After the examinations, x-rays, and surgeries, lives another major part of a physician’s day that happens behind the scenes. All the hard work needs to be processed through a successful claim submission, meaning that ultimately earning payment all boils down to one thing – coding. Evaluation and management codes, or E/M codes, are codes a physician uses to report a patient visit. This administrative task – a necessity for any physician – is often cumbersome and prone to errors. Most importantly, it uses up valuable time that could be better spent.
How many of us have experienced the “hurry up and wait” scenario? The type of appointment where you wait in a waiting room, then wait a little more in the exam room, then eventually get 10 minutes with your doctor…only to be rushed out so the next patient can be shuttled in. Unfortunately, it’s all too common. It’s safe to say that many patients could benefit from more face-to-face interaction with their providers.
Many people claim that payment for evaluation and management services is undervalued, specifically when it comes to ambulatory services. Additionally, it’s been argued that the fee schedule itself is not well-designed to support primary care, which requires ongoing care coordination for patients. Pressure existed to increase payment rates for ambulatory E/M services while reducing payment rates for other services. Thankfully, The Centers for Medicare and Medicaid Services (CMS) took notice. With the goal of increasing efficiencies to reduce unnecessary burdens, the “Patients over Paperwork” initiative was established. Per CMS, E/M codes make up 20% of total spending under the physician fee schedule. Part of this initiative aims to reduce the coding and documentation requirements for E/M codes, in turn giving physicians more time to spend with patients. In partnership with The American Medical Society (AMA), CMS worked to revise the rules for evaluation and management coding requirements. These changes were finalized in the 2020 Physician Fee Schedule (PFS) with an effective date of January 1, 2021.
So what exactly was revised? The E/M updates affect codes 99201 through 99215 and include the deletion of code 99201 along with revisions to the code selection for 99202 – 99215. Below is a summary of the revisions to E/M codes:
Elimination of code 99201
Decrease the burden of coding requirements
Decreases the burden of documentation
Decreases the need for audits
Revises the definitions for Medical Decision Making (MDM)
Revises the definition of time spent with the patient to total time including non-face-to-face for E/M services by a physician and other QHP
Requires a history and/or examination when medically< necessary
Offers a clear time ranges for each code for time spent with the patient
Addition of a new 15-minute prolonged service code
Clinicians will choose a code based on MDM or total time
These changes apply to office visits and other outpatient services. It’s noteworthy that these changes represent the first changes to the E/M codes in over 25 years! More importantly, the changes streamline the coding process, reduce clinician burden, and will allow physicians to put the focus back on patient care.
Billing and coding should always be top of mind, but it can be hard to keep up. This is why it’s critical for physicians, clinicians, coders, and billers to completely understand these changes. To help comprehension, the AMA released a checklist identifying ten steps to help the practices prepare for the upcoming changes that can be accessed here. To learn more about the medical coding changes and the summary of revisions, visit the AMA website.
Note: This article is not a comprehensive overview and is NOT intended to provide coding advice, rather it is intended to highlight the new changes in effect and the need for physicians to ensure they have received the proper training for the upcoming changes.
Deborah Rieser founded Spectrum Medical Billing Services in Anchorage, Alaska 15 years ago to make extra money to help with paying the family’s bills. Today, she owns a thriving medical billing service with a team of “twelve lovely ladies”—as she likes to refer to them—that services clients nationwide. Rieser originally selected EZClaim’s medical billing software platform—because of its pricing structure—to use for her medical billing service.
Over the years, since her original purchase, she has upgraded to each new EZClaim version, which adding new features and efficiencies. Recently, she has made the transition to EZClaim Cloud, and continues to use it exclusively today.
With team members nationwide, Rieser prides herself on training her billers on properly classifying billing for medical offices so that there are minimal insurance denials. She is very particular about this since one of the reasons Deborah began billing was the insurance qualification struggles she had for her daughter with Autism. So, accurate billing is ‘personal’.
Recently, we found time to interview Rieser about her start in the industry, the ups and downs of being a business owner, and what hard-fought expertise she has gained that might help others considering to start their own medical billing service.
EZCLAIM: When did you get into the medical billing industry and why? RIESER: “I always had an entrepreneurial spirit, and I had an orchid business out of our house. Then my daughter, who was born with Autism, started working with an Occupational Therapist (OT), and they came to me to help with billing. I thought about it, and after a few weeks, I took it on. That was back in 2005.
“At that time, my daughter had over 75 volunteers and therapists in the community work with her from age three to age five, and had 50-60 hours a week of therapy. Today, she is a sophomore in university, has a boyfriend, is driving her car, and is thriving. From all of that, I have always felt the need to give back to the community for all their help. So, I used my business to take on other Pediatric, Occupational Therapy, Physical Therapy, and Speech Therapy clients, as well as, using my experience to help patients take care of their billing needs and get their bills paid by insurance.”
EZCLAIM: What are you passionate about when it comes to billing? RIESER: “For me, the biggest thing that I am passionate about is seeing my clients [medical offices] getting paid from insurance claims. I also enjoy helping patients get properly classified during medical visits, so claims are accepted. I have learned a lot from the mistakes and errors that have led to denied claims. From my experience, I can help medical practices observe their approach to patients’ needs so that services qualify when billing insurance companies. Being able to offer that to my clients is very satisfying.”
EZCLAIM: What are some of the challenges you have had to overcome? RIESER: “Originally, we grew word-of-mouth. I didn’t even want a website at first, but now I do have one. Going from one client to 65 is challenging because as your clients grow, your staff grows. Recently, I lost a client. You then have to decide what you’re going to do with your staff. The hardest part is that, for a business owner, your business consistently goes up and down. That fluctuation can be stressful. For me, I deal with that by going outdoors. My husband and I will go for a walk in nature and that will help relieve my stress.”
EZCLAIM: What advice would you offer others in the billing industry that have similar experiences? RIESER: “If you’re starting your own business, make sure it’s one you love. Know that there will always be highs and lows. Also, be sure to price yourself accordingly. You can’t go too high or people will look elsewhere.
“I do want to step back and highlight that some of my billing practices only do 2-3 claims a week, and that’s why I love EZClaim. The price of the software. When I was growing, I was working on EZClaim “Advance,” which is being retired. So, when I started looking around at other software providers, they were billed on a ‘per provider cost.’ Fortunately, EZClaim “Cloud” billed based on the number of concurrent users, which worked for me.”
EZCLAIM: How has your relationship with AMBA (American Medical Billing Association) benefitted you? RIESER: “I just joined last year in 2019, thanks to EZClaim and Dan Loch’s referral. I love that group. I joined their Facebook group because they have very useful information for us billers. I recommended that my team members join as well. They are good at supporting US-based companies and put the focus on supporting the group.”
EZCLAIM: What would you tell people who are wondering if EZClaim Cloud is right for them? RIESER: “The transition to EZClaim Cloud was easy. I was worried about the providers and the tax ID’s, but it all was very smooth. I would add that customer support was very helpful. As daunting as moving things over felt, it was very smooth. I attribute that to the planning and support.”
EZCLAIM: What would you say would be a strength of someone who is good at billing and coding? RIESER: “It is important to be a very good communicator, professional, out-going, and enjoy what you do. One must be able to communicate with providers over denials, success, celebrations, and always keep talking with the staff and the providers. Also, always try to put yourself in the patients’ shoes by offering patience and compassion. Lots of times patients don’t understand their benefits and why they are denied. So, try to explain in layman’s terms. They understand better and appreciate that. It ends up being a good connection with the patient, and benefits you as the biller, too.”
EZCLAIM: Final thoughts? RIESER: “I am grateful to EZClaim for their services. As a business owner, you have to monitor expenses and things can add up fast. So, I am thankful for EZClaim Cloud and its pricing structure. That has helpedSpectrum Medical Billing Services to grow and thrive.”
[ The above answers were paraphrased as closely as possible to the original answers given by Deborah Rieser on November 25, 2020 ].
ABOUT EZCLAIM: EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call a representative today at 877.650.0904.
It IS POSSIBLE to improve medical billing revenues, and here are a few ways to do just that.
Healthcare practitioners, whether established or just starting out, have many overwhelming tasks: Managing a practice; Seeing patients; Working to staying up-to-date on administrative tasks; The whole host of compliance at the federal, state, and local level; and Overseeing the billing.
One of these that can lead to loss of revenue is not properly managing the medical billing, which can also lead to HIPAA fines and rejected claims. However, there is a solution: a medical billing system that balances the budget and optimizes revenues of medical practice.
EZClaim, an expert in the medical billing software market since 1997, provides a solution that improves the efficiency of an office’s billing process in many ways. The following are the primary reasons.
Reduce Coding Errors Medical procedures become codes, codes become claims, and claims become revenue. Any error in this process can make claims to be denied, your workload can be increased, and revenue can be lost. To help in avoiding errors, it is essential to use billing software that offers the easiest implementation and access to descriptive diagnosis and treatment codes. EZClaim’s medical billing solution offers ease-of-use in coding, billing, and strong partnerships with Clearinghouses which act as an additional ‘safety net’ for catching errors.
Administrative Support Most medical practices are a small team of people tackling a wide range of tasks, so when one cannot understand the function of the billing software, accessing reliable support is very important. EZClaim prides itself on having dedicated support experts available, and that was how the company was established. Founder and President Al Nagy has said, since day one, “We are a support company that happens to sell medical billing software.”
Maintain Industry Compliance It is important to recognize that industry compliance and a practice’s revenue go hand-in-hand. Filing and batching inaccurate and non-HIPAA compliant claims can often be traced back to an outdated healthcare revenue management system. Conquering these tasks requires a focus on multiple fronts: A properly trained billing team, clear office procedures, patient payment policies, and a reliable medical billing company. These are all ways to help buttress against non-compliance and rejected claims.
Streamline Workflow Recently, a study was done that showed almost 80% of medical bills contain errors. These incorrect medical claims often end up as lost revenue originally, not to mention the additional cost of resubmissions and collections. One of the best ways to resolve this problem for your practice is to make use of both well-trained, experienced billers and coders, combined with a competent medical billing solution that aids in catching these errors. EZClaim software features a library of standard validation, the ability to add custom validation, and integrates with Alpha II for full claim scrubbing.
Follow up Errors will and do occur, so establishing a system for follow-up on all denials will close the loop and protect against lost revenue. Being consistent with the follow-up process, and having a medical billing solution that tracks these things will help close that gap.
Collections Finally, probably the most important aspect that optimizes a practice’s revenue is to get paid. Portals and payment collection systems definitely help with this, but having collections integrated into the medical billing system is, of course, the best. EZClaim has pain-free payment processing integrated into their solution, called EZClaimPay. It solves all the problems associated with payment processing: Bank deposits, reconciliation, statements, changing fees, and ‘finger-pointing’ when there is a problem. EZClaimPay’s robust platform will greatly increase a practice’s collections success, and improve their revenue.
ABOUT EZCLAIM: EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at firstname.lastname@example.org, or call a representative today at 877.650.0904.
So, it looks that there will be a lot new for E/M coding (Evaluation and Management) in 2021, and practices should start to get ready for it.
Well, it seems the only constant in the world of medical billing is change, and 2020 would only compliment that cliché. While the chaos of COVID-19 forced many unexpected changes—how you see your patients and bill for services—a bigger change is in the works for 2021. This change will complement the “Patients Over Paperwork” initiative from CMS and the AMA, which has been developed to eliminate “Note Bloat.” So, since the new year will roll out changes to E/M visits, now is the time to make sure that all parties are prepared for this long overdue and welcome change to medical billing.
Evaluation and management services have been long overdue for an overhaul. The 1995/1997 guidelines were in place well before electronic medical records, and with the growth of EMR’s, the process to document for a specific level required a lot of tedious, unnecessary documentation. (A cursory a look at some of the proposed updates for E/M CPT coding and documentation requirements will verify that!)
PROPOSED CHANGES: • History and Examination: While the elements of history and examination that are pertinent to a specific visit shall be recorded, they will no longer be used to ‘score’ the level billed • Code Selection: It will be based on MDM or time • Medical Decision Making: It will still utilize the CMS Table of Risk. However, the wording and explanations are being updated to provide more concise language. For instance, definitions will now be included to clearly identify subjective wording like “self-limited and stable chronic illness.” The clinical example will likely be removed, and terms are more clearly defined. We will see this same type of clarification in the MDM table. For example, the 2021 guidelines will specify that the amount and/or complexity of data to be reviewed must also include analysis. • Time-based Code Selection: It will also be easier. The guidelines will give specific amounts of time rather than the generic estimate that we currently see attached to E/M codes. Another major advantage to the codes selected based on time, it will now include non face-to-face services. There will also be additional add on codes—in 15-minute increments—if the time has been exceeded for the 99205 or 99215.
While changes are daunting, this change will be rewarding from a documentation standpoint. So, if you need help with training your team on these new updates, there are FREE videos available on the AMA website, or you can enlist the help of an independent consultant like RCM Insight.
One way of keeping up with these changes is to use EZClaim’s medical billing software, which is continually updated. For more details, visit their website, ezclaim.com, contact them, or just give them a call at 877.650.0904.
Credit card collections are a BIG part of any successful medical practice, and there has been a shift, in the last decade, that more insurance policies are adding co-pays with higher deductibles—which makes getting paid even more challenging.1 One industry report said that “73% of physicians shared that it typically takes at least one month to collect a payment, and 12% of their patients wait more than three months to pay.”2 With the current trend, more medical practices and their billing departments (or outsourced billing firms) are going the route of processing payment via credit cards, which has its PROS and CONS.
In light of this new information, the following are a few pros and cons for credit card processing that we anticipate in the near future, and some insights for choosing the best billing software that supports the credit card processing needs of medical practices:
PRO: To protect against the dangers of stolen data, fraud, or other compromises in security, practices should seek out medical billing software that has credit card processing built-in, which can help safeguard against these dangers.
CON: Security is a big risk, and a leak in data leading to stolen funds can end up in a physician paying out-of-pocket for the breach. It is also important to note that breach of credit card data is also considered a violation under the federal Health Insurance Portability and Accountability Act (HIPAA).
PRO: Implementing credit card processing will reduce long waiting periods for payments from the majority of your patients, and will also reduce the additional effort your billing staff has to extend to collect on overdue notices.
CON: Practices cannot require patients to share their credit card information to receive medical care, and even if patients do share their credit card information, physicians cannot continue to charge the credit card without a patient’s consent.
PRO: Physicians can end the process of being a “line of credit” to unpaid or underpaid claims, and collect on funds immediately.
CON: You will need to implement internal processes that include, but are not limited to proper personal information storage and security, establishing guidelines on maximum percentages charged per bill, and personal consent forms.
Overall, there are definitely MORE ‘PROS’ than cons for implementing credit card processing for your medical practice, and all the trends are pointing to this being the PREFERRED METHOD of payment in the near future. EZClaim is proud to announce that it will release an integrated credit card processing solution, EZClaimPay, that is backed by a national merchant services vendor. [ EZClaim will be sharing more details about EZClaimPay in the weeks to come, via their social media platforms, their monthly newsletter, direct communications, and more ].
In addition to the credit card collections PROS and CONS above, we reached out to one of our partners, Live Compliance, to gather some regulatory and security advice. They suggested the following:
When accessing, transmitting, storing, or receiving any Protected Health Information (PHI), Health and Human Services (HHS) Office of Civil Rights (OCR) mandates that you are to maintain HIPAA compliance.
When accepting, processing, or maintaining credit card information and debit card information, you must ensure that your organization is PCI DSS compliant (Payment Card Industry Data Security Standard).
In addition to the above Federal regulatory requirements, most states require privacy and security compliance requirements to be implemented, along with strict adherence to the privacy of Personally Identifiable Information (PII) and Breach Notification requirements.
For more information on your compliance requirements, visit Live Compliance for a Free Organization Assessment to identify and uncover your organization’s vulnerabilities.
If you are not a current customer of EZClaim, we would very much like to connect with you. You can either schedule a one-on-one consultation with our sales team, view a recorded demo, or download a FREE 30-day trial right now. For detailed product features or general information about EZClaim, visit our website at ezclaim.com.
[ NOTE: If you would like a quote on the upcoming merchant services, please e-mail email@example.com your last three merchant statements. For more on our ongoing updates and industry news, you can follow EZClaim on Facebook and LinkedIn ].
Source Material: 1 – America’s Health Insurance Plans” report that there were 20.2 million co-pays in 2017, which was up tremendously from just over 1 million in 2005. 2 – Source: From InstaMed’s annual “Trends in Healthcare Payments” report.
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