Crossing the finish line
In a relay race, no matter how hard all the others run, if one runner drops the baton, the team will likely lose the race. Likewise, if you provide and document a patient's care and select the correct codes and modifiers for that care, but the claim gets sent to the wrong payer, denied, and written off as bad debt, you have likely missed the goal of getting paid for services provided. There are many steps and hand-offs in the race to getting paid so you need to be sure that each runner finishes his or her leg.
Now, I am not saying that there aren’t a lot of other factors influencing the financial health of your practice, such as payer fee schedules that are set too low. However, I’ve seen firsthand, and the statistics show, that a lot of the money that physicians should collect is left behind due to lack of training and discipline in the billing process. To collect all that is due your practice, you need trained and disciplined staff using a well-designed system.
I’m not talking about expensive computer systems or consultants. Much of this comes down to the basics that haven’t changed since the days of using a typewriter and a whole lot of White-Out to produce claim forms. Good billing practices have always depended on team work and efficient processes.
Some simple steps include the following:
- Verify the patient's insurance coverage each time a service is scheduled.
- Know what services may not be covered or require prior approval.
- Get charges to the biller as soon as possible after services are provided.
- Verify charges billed against the sign-in sheets or other records of what patients were seen each day.
- Update insurance information every time charges are entered.
- Research all unpaid claims and take any necessary action within 45 days of date of service.
- Review a report of write-offs each month to determine appropriateness.
These steps illustrate that the process depends on a team of people (though in smaller practices, each person may run longer legs). The scheduler gets the initial information. The front desk staff copy the cards and update demographics. Clinical staff get any necessary prior approvals and document all charges promptly. Billing staff update information, enter charges correctly and follow-up on the account until paid. Finally, a manager or physician reviews what was paid and what was written off and makes adjustments as necessary to keep the team fit.
Need more information or some resources on billing and accounts receivable management? The AAFP has some resources to help. See the Billing & Claims section of the AAFP Coding Resources web page -- and, of course, the FPM Toolbox (click on the link titled "Billing, Collections and Claims Processing").
Posted at 12:51PM Nov 02, 2009 by Cindy Hughes | Comments[0]
Getting paid for H1N1-related services
Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?
Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.
Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.
Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.
Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.
Posted at 02:31PM Oct 02, 2009 by Cindy Hughes | Comments[0]
ICD-10: Y2K all over again?
People often see things differently. Two neighbors may call their county government offices, one to ask that weeds be sprayed along the road and another asking for a no-spray ordinance. Health care is not immune to such conflicting priorities.
Some are anxiously counting the days until the Oct. 1, 2013, deadline for adoption of the ICD-10-CM codes and the "granularity" they promise. I doubt many practicing physicians are among that group. A letter to the Centers for Medicare & Medicaid Services from Jim King, MD, chairman of the AAFP Board of Directors, left no doubt the AAFP did not support this change. That said, I hope you are not losing sleep, hoarding canned goods or preparing to duck for cover. The transition from ICD-9 to ICD-10 will create some challenges but will not likely result in widespread calamity.
Don't get me wrong. This is not your average annual code update. As reported by the American Academy of Professional Coders, when the Blue Cross Blue Shield Association converted the 164 ICD-9 codes included in FPM's model superbill to ICD-10, the resulting mess was seven pages longer than the original list. (The FPM Superbill has been updated for 2009; you can download it from the FPM Toolbox.) Clearly the ICD-10 code set is cumbersome compared to ICD-9, but it's not as difficult as learning to diagnose and manage the 68,105 conditions that may be reported with ICD-10. You can handle this.
Here are some things to consider as the Oct. 1, 2013, implementation deadline approaches:
1. You will no doubt soon receive ads for ICD-10 products and educational resources. Please don't waste your money. Learning a complex coding system that you will not use for nearly five years isn't productive, and changes could be made to the code set before 2013. Keep reading FPM and plan to learn more when implementation is closer.
2. Don't let ICD-10 overshadow another change with the potential for significant financial impact, especially for solo and small practices -- the conversion to the HIPAA 5010 electronic transaction standards, which must be completed by Jan. 1, 2012. Version 5010 is an extensive revision and paves the way for submission of ICD-10-CM codes. If your software vendor charges for upgrades or floundered during prior changes, now is the time to start asking questions about implementation plans and considering your options (e.g., upgrade or change vendors).
3. If you think you might need to change your software, consider a combined EHR/practice management system. A combined system may relieve some of the ongoing burdens and costs of transitioning to ICD-10. Imagine having an ICD-10 look-up tool similar to the FPM ICD-9 Look-Up Tool built into your EHR and integrated with your billing system, or a system that automatically converts standardized nomenclature to codes.
Most of you have endured the Medicare enrollment process, so you are combat-tested. And you are not alone. The AAFP and FPM will continue to provide you with the best resources that we can find or create to help you make the transition to ICD-10.
Posted at 03:50PM Jan 29, 2009 by Cindy Hughes | Comments[1]
Injection rejections
It’s annoying. You’ve submitted your claims for subcutaneous injections with code 90772 for a couple years now and all of a sudden, rejections! The code has been changed to 96372. Who's responsible for this disruption to your cash flow? It was the insurance companies, wasn’t it?
No. Insurance companies do have some influence on CPT code changes but really not that much. CPT code changes can be proposed by anyone who identifies a problem or gap in existing codes. Many originate from physician complaints made to specialty societies about payment policies that don’t align with CPT or current practices. All proposed changes are vetted and recommended for approval, modification or rejection by physician volunteers from each of the medical specialty societies that participates in the AMA's CPT process. Proposals are then approved, postponed or rejected by the AMA's 17-member CPT Editorial Panel. Most of the panel members are physicians nominated by their specialty organization and appointed by the AMA Board of Trustees. David Ellington, MD, of Lexington, Va., and the AAFP Board of Directors is a member of the panel. A handful of the panel members represent payers.
So what else has changed in CPT 2009 and how are you, a busy physician, supposed to care for your patients and your practice and keep up with all of this? You can look to Appendix M of your 2009 CPT book for a summary of the deleted codes and their replacements. Also, watch for an article in the January/February issue of FPM on the code changes most affecting family medicine. And finally, don’t hesitate to contact me (chughes@aafp.org) or join the AAFP e-mail discussion list for coding issues to find help with coding questions and keep up-to-date. (The discussion list is also open to non-members so that your coding and billing staff can take advantage of this free resource.)
Posted at 05:15PM Jan 14, 2009 by Cindy Hughes | Comments[1]
