Do Not Miss Out on EM Fees by Initiating OB Record Too Soon

Take this four part challenge to find out where you stand.

If your ob-gyn simply confirms a patient's pregnancy during an office visit, you will be able to report V72.42 (Pregnancy, confirmed). But when should you begin the ob record? Check your ob record skills with this four part challenge.

Scenario 1: The ob-gyn sees a patient who knows that she's pregnant via a positive home pregnancy test and simply "confirms the confirmation." When should you begin the ob record?

The key: At the next visit.

If the ob-gyn carried out only the urine pregnancy test, you would report 81025 (Urine pregnancy test, by visual color comparison methods) or possibly a low-level E/M service if there was some discussion about her health. Go for V72.42 (Pregnancy examination or test, positive result). You'll make use of this code when your ob-gyn simply tests to see if the patient is pregnant. This code will go on both the E/M code and the urine test, as you will be coding for what you know at the end of the visit. You will not require any other V codes.

Scenario 2: A patient comes in for an annual check-up and the ob-gyn diagnoses pregnancy. When should you begin the ob record?

Answer: At the next visit.

If you began the ob record during the annual exam visit, most carriers will consider the annual exam part of the global ob service. You cannot bill the global service until delivery, but you should inform the insurance company about the pregnancy. Remember to code any complaints, such as malaise, general fatigue, spotting, nausea, vomiting, pelvic pain, etc., that the patient reports of. You can report 99384-99386 for new patient or 99394-99396 for established patients.

Rule of Thumb: You shouldn't initiate the global care until you know that the patient wants her pregnancy to continue.

Scenario 3: A patient sees your ob-gyn after her family physician discovered that she's pregnant and wants to have her ob care with your practice. She has been under your practice since the last 12 months. When would you begin the ob record?

Answer: During this visit.

As some other physician made the diagnosis, your ob-gyn probably wouldn't need to "confirm the confirmation." Hence, he would begin the ob record, which means this service is part of the global ob package.

Tip: Some practices confirm intrauterine viability before they begin the barrage of ob coordination.

What's included: The ob coordination is lengthy, usually lasting about 30 minutes, and involves going over procedure guidelines, including a timetable of when to do lab tests, pelvic exams, amniocenteses, etc. The ob-gyn will usually provide vitamins and iron supplements and discuss when to call him.

Scenario 4: Your practice scheduled an initial ob appointment for a pregnant patient (who confirmed her pregnancy at home), but she can't wait to have some of her queries answered. She wants to come in earlier for counseling. The ob-gyn would perform no initial visit or ob panel blood work during this visit. When should you start the ob record?

Answer: This scenario could go either way.

Normally, carriers consider all counseling related to a pregnancy included in the global ob service. If the patient had significant health reasons to warrant counseling, you would wrap this visit into the global care of the patient. However, you'd report an E/M code such as 99201-99205 for a new patient, based on the time the ob-gyn spent with her, if you want to report this separately. The ob-gyn must document the duration of the counseling visit. The ob-gyn might ask,"Does the patient intend to keep her pregnancy? Are there extenuating circumstances about high-risk situations, such as drug abuse, need for genetic counseling, or current high-risk medications?"

If the patient is established, you'd report an established patient E/M visit (99211-99215). If a nurse who was not a certified nurse midwife or a nurse practitioner saw the patient, you must use 99211 for the encounter. As for a diagnosis code, you might try V65.40 (Counseling NOS) or V65.49 (Other specified counseling), but carriers do not usually allow you to use these codes as the primary diagnosis. Also, if the ob-gyn discusses genetics with the patient, you can use V26.3 (Genetic counseling and testing) instead.

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Crossing the Bridge of Hyper-Investigation

I have to start this post off by being brutally honest. It's a bit of a down week news-wise. Other than the fact that Palmetto GBA has now been designated as the MAC for Jurisdiction 11 (West Virginia, Virginia & the Carolinas), there isn't much of grand importance to report in the world of medical billing. I hope the following paragraphs make sense to all of you. Maybe I'm sitting too close to my terminal today, but what's below looks borderline insane to me. If you leave a comment, be kind and let me know how I did.

Seventy-three years ago today, the Golden Gate Bridge in San Francisco first opened to traffic.

Man-made marvels can be found all around the world, from the Eiffel Tower in Paris, to the Burj Khalifa in Dubai and the Empire State Building in New York City. For most of us, these assorted modern wonders stand as a testament to human achievement. Having said that, we have learned over the years that most structures of this type have a dark history. Grand designs such as these present dangers to the workers involved in construction, some of whom never live to see the grand opening. Once completed, they tend to attract people from the darker and more unrestrained recesses of the human condition. Nearly three-quarters of a century on, the Golden Gate Bridge has the distinction of being the most popular destination for those wishing to commit suicide on the planet.

Having internalized this bit of gallows knowledge, take the paradigm of buildings and structures as magnets for the unhinged and the sociopathic and apply this to anything that is created with the idea of serving the public good. Our system of law has created lawyers of the ambulance-chasing variety as one of its unfortunate side effects. Given the current state of the economy, one could make the argument that our banking system in its current configuration has attracted people that we don't usually think of as the friendly, fiscally conservative bankers of years gone by.

In medical billing and compliance, specifically the Medicare and Medicaid programs, the existence of money supplied for public health payable to providers has had the unwelcome effect of attracting all manner of grifters, crooks and thieves looking to fatten themselves at the public trough.

Eliminating fraud and waste has been a CMS and OIG goal for quite some time. The final report for fiscal year 2009 shows a total of $2.51 billion being returned to the Medicare Trust Fund as a result of investigations. While that can be seen as positive news for the program, it should be viewed as small in comparison to the current stated backlog of nearly 2,800 cases of either health care fraud or civil health care fraud that are currently pending with the Justice Department.

Coming soon to this current climate will be the expansion of the Recovery Audit Contractor program to include state Medicaid programs. RAC's present an interesting problem in that they aren't particularly looking at one individual provider's services or tendencies, but rather coding and reporting norms for certain types of services. I tend to think of RAC's in the same way as I think about chemotherapy in that it holds the potential to eradicate the good with the bad. It is one of the unfortunate side effects to participation in a publicly funded health program that the honest members of the medical profession are very nearly presumed guilty until proven innocent.

Knowing that investigators cast a wide net can add to the anxiety of a practice who is following the rules to the best of their ability. We all have a common interest in eradicating the worst offenders from the medical delivery system, but it has been my experience that the majority of medical providers want to do the right thing. My advice to the above-board practices is to do their level best to surround themselves with people keenly attuned to changes both within the medical billing industry and their medical specialty. Be the physician who crosses over the bridge, rather than the one who leaps from it.

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The Four Steps of Developing a Medical Practice Compliance Program

The health care regulation laws that now exist were created to ensure that the interest of every medical group will be protected. Failing to abide by such laws could pose significant risk due to fines, penalties and even potential criminal charges. Benefits of a well designed compliance plan consist of the following at a minimum:

· Increase speed and minimize improper payments of claims

· Minimize billing mistakes

· Reduce the odds that your physician group will be audited by a governmental agency

· If a governmental agency does conduct an audit, a compliance plan can reduce any negative outcome.

There is no exact defined compliance plan that will meet the needs of every healthcare organization. A compliance program must be designed to conform to a specific organization so that it can be supported by available resources.

Four- Step Process

The development of a physician group corporate compliance program consists of four steps:

The first step is merely recognizing the importance of creating a practical approach to maintaining an effective compliance program. Second is ensuring your organization's ruling authority is committed to implementing and maintaining a formal compliance plan. The compliance program would be a significant part of any organizations policy and procedures and it would be management's commitment of supporting the program with the appropriate necessary resources. It is essential to form a committee that would be solely devoted to the task of implementing and managing the compliance plan. Assigning members within all departments of the organizations as committee members would ensure companywide cooperation on the corporate compliance program. The last step is to prepare responsibilities of the compliance committee and delegate them to appropriate staff. The practice leaders of an organization must initiate this and utilize allotted resources in designing the compliance effort.

There is one stipulation that remains the same across the board regardless of the size of the health care entity and that is the "code of conduct". This consists of the policy and procedures that dictates the ethical business processes within any organization. The program must be a direct expression of the company's intention of conducting business in an ethical manner.

Development of Policies

Developing and documenting policies is the next step in designing a compliance program. It is critical to look at the group's risk factors and come up with policies and procedures that would appropriately address the risks of the physician group. This would reduce and help mitigate any risk associated with any unlawful conduct within the organization.

The following are the essential elements of a formal compliance plan:

Auditing and monitoring; of coding and billing Training and education; Responding appropriately to detected offenses and initiating corrective action plans. Assignment of a Formal Compliance Officer. Developing open lines of communication Human resources screening such as performing background checks.

Proper training and education for all staff is the foundation of a positive compliance culture, therefore the policies must clearly indicate the methods, subject matter and scheduling of when trainings will occur.

Auditing and Monitoring

It is critical that the compliance plan consist of both on-going auditing and monitoring of coding and billing. This will help organizations identify, prevent and correct any incorrect billing or coding and implement internal controls to ensure that such errors are mitigated and reduced. Depending on the resources at hand, some organizations choose to do this internally or hire third party consultants to assist with the auditing and monitoring of billing and coding.

Risk Prevention Requires Detection

An effective compliance program must be capable of detecting risk factors. Review of the following may lead to identification of risk areas:

- Internal processes and documents (billing and performance surveys)

- Complaints (staff and patients)

- Coding and billing errors

Risks that are communicated by the Office of Inspector General's (OIG's) on their fraud alerts and annual work plan absolutely require reviews. This is becoming more important as scrutiny from governmental agencies continues to significantly increase.

Policies on reporting violations must be clearly stated in the compliance plan. Discipline must coincide with the particular violation that was committed and the organization must show through the formal compliance plan that it does follow through with enforcement of disciplinary action.

All staff must be aware of these policies and this should be reflected in the documentation that is maintained by the Compliance Officer as a result of the compliance plan.

Program Supervision

The organizations leadership has to set the tone for an effective compliance program; hence both administrative and medical directors must have a thorough understanding and participate in the supervision of the compliance program components.

Through simple systems of reporting relevant concerns, open lines of communications will be achieved. Such systems include hotlines and anonymous reporting procedures. In addition, policies to protect informants against retaliation must also be directed.

The compliance officer must be a high-ranking person. This individual will directly report to the governing authority about the timely updates of the program's effectiveness. The governing within an organization will vary depending on the size of the organization.

Program Execution

An effective compliance program cannot be executed unless it meets an organization's requirements in terms of the size of the practice, known risk factors and the existence of the necessary resources to manage such risks. The final and hardest step of developing and implementing a compliance plan is the actual execution of putting the plan in place.

The compliance officer typically oversees the execution of the plan. The officer must ensure that it follows the code of ethics, program polices and procedures that were agreed upon by management of the organization.

Moreover, governing authority is also ultimately responsible in supervising the implementation. To continually support the compliance program to make sure it remains in place, it is important to have the buy-in of all leaders.

Monitoring Program effectiveness

Accountability and responsibility are important factors in achieving successful performance of a compliance program. To create an accountable and responsible group culture, it is necessary to conduct a well -defined and properly structured program that is constantly monitored.

The following assures proper monitoring:

- Dividing and assigning roles and responsibilities to staff;

- Setting and planning measurable goals and objectives;

- Periodic evaluation of results.

Corporate Compliance Benefits Practices and Patients

A formal compliance program is without a doubt a necessity for any medical practice regardless of size. Practices that do not utilize a compliance programs are putting themselves at risk of facing avoidable risks.

Effective compliance programs provide group awareness of the legal and ethical procedures applicable to their practices. Every practice must identify their areas of risk, have their own specific policies and procedures and develop a compliance culture that will ensure the compliance plan will be taken seriously and implemented effectively.

A well defined compliance program could be your organization's life raft in today's health environment due to the Medicare RACs, ZPICs and Medicaid MIC audits that are currently in process.

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Medical Insurance Billing and Coding Explained

Medicine is an art, a science and a business. Doctors learn the artistic and scientific aspects of their profession in medical school. But the business aspect of their practice - getting paid - requires a completely different set of skills - skills most doctors have neither the time nor the interest to acquire. Even if they did, few doctors would have to time to handle the complex administrative aspects of a modern medical office. Enter Medical Insurance Billing and Coding.

Medical Insurance Billing and Coding specialists work in doctors' offices, clinics and other medical facilities. Their primary job is to submit claims to insurance companies to ensure doctors and support staff are properly reimbursed for the services they render. Medical Billing and Coding professionals tend to deal mostly with private insurance companies and the agencies of state and federal governments who pay medical claims, e.g. Medicare. The Medical Billing department is often also responsible for collecting co-payments or deductible amounts from patients directly.

Processing a Claim

To process claims, the Medical Insurance Billing and Coding specialist first deals with the patient's medical record, which contains the physician's notes on what services were performed. The specialist must then translate this information into a five-digit numerical code drawn from the American Medical Association's Current Procedural Terminology (CPT) guide. The actual diagnosis is also coded based on a government guide called the International Statistical Classification of Disease and Related Health Problems (ICD). It is very important that the CPT and ICD codes match up, or a claim will likely be rejected.

In fact, according to the Healthcare Billing and Management Association, up to one half of all medical claims are initially rejected by insurance carriers. Medical Insurance Billing and Coding specialists must therefore need to learn how to skillfully adjust and resubmit claims in a way insurance companies are more likely to accept.

Paper vs. E-Claims

In the past, virtually all medical billing and coding was done on paper, which was slow, inefficient and expensive. Today, more and more claims are being filed electronically, although paper-based billing is still very common. In the coming years, computer skills will be increasingly important to Medical Insurance Billing and Coding professionals.

Training & Certification

To become a Medical Insurance Billing and Coding professional, one should take a specialized training program in this field from a recognized and accredited college or university. Such programs can normally be completed in about a year. After that, industry certification is also recommended. The Certified Medical Reimbursement Specialist (CMRS) accreditation by the American Medical Billing Association is one of the most recognized of specialized certification in this field.

Medical Insurance Billing and Coding is a highly specialized field that is critical to the operation of modern medical offices. The need for well-trained Medical Insurance Billing and Coding specialists is likely to grow significantly as America's population - and the need for quality medical care - grows over the next few decades.

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The Dangers of Digital Immortality

One of the more interesting stories that came out over the past week involves Affinity Health Plan, a managed care plan in New York. On April 21st, Affinity began to notify over 409,000 people that their personal data may have been released. The list of people contacted included current and former customers, employees, providers and applicants for jobs and coverage through Affinity. Affinity had leased a digital copier from a company in New Jersey. The copier was equipped with a hard drive that saved every piece of data that went through the copier. When the leased copier was returned to its owner, the hard drive was not erased, leading to a security breach.

In thinking about the world we live in in 2010, there are very few places we can go that offer safe haven from the digital age. What many people fail to realize is that every bit of data ever transmitted in a digital format either already has been or at the very least offers the opportunity to be saved and stored forever. I must admit that the very idea of this can be frightening. Every text message from my phone, every night spent playing computer games and every profanity-laced tirade in e-mail form that has ever been emitted from my fingertips can be accessed by someone somewhere. I guess we can scratch off a career in politics from my to-do list.

Now let's bring this ominous fact of life into the realm of medical billing and compliance. It's safe to say that in every office involved with protected health information, there exists the possibility of the information becoming vulnerable.

The Affinity case is a good starting-off point. The thing that really jumped out at me in this story was the idea that an unsuccessful job applicant of Affinity being contacted perhaps years later and being told "Remember all of that personal information you gave us before we flatly rejected you? It's freely available in a warehouse in New Jersey". When it is determined that an employee isn't a good fit after the interview process, companies are used to sending out the standard "we'll keep your resume on file for six months" letter and moving forward, with the company holding all of the cards. Now imagine the embarrassment of having to send out a second letter years later telling the person you never planned on seeing again that you exposed them to identity theft via the office copier.

HIPAA regulations make very clear the responsibilities of digital gatekeepers of patient information. It is best to remember that the computer screen in front of you and the servers to which it is connected are only a small part of machinery utilized on a daily basis that stores PHI for a legitimate business purpose. Take a quick look around you. Did anyone leave papers on the copier? Fax Machine? In a common area while getting a beverage? Take a moment to think about what documents you have placed in a medium offering some type of digital storage. After that, look around your work area. Ask yourself whether in the eventuality of someone breaking into the office whether your desk is vulnerable to letting PHI fall into the wrong hands.

As a pertinent afterthought, I'll share this. Spaces such as this included, more people are sharing their thoughts with an ever expanding worldwide audience on a variety of subjects. When someone feels passionate about a topic, it is now easier than ever before to stand on a virtual rooftop and shout extemporaneously to the world at large. It is the world unfiltered, and it's unlike any form of communication that came before it. It brings into focus not only how many bright and talented people have been falling through the cracks for generations, but it is also demonstrating how many unhinged people once took a typing class.

While life has been simplified to a degree in the digital age when it comes to quick access to information, in the immortal words of Peter Parker's Uncle Ben, great power also brings with it great responsibility. Take a moment to internalize the idea that hitting the delete button does not translate to the end of life in the digital age. Conversely, itis also a good idea to review what you have typed prior to hitting the Send button. Consider everything you do with anything that can be plugged in and has the ability to store data to be permanent and retrievable once it has left you. The biggest thing this story has taught me is that it should be a long time before anyone sits on a copier with their backside exposed again.

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Medical Insurance Coding and Billing Training

Medical insurance coding and billing is a field which is a familiar territory to accountants, book keeping and payroll attendants. Summation of all health assurance premiums as well according to the codes is the general function of the billers.

Those who are interested in getting a profession in this medical insurance coding and billing must have had professional training from either a college or vocational centre. If you are interested in a career in this field, it is absolutely imperatively important involving the computer systems which are conventionally-used in the procedure.

There are many mathematical-approach subjects which is compulsory for the students wrap-around their hands with. Not only that, the study includes the comprehension of the scientific and health terminology. They must be able to assess the patient health check up chart to list down the exact amount of costs involved in the treatment.

Not only that, there are two other areas which the medical insurance coding and billing is related with which is computer skills and accountancy. The biller must understand that the patient usually visit doctors with a health coverage therefore the patient is covered by insurance. However not all health treatment is covered by the policy provided by the insurance company. The fine prints in the terms and conditions section must be read in detail to properly ascertain the limitations of the health policy.

Hence, the payment is subsidized by the premium and the charges differ depending on their personal premium rates. This is considered as a co-payment because the cost is accepted by the coverage agency and not entirely by the patients themselves.

Just like coverage premiums, the biller must be capable of analyzing the denial of reimbursements for certain perspectives involving the treatments and medications. The biller ascertains on whether the patient is allowed to claim coverage for the treatment at the health institution.

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