests or interpretations which are not reported separately, will be considered standard decision-making on the part of the physician. 

Examinations and patient histories 

Patient examinations can be reported, using the appropriate codes, as can interviews which constitute a review of the patient’s medical history. It is at the discretion of the physician what the nature and extent of such interviews should include, and information can be gathered both verbally, and through questionnaires or other written vehicles. Patient portals may also be used in the gathering of patient information, provided that it relates to the patient’s medical background, and will be considered during future treatments.

Number of issues addressed, and levels of complexity 

It is entirely possible that several issues will be addressed during a single medical encounter with a patient, and these issues may be characterized by varying degrees of complexity. There are specific guidelines which relate to the complexity of any issues which might be treated during a patient encounter, and that of course will impact the medical billing code used. As an example, a chronic illness would be handled in a different manner than an acute illness would, and that means different billing codes must be used when making any claims. 

Office and outpatient services 

A patient is considered an outpatient until he/she is admitted to a healthcare facility as an inpatient. Care must be taken to use the appropriate billing codes to reflect this potentially changing status. There is a complete set of codes which can be used for delivering outpatient services, just as there are corresponding codes which must be used for observation care, for inpatient services, discharge services, and for any kind of services which are provided in the emergency room.

New Patients

The billing codes used to cover new patients are 99202-99205, and they are reflective of the length of time necessary to conduct a physical examination of the patient, as well as to conduct some kind of interview regarding the patient’s medical history and background. The different codes are used so as to denote the length of time which was necessary to accomplish the exam and patient history interview. For example, code 99202 would be used for a session which lasted between 15 and 29 minutes, whereas 99205 would be used for a session between 60 and 74 minutes duration.

Established Patients

In the same way that several different billing codes are used to represent the time needed for a session with a new patient, a set of different codes must be used for sessions with established patients, those being 99211-99215. Each of these will also represent varying lengths of time necessary to deliver services to the patient at the session, with 99212 being used for 10-19 minutes of time and 99215 being used when the time required falls between 40 and 54 minutes.

Prolonged Services 

It will be necessary to use billing codes 99354 thru 99357 when the services delivered to a patient are considered to be beyond usual service, either in an outpatient setting, or an inpatient setting. These are face-to-face services which include other services not considered face-to-face, such as those which might be administered in a hospital setting or a nursing facility. These are services which can be reported in addition to primary services offered, and it will be necessary to choose the correct billing codes when claiming such services as supplies provided to the patient, or other procedures which are performed on the patient during this period.

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Nursing Home Billing Guide For 2021

Nursing Home Billing Guide For 2021

Each federal fiscal year, the payment rates for Skilled Nursing Facilities (SNF) are increased by the government, in accordance with the SNF market basket index, which takes into account prevailing conditions for medical treatments. The overall system under which payments are made is known as the Prospective Payment System (PPS), and this system is continually adjusted for case mix and for the geographic differences in wages which may be in effect for certain areas of the country. It also considers the current costs of providing routing SNF medical services such as ancillary and capital-related costs. 

SNF consolidated billing

The consolidated billing requirement puts the responsibility on the SNF for the complete package of care which residents receive during any covered stay at the facility, as well as the physical, occupational, and speech therapy services which are provided during a non-covered stay. There are a few services which are specifically excluded from this billing schedule, and are payable separately.

Each new fiscal year, the consolidated billing requirements for skilled nursing facilities are carefully reviewed, and this includes billing for occupational therapy, physical therapy, and speech language pathology services. Also reviewed are any specific exclusions which are billable separately including some services which are considered to be “high cost, low probability”, as identified by the Healthcare Common Procedure Coding System (HCPCS).

These categories include customized prosthetic devices, radioisotope services, chemotherapy administration services, and chemotherapy items. The codes which are excluded from the consolidated billing all represent situations which could have major financial impact, because their costs greatly exceed the skilled nursing facility PPS payments. 

SNF excluded services

There are several types of services which are specifically excluded from the skilled nursing facility consolidated billing agreement. These services would be separately billable to part B Medicare when furnished by an outside supplier to any resident of a skilled nursing facility. It will still be necessary for these excluded services to contain the SNF’s Medicare provider number, when they are furnished to SNF residents. Here is a listing of most of the excluded services which would have to be handled by separate billing:

  • certified nurse midwives
  • qualified psychologists
  • certified registered nurse anesthetists
  • physician services furnished to SNF residents which are not subject to consolidated billing, and must therefore still be billed separately to the part B carrier
  • physician assistants working under the supervision of a qualified physician
  • hospice care related to some terminal condition of a resident
  • ambulance services which transport a patient to the skilled nursing facility, or from the facility after discharge
  • all those services described in section 861(s) of the Social Security Act
  • nurse practitioners or clinical nurse specialists who are collaborating with a qualified physician.

Physician “incident to” services

The consolidated billing agreement does exclude those types of services described above, but it does not exclude those services known as “incident to” services which are furnished by a third party as an incident to the professional service of the practitioner. These kinds of services furnished by others to residents of a skilled nursing facility are subject to the consolidated billing agreement, and must therefore be billed to Medicare by the SNF itself. Here is a listing of some of those “incident to” services:

  • some venous and lymphatic procedures
  • angiography
  • magnetic resonance imaging
  • emergency services
  • radiation therapy services
  • cardiac catheterization
  • computerized axial tomography
  • ambulatory surgery which requires usage of an operating room.

2021 Skilled Nursing Facility PPS unadjusted federal rates per diem 

The most important of the services offered by an SNF, along with the federally mandated payment schedules are listed below:

  • Physical Therapy for urban centers – $62.04, and for rural centers – $70.72
  • Occupational Therapy for urban centers – $57.75, and for rural centers – $64.95
  • Speech-Language Pathology for urban centers – $23.16, and for rural centers – $29.18
  • Nursing for urban centers – $108.16, and for rural centers – $103.34
  • Non-Therapy Ancillaries for urban centers – $81.60, and for rural centers – $77.96
  • Non-case mix adjusted for urban centers – $96.85, and for rural centers – 98.64.

The Center for Medicare and Medicaid Services (CMS) reviews all relevant factors, including the historical information, before establishing the initial federal base rates for billing. These rates are periodically updated for inflation and other factors which have a bearing on the billing process, so that the fairest payment rates can always be in effect, and allow SNF’s to remain economically sound.

In this case, the CMS has finalized a market basket increase for 2021 of 2.2%, based on historical data from 2020 as well as a forecast provided by IHS Global Insight. This forecast takes into account the expected increases for routine, ancillary, and capital-related expenses, in order to arrive at the best possible projection of costs and expenses which are likely to be in effect for the coming year.

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