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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ED Specific Exception Allows You to Bypass Some HPI Rules

Use these frequently asked questions (FAQs) to reach level 5.

A patient reports to the emergency department (ED) in such severe respiratory distress that she can't communicate during the history of present illness (HPI) portion of the Evaluation/Management service. The patient also presents to the ED alone via ambulance, which means there was no one else to speak for her.

How can a medical coder decide on the history level for this emergency department E/M service? Knowing an important exception to the HPI rules in emergency department settings will help you report these incidents correctly.

When a doctor documents that an HPI is unobtainable due to patient condition, you can invoke the caveat, says Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.

Advantage: The ED caveat can put off E/M downcoding based on the E/M HPI component. Follow this frequently asked question to get the lowdown on all the ED caveat rules you will require to code correctly every time.

What're the caveat basics?

"In real life, emergency department physicians are not always able to get a thorough and comprehensive history from a patient. The doctor should of course always document any history they can obtain from the patient, family or friends, EMS, nursing home, and the like," says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. If the history is limited, but, the caveat "allows the physician to get full-credit' for even an all-inclusive history - if you document why the history could not be obtained," stresses Lemanski.

"The caveat is a CPT omission exclusive to emergency medicine 99285 services. It provides an exception to the Evaluation/Management content requirements when the physician is not able to acuire the required [history] information," says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. This could be owing to the urgency of the patient's condition or the mental status of the physician.

For example: The emergency department physician carries out an all-encompassing exam and high-complexity medical decision making for a patient, but she can't get adequate information from the patient for a comprehensive history. If you invoke the emergency department caveat in this instance, you might be able to go for 99285 (Emergency department visit for the E/M of a patient, which calls for these three vital components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a complete history; a comprehensive exam; and medical decision making of high complexity...).

How about a clinical instance? Think about this probable ED caveat scenario, courtesy of Edelberg:

A patient, aged 64, presents to the emergency department with altered mental status and left-sided facial droop. The physician examines the patient, however the patient can't provide any useful history information. The doctor orders a CT scan of the head, the patient is admitted to rule out a stroke. Notes point to the fact that the physician performed a comprehensive exam and high MDM.

In this situation, you might be able to call upon the emergency department caveat if the doctor documented her inability to obtain a full history, and report 99285 for the encounter.

How can I identify potential caveat claims?

In an ideal world, the doctor would stamp "ED caveat" on each relevant claim, however coders will have to be good spotters in order to make the caveat work for them.

How? Coders might be able to spot caveat situations based on terms the doctors uses, Bettencourt says. Some terms that could point to a caveat if they appear in the notes cover:

- history unobtainable - history obtained by family member owing to altered mental status.

Other possible keys: Lemanski offers these terms that might point to a patient that is not capable to fully communicate:

unresponsive obtunded comatose aphasic paralyzed and intubated incoherent owing to intoxication or drugs.

How should I document the caveat situation? In order to submit a successful caveat claim, however, you need to take in two specific pieces of information. Figure out what they're by registering for the ED Coding Alert.

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CoP Compliance Challenges You Need to Overcome

Conditions of Participation (CoP) are a set of regulatory standards which hospitals need to agree to meet as a condition for getting federal funding through the Medicare program. These COPs are established by CMS.

You may often encounter CoP compliance challenges and claim denials in your effort to get the rightful reimbursement. It has left even the most hardworking compliance staff with the nagging feeling that they are missing something. So you and your staff need to stay abreast of all compliance issues, documentation loopholes, and claim denials.

A good way to stay tuned to all these is an audio conference. When you sign up for one, it'll coach you on specific CoP requirements, explanation of evidence required to show compliance, strategies to master a compliance survey, tools to gain compliance, among other things.

On signing up for it, you will get up to the minute information on CoP compliance challenges in addition to any new guidance from CMS and NHPCO, what you need to know about criminal background checks for your regular staff versus contracted staff, new issues for hospices, and lots more.

But the best part of attending such a conference is that you can attend them from the comforts of your office or meeting room. Thus you save on your travelling costs here. And even if you miss out on a scheduled conference, you can always come back and listen to CD and PDF transcripts.

And to top it all, on attending such a conference, you also stand to acquire CEUs. So go for one and bid goodbye to all your CoP compliance woes.

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Using Modifiers Correctly

We get a lot of questions regarding the correct use of modifiers. Well, actually the questions are usually more on the lines of "One of my services was denied, what modifier can I use to get the service paid?"

The first thing I want to make clear is that it is never okay to add a modifier strictly to get a service paid. Modifiers, like cpt codes, help to describe the services that were performed. So the provider, or a coder who is reviewing the chart would have to determine if a modifier would be appropriate. A biller, just looking at the services cannot add a modifier just to ensure payment.

Having said that, it is important that billers understand modifiers and their use. Many providers do not understand modifiers, or even know that they exist. As a biller, you can educate the provider as to what the modifiers mean and what situations they should be used in. It is ultimately the provider who must determine if the services that were performed warrant adding the modifier.

A good example of this is if you receive a superbill indicating that the patient was seen for hypertension, diabetes, hypercholesterolemia and bursitis of the shoulder. The doctor indicates that he did an established office visit level 4, or a 99214 and an injection of cortisone, 20610. The provider doesn't indicate that a modifier should be used. If both of these charges are billed out for the same date of service, most insurance carriers will bundle the office visit in with the injection.

As a biller you should question if the provider should be reimbursed for both since there were other medical conditions that the provider addressed. You can't assume this based on the information that you have and since you were not in the room. That's why you must check with the provider, not just add the modifier. Ask the provider what the main reason for the office visit was, if the other medical conditions were addressed, how much of the office visit was spent on the bursitis vs the other conditions, and advise him/her that the codes will most likely be bundled together.

Then you can advise him/her that there is a modifier, 25, that indicates that the office visit was a significantly separately identifiable service from the other procedure that was performed. The provider would need to advise the biller if the 25 modifier would be appropriate to use for the situation.

There are many other modifier that can be very useful as well. It is important though that billers do not get caught up in the task of getting claims paid and just use modifiers to accomplish that task. They must be used appropriately, when indicated by the provider of service. You may want to have some of the most commonly used modifiers added to the superbill so that the provider can easily indicate when the modifier is to be used.

Here is a list of some of the more common modifiers:

RT - right LT - left 25 - significantly separately identifiable E&M service 26 - professional component TC - technical component 50 - bilateral 59 - Distinct procedural service 79 - Unrelated procedure or service by the same physician during the postoperative period

Copyright 2010 - Michele Redmond

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Medical Billing - Basic Concept of a Medical Claim Billing Process

Is your business requiring to extremely benefits of cost saving and time consuming solution? Are you searching to increase profits and productivity, reduce collection times and successfully process claims? If yes, then you are at right place. Today, most of medicare billing companies provides a wide range of services.

Electronic medical billing is the process of billed and the payments which submitted to the insurance medical billing companies and the claims to insurance companies is followed up. Medical billing is one of the fastest growing and most dynamic sectors of the health care industry.

The process of medical billing is follow below steps:

• Claims Transmission: The hospital forwards the medical claim to billing companies. • Retrieval and Checking of Medical Claims: Companies team checks all documents. • Medical Coding: Fixed the diagnosis code for patient. • Charge Creation: Company create claim based on billing rules. • Medical Claims Audit: Check for verify the complete procedure and information • Medical Claims Transmission: Creating claims before send electronically to the claims transmission department • Claims Submission to Insurance Agencies: Ready to dispatch to the concern insurance agencies or government department • Follow up and Settlement: Billing companies follow up the consistently with the insurers and payment agencies until the final settlement is disbursed.

Thus, medical claim billing is follow up simple process of insurance verification, patient demographic entry, CPT & ICD-10 coding, Charge entry, Claim Submission, Payment posting, A/R follow-up, denial management and last important is reporting.

If you are facing problem of increasing billing operating cost and spending more time on your practice administration than patient care, then outsource your requirements to the reputed medicare billing company.

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Benefits of Having a Medical Billing Expert

Many doctors have problems with their medical billing, but only some are aware of the many benefits they can enjoy when they choose to hire a medical billing consultant. Expert billing consultants can solve the insurance claim nightmares, leaving you and your staff free to focus on what you do best- practicing medicine.

Surely you know the importance of efficiency in your medical practice. Your profession is one that relies on time. A few minutes late and a patient could have experienced fatal complications. A few days late and you could experience possible bankruptcy. It is important that you learn not just to manage your time so you could attend to the needs of your patients with ease but so you could also handle your finances without difficulty. Medical billing is a matter you need to consider seriously.

One of the things a insurance billing consultant can do is enhance the profitability of your medical practice. Somewhere along the way, your billing issues have probably gone haywire, resulting in the rise of your overhead and other profession-oriented costs, such as employee salaries and claim fees. With an expert in charge of handling your medical billing, you can expect increased efficiency resulting in a more cost-effective medical practice.

Hiring a medical billing consultant means having someone implement expertly designed solutions to improve your earnings. While being a doctor is a privilege and a gift, it is also a means of living. It is only right that you take necessary actions to guarantee your practice's profitability and credibility. An expert can show you the correct processes you need to utilize in order to make your medical billing not just more efficient but also more effective for the sake of your patients.

Being a doctor certainly requires a huge amount of your time and money. These are the two major investments you need to make once you decide to join the medical profession. With an expert at the helm of the financial aspect of your medical practice, you can rest assured that you have all the time you need to concentrate on the treatment of your patients without worrying about how much you're making. Also, if you hire a medical billing consultant, you can be sure that your practice will be managed well in its entirety, and you won't have to worry about losing patients to better-equipped colleagues.

Don't waste any more time and money better spent on your patients. You should be using all your energy on treating people for their conditions. For your medical billing, hire a professional billing consultant and let this expert on the matter do the job.

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Medicare's New Timely Filing Rules

Medicare has always had the most relaxed rules regarding timely filing. Under the old rules Medicare claims could be submitted for the last quarter of the year prior to the previous year - which means that claims for dates of service 10/1/08 or after can be submitted up to December 31st of 2010. There was a 10% penalty for any claims older than one year, but they would still be paid on. That has come to an end.

Under the new edits, claims will only be processed for payment for up to a calendar year. So for date of service June 22, 2010 the claim must be submitted prior to June 22, 2011.

The implementation of the new edits will be as follows: All claims with service dates prior to 1/1/2010 must be submitted prior to 12/31/2010 and will be processed according to the old guidelines. All dates of service 1/1/2010 and after will be subject to the new guidelines and will only be allowed within one calendar year.

This new ruling affects all Medicare provider types. It affects all physicians, providers and suppliers that submit claims to Medicare contractors including durable medical equipment suppliers, home health, Medicare Parts A & B. Basically anyone who provides services to Medicare beneficiaries and submits claims for those services.

It is important that anyone who does billing for Medicare providers understands the new edits. Much money can be lost. Don't wait till the last minute. Begin clearing up any Medicare claims for dates of service prior to January 1st of 2010 now.

If you follow some key guidelines you should not have any problems even under the new edits. Claims should be submitted as close to the date of service as possible. If submitting electronically, electronic reports should be read and acted upon. Whether submitting on paper or electronically, follow up or aging reports should be run regularly and worked on. Any claims over 20 days if submitting electronically and 45 days if submitting on paper should be checked on. Any denials received by Medicare should be acted upon quickly. If there is something that can be corrected, fix it and rebill quickly. If it is a patient issue, bill the patient so that they can handle anything from their end that needs to be done. This allows time to resubmit if necessary.

Honestly, the old rules were nice for us as a billing service. If we went into an office that was having billing issues we could usually recover most of their Medicare money. But with current accounts the timely filing edits didn't effect us. Our policy is to not let claims get that old. But for offices that do not have good billing practices, the new edits may be tough.

Copyright 2010 - Michele Redmond - Solutions Medical Billing Inc

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Using Both EIN and SS Numbers For Medical Claims Submissions As a Tax Identifier

We often run into providers who are having serious issues with their medical insurance billing that all stem back to billing under both an EIN# and their social security # as identifying tax information. Most people think it's not a big deal, and how messed up can it get. But you would be amazed at how much a providers income can be affected by the billing not being submitted correctly regarding the tax ID# that is submitted to the insurance carriers. With NPI numbers now in the picture, the confusion has grown.

It was very common for a provider to have begun their practice years ago and to have started out billing under their social security number. Many did this because it was just easier. They figured they could switch over to an EIN# number later on, when their practice was bigger. The problem is that switching from a social security number to an EIN number is not a simple task and it usually freaks your accountant out. Actually, the problem is that the accountant doesn't understand that it is a problem with the insurance carriers and they switch them over without advising them. The accountant tells the provider it's no big deal to switch, when it is.

When a provider changes any information regarding their practice they must notify all insurance carriers using the required method of each insurance carrier. When changing tax ID information, many commercial carriers require that new contracts be signed. Even though the provider may have been in network with an insurance carrier for years, when switching to an EIN# it is as if it is an entirely new provider. Medicare requires that the appropriate CMS forms be completed. In any case, the switch must be reported using the appropriate format.

In addition to switching to a EIN#, the provider must also obtain a group, or Type II NPI number to correspond with the tax ID number and business name. The provider keeps the individual or Type I NPI to identify themselves as the rendering provider but uses the Type II NPI for billing purposes. An individual or Type I NPI cannot be used with an EIN# and a legal business name.

When billing insurance claims the correct information must appear in the correct locations. For example, the individual NPI must be in the rendering physician box (24J on the CMS form) and the type II or group NPI must be in the provider billing information (33A on the CMS form). The EIN# must be in box 25 on the CMS form with the EIN box checked. But just having the information in the right boxes does not ensure claims will be processed that way. The insurance carriers must also have this information on their provider files this way as well.

We have had many providers who have switched from their social security number to an EIN# number somewhere along the line and cannot figure out why the are not getting payments. Many times when we look into the problem we find that they are billing under their tax EIN# but they are enrolled with the insurance carrier under their social security number. When claims are submitted under the EIN# they are either processed out of network or denied. So if you have a provider who is receiving a lot of unexplained denials, or claims are being processed out of network when they are participating, you may want to see if they have switched to a tax ID number recently. That may be the whole problem. Whether billing under a social security number or a tax ID/EIN number, it is important to make sure you are billing the way it is set up in the insurance carrier's system or you can experience major problems with your insurance claims causing your accounts receivable to get out of control.

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Difficulties With Insurance Carriers Lead to High Cost of Healthcare

With the cost of delivering quality healthcare on the rise, insurance companies continue to add to the problems facing physicians nationwide. Many people believe doctors spend the majority of their time on golf courses while earning millions of dollars. That may have been true in the past, but today there are formidable obstacles preventing those that provide care from collecting their fees. These days many physicians are forced to write-off a large portion of revenue due to the unreasonable practices of insurance carriers.

Insurance companies employ teams of representatives responsible charged with the receipt, processing, and servicing of insurance claims. When healthcare providers submit insurance claims, they are forced to follow-up vigorously in order to ensure that they receive reimbursement. The process of submitting and following up on claims is marred with holes and inconsistencies making it difficult to communicate with insurance carrier representatives. After navigating through a maze of automated responses, healthcare providers and their billing representatives are lucky to actually reach a live person. Once reaching a representative, all the information previously submitted must then be re-verified as if none of the previous entries were recognized.

As if the process had not been time consuming and difficult enough, healthcare professionals usually realize that the person on the other side of the line only has basic information available to them. What's worse is that they usually expect providers to simply accept the lack of information available and move on. In most cases, providers and their staff must demand the help of a supervisor just to receive any sort of reasonable insight in to the matter at hand. What's funny is the consistency with which these "Insurance Company Supervisors" seem to have more detailed information available to them. In the end, it often takes more than one insurance company representative and 45 minutes of time to receive relevant information pertaining to just one insurance claim.

With this being the case, one can see how the term "wasteful healthcare spending" is so common today. It seems as though the insurance companies are wasting time and money every day. Insurance companies profit billions of dollars each year while making it extremely difficult for healthcare providers to receive reimbursement for the services they perform. Even after healthcare providers verify coverage and obtain prior authorization, insurance companies still delay payments and deny claims.

A recent report from PriceWaterhouseCoopers states that "inefficient claims processing" is the second largest are of wasteful healthcare spending, costing as much as $210 billion annually. The New England Journal of Medicine reports that billing and overhead expenses consume as much as 43% of a physicians annual revenue. With statistics that these, it's no wonder the cost of healthcare is spiraling out of control. Insurance companies are profiting while individuals can hardly afford coverage, and helathcare providers find it hard to turn a profit. Surely something is wrong.

Although healthcare professionals are focused on reducing costs and expanding coverage, they cannot do it alone. If we are to be successful controlling the rising costs associated with healthcare, insurance companies and government regulators must commit to change. Only through a concentrated, coordinated effort will we achieve affordable healthcare.

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