What’s Current in Coding? EZClaim Answers

EZClaim-What's Current In CodingEZClaim is always looking for ways to help our medical billing clients improve. In an effort to further that mission, this month we are kicking off the first in a series called, “What’s Current in Coding.” In this series, we will highlight coding topics, events, webinars, and more, all with the aim of keeping you current in medical billing and coding.

This month our focus came from two articles on coding sourced from the AMBA Newsletter that we feel are hot topics of the industry: “Coding for Group Visits” and the “Telehealth Coding Guide.”

Below you will find full articles and source links.

 

ARTICLE 1: “Coding for Group Visits”
Many physicians are interested in providing group medical visits. Whether the drop-in group medical appointment (DIGMA), chronic care health clinic (CCHC) or other model is delivered, the coding and billing of these services raise questions about codes and payment policies.

While past instruction on coding for group visits often indicated that physicians should report code 99499 for unlisted evaluation and management services, using this code requires that documentation is sent with the claim to identify the service(s) provided and leaves valuing of the service in the hands of the payer.

No official payment or coding rules have been published by Medicare. However, the question of “the most appropriate CPT code to submit when billing for a documented face-to-face evaluation and management (E/M) service performed in the course of a shared medical appointment, the context of which is educational”, was sent to the Centers for Medicare and Medicaid Services (CMS) with a request for an official response. The request further clarified, “In other words, is Medicare payment for CPT code 99213, or other similar evaluation and management codes, dependent upon the service being provided in a private exam room or can these codes be billed if the identical service is provided in front of other patients in the course of a shared medical appointment?”

The response from CMS was, “…under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face E/M visit (CPT code 99213 or similar code depending on level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary.” The letter went on to state that any activities of the group (including group counseling activities) should not impact the level of code reported for the individual patient.

Some private payers have instructed physicians to bill an office visit (99201-99215) based on the entire group visit. For compliance purposes, we recommend that you ask for these instructions in writing and keep them on file as you would any other advice from a payer.

Where each individual patient is provided a medically necessary, one-on-one encounter, in addition to the time in the group discussions, there should be no problem in billing for the visit based solely on the documented services provided in a direct one-on-one encounter.

If your group visits include the services of nutritionists or a behavioral health specialist, contact payers to determine if that portion of the group visit can be directly billed by the non-physician provider. This typically would include codes for medical nutrition therapy (97804) or health and behavior intervention (96153).

Other codes that may be applicable are the codes for education and training for patient self-management involving a standardized curriculum (98961-98962). Neither these codes nor medical nutrition or behavioral health therapy are billed by physicians. Physicians must use evaluation and management codes to report these services.

Code 99078 describes physician educational services in a group. Again, it is necessary to contact the payer to verify that coverage of this service is a payable benefit.

As with many services, coding for group visits requires that billing and coding staff do preliminary work with payers to identify desired coding applications.

Source: https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/group-visits.html

 

ARTICLE 2: “Telehealth Coding Guide”
There’s nothing more frustrating than rendering a service and not being paid. Nuanced coding rules are difficult to understand, and physicians aren’t taught this information in medical school.

Still, health care is a business. As business owners, physicians need to know how they’re paid, including what codes to use, what modifiers to append, and what details to document. Brushing up on common coding mistakes helps avoid costly recoupments and denials. We’ve asked several coding experts to provide their best advice on how physicians can maintain compliance and collect all of the revenue to which they’re entitled.

In part 1 of our two-part coding guide, we focused on coding for Telehealth and other forms of remote patient care — important codes for physician practices’ short-term survival as the U.S. continues to grapple with the COVID-19 pandemic.

Telephone services
In times of social distancing, telephone services have become a practical way to improve patient access and prevent the spread of COVID-19. Telephone services are ideal for straightforward problems (e.g., simple rash, asymptomatic cough, medication refills) that require a minimum of five minutes of medical discussion, says Toni Elhoms, CCS, CPC, chief executive officer of Alpha Coding Experts, LLC, in Orlando, Florida. Consider the following codes that Medicare accepts during the current public health emergency (PHE). Commercial payers may accept these codes, as well. Note that once the PHE has concluded, Medicare may only accept G2012 (virtual check-in) for telephone services.

Elhoms provides these tips to ensure compliance:

  • Document verbal consent, including patient acknowledgment and acceptance of any copayments or coinsurance amounts due.
  • Only count time spent on the phone engaging in medical discussion with the patient or caregiver. Do not report these codes for conversations lasting less than five minutes.
  • Clearly document what was discussed, as well as the outcome of the conversation (e.g., medications prescribed, referrals to specialists, additional steps for the patient to take).
  • Don’t report these codes when the telephone service ends with a decision to see the patient in 24 hours or the next available appointment.
  • Don’t report these codes when the telephone service relates to a related E/M service performed within the previous seven days or within the postoperative period of a previously completed procedure.
  • Only provide 99441-99443 and 98966-98968 for established patients. During the PHE, Medicare permits providers to bill G2012 for new and established patients.

‘The best way to operationalize these codes is to set up an edit in the practice management system that pends claims for a manual review to determine whether and which services are ultimately billable, Elhoms says.

Telehealth services
In the last few months, providers have adopted Telehealth to improve patient access and generate revenue during COVID-19. Among the services physicians can render via Telehealth to patients with Medicare during the current PHE are Medicare annual wellness visits, new and established patient office visits, prolonged services, smoking, and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and more. Medicare covers more than 200 services via Telehealth, many of which were added for temporary coverage during the current PHE. Commercial payer coverage of these services may vary, and it’s best to check with individual payers, Elhoms says.

Elhoms provides these tips for billing Telehealth services:

  • Pay attention to audio-only vs. audio-visual requirements. Medicare requires the use of audio-visual technology for certain Telehealth services and permits audio-only for others. Commercial payers also may have specific requirements. For example, physicians can render a Telehealth visit for advanced care planning using audio-only, but they must use audio-visual technology for a new patient telehealth office visit.
  • Don’t render Medicare’s Initial Preventive Physical Exam via Telehealth. Medicare does not permit it.
  • Document verbal consent for Telehealth, including patient acceptance of any copayments or coinsurance amounts due.
  • Use place of service (POS) code 11 and modifier -95 when billing Medicare. Note that commercial payers may require a different POS code (e.g., POS 2 or POS “other”) and modifier.
  • Document, document, document. Physicians need to prove they met all of the code requirements even when rendering the service via Telehealth, Elhoms says. “Don’t pull in a problem list if you didn’t treat or manage all of those problems,” she adds. “Physicians need to link the diagnosis with the assessment and treatment plan. That’s imperative.” One caveat is that during the current PHE, physicians can bill 99201-99215 rendered via Telehealth based on time or medical decision-making. “The total time in direct medical discussion with the patient is going to be critical,” Elhoms says.

“The best advice I can give anyone doing Telehealth right now is to watch the CMS [Centers for Medicare & Medicaid Services] and commercial payer websites pretty much on a daily basis,” says Rhonda Buckholtz, CPC, CPMA, owner of Coding and Reimbursement Experts in Pittsburgh, Pennsylvania. “The coding of services changes constantly, and practices really need to be careful.”

Online digital E/M services
Though online digital E/M services are relatively new, they also can help practices increase patient access during COVID-19. Here’s how it works: An established patient initiates a conversation through a HIPAA-compliant secure platform (e.g., electronic health record portals, secure email, secure texting). A physician or other qualified health care professional reviews the query, as well as any pertinent data and records. Then they develop a management plan and subsequently communicate that plan to the patient or their caregiver through online, telephone, email or other digitally supported communication.

Elhoms provides these tips to maintain compliance:

  • Use these codes when physicians or other qualified health care professionals make a clinical decision that would otherwise occur during an office visit. Do not use them for scheduling appointments or nonevaluative communication of test results.
  • Use these codes only for established patients.
  • Do not use these codes for fewer than five minutes of E/M services.
  • Document verbal consent, including patient acknowledgment and acceptance of any copayments or coinsurance amounts due.
  • Do not report these codes when the online digital E/M service ends with a decision to see the patient in 24 hours or the next available urgent visit appointment.
  • Do not report these codes when the online digital E/M service relates to a related E/M service performed within the previous seven days or within the postoperative period of a previously completed procedure.

Promoting these services is often the biggest barrier, says Elhoms, who suggests putting up signs letting patients know they can access their provider electronically for non-urgent medical issues.

Remote patient monitoring
Remote patient monitoring (RPM) is a relatively easy way for physicians to keep tabs on patients without requiring them to come into the office. Medicare covers RPM for patients with one or more acute or chronic conditions, and commercial payer coverage may vary. During the PHE, physicians can initiate RPM on new and established patients. Normally, Medicare permits it only for established patients.

RPM consists of two forms: monitoring data through either a non-manual or manual data transfer, says Jim Collins, CPC, CCC, a consultant at CardiologyCoder.com, Inc. in Saratoga Springs, New York.

For example, physicians can remotely monitor a patient’s pulse oximetry, weight, blood pressure or respiratory flow rate using a device that transmits daily recordings or programmed alerts. Physicians can purchase them directly from manufacturers or patients can purchase the devices themselves. Collins says patients should look for Bluetooth-enabled devices or ones that include a built-in Global System for Mobile Communications (GSM) transmitter. The former requires an Internet connection, and the latter automatically transmits data to an internet cloud service through an encrypted bandwidth. Physicians can bill for the initial setup, cost of the device itself (when applicable), and data monitoring.

Another example is the self-measured blood pressure monitoring. When patients supply their own blood pressure device that a physician calibrates, physicians may be able to bill for patient education, device calibration, reviewing the data that the patient provides and communicating a treatment plan to the patient or caregiver.

“Monitoring physiologic data on a regular basis substantially reduces hospitalizations, trips to the emergency room and exacerbations of chronic conditions,” says Collins. “It can also be a huge chunk of revenue.”

Collins provides these tips for compliant RPM billing:

  • Document patient consent. Patients must opt-in for these services.
  • Document total time spent rendering these services to support time-based requirements.
  • Know when these codes are appropriate. It’s unclear whether Medicare will pay physicians for monitoring physiologic data derived from internal devices (devices placed within the patient’s body) or data derived from wearable fitness devices.
  • Only bill 99457 when the provider renders at least 20 minutes of live, interactive communication with the patient or caregiver. “It’s not going to be medically necessary to spend 20 minutes every month on every patient,” Collins says. “Patients could go for several months without physicians needing to do anything for them.”

Source: https://www.medicaleconomics.com/view/telehealth-coding-guide


 

What’s Current in Coding?” is brought to you by EZClaim, a medical billing solution. To find out if it may work for you, either schedule a one-on-one consultation with their sales team, or download a FREE TRIAL to check it out the software yourself. For additional information right now, view their web site, send an e-mail to sales@ezclaim.com, or contact the sales team at 877.650.0904.

Improve Your Billing Processes

Improve Your Billing ProcessesIf you are a member of the MEDICAL BILLING COMMUNITY, the norms of the day-to-day have changed. With the recent COVID-19 pandemic and the ‘stay-at-home’ order, you may find yourself with either more time on your hands and/or an increase of claims with new patients.  During this time, we want to offer you a couple of suggestions so that you can make the best use of the additional time you have, and also help you improve your billing processes.

The first thing to consider is to review your Accounts Receivable (AR)—to collect payments due you to INCREASE YOUR INCOME.  According to the American Medical Association (AMA), claim denial rates range between 0.5% and up to 3% or more, and that 90% of claim denials are preventable. Some of the most common claim denial reasons can be rectified by correcting claim management workflows, including claim submission and patient registration procedures. The following are a few of the most common oversights for claim denial.

  1. Use EZClaim software to check automatically for missing information, including absent or incorrect patient demographic information and technical errors
  2. Make sure you do not have duplicate claim submissions
  3. Check that claims do not have services previously adjudicated
  4. Review for claims with services not covered by the payer
  5. Make sure the time limit for claim submission has not expired

Secondly, revisit and resubmit open claims.  Surprisingly, 31% of providers still use a manual process to resubmit. Our partner, TriZetto Provider Solutions (TPS), has an Advanced Reimbursement Manager Pro (ARM) that has two great tools that can improve your ability to tackle collecting and repaying underpaid and overpaid accounts. Below are some key features that can be automated by their software, and will help to improve your billing processes:

  • Identify common errors and payer trends
  • Analyze contract performance
  • Customize and assign work into queues
  • Quickly access information from interactive dashboards
  • Automate the appeal process

Thirdly, know that EZClaim and our partner TPS have worked together to bring you the most powerful medical billing software tools to solve claim denials. Our partnership not only simplifies the billing process but also helps resolve denied claims in an efficient way. In addition to that, our customer support team is available to help you learn best practices with these tools, and support you however you need it.

Finally, if you are frustrated with your current medical billing solution, investigate how EZclaim’s medical billing solution may work for you.  You can either schedule a one-on-one consultation with our sales team or download a FREE TRIAL to check it out the software yourself. For additional information right now, contact EZclaim’s sales team at 877.650.0904 or send an e-mail to sales@ezclaim.com.

9 Signs It’s Time to Outsource Your Medical Billing and Coding

9 Signs It’s Time to Outsource Your Medical Billing and Coding.

Contributed by James EasleyVP, Marketing of NexTrust, Inc

Should a practice outsource their billing and coding or manage it in-house? This is one of the most important business decisions for practices to get right. Which is the better option for your practice? Here are nine signs that it may be more financially beneficial to outsource medical billing.

1. Do You Lack Visibility into Billing and Payment Metrics?

Do you know your key financial metrics and how to improve them? Many practices are not aware of their actual revenue metrics which are the “vitals” for the financial health of their practice. For example, only about 35% of practices appeal denied claims, which means most are losing out on thousands of dollars every month.

Without the ability to measure these financial vitals, it’s difficult to know how to improve. Does your practice have a financial analyst as well as the staff with the skills to identify problems and make improvements? If not, practices should consider looking at external experts to provide these metrics and are able to make the necessary billing improvements.

2. Is Your Revenue Decreasing?

For practices that are aware of their billing and payment metrics, are you seeing your collections decrease? Is the time it takes to collect increasing? Unfortunately, this is more and more common among practices due to the ever-changing complexity of the insurance billing processes. Outsourcing is not the only solution, however fixing this problem internally can often be costlier and time-consuming than outsourcing.

You need a solid income stream to keep your clinic operating effectively. If billing mistakes, coding complexities, and reduced reimbursements or denials have negatively affected your collections, then you need to consider outsourcing your billings and collections to keep your company from falling victim to a bad revenue stream.

Not only does this keep your business running optimally, but it also allows your personnel to focus on other responsibilities and ensure quality customer service.

3. Are Billing Errors and Rejected Claims Costing You Money?

The American Academy of Family Physicians reports that a 5-10% denial rate is the industry average. To be financially sound, practices should do what’s necessary to keep this rate below 5%. Because high claim denial rates require additional costs and staff time to correct and resubmit, many practices have found the outsourcing resolves this issue and provides higher net income overall.

4. Are You at Risk of Staff Absence or Turnover?

While every industry faces the challenges of staff turnover, the effects are often felt acutely among medical practices when billers leave. Since claim processing is integral to the lifeblood of a practice, replacements or new additions to your billing department unavoidably result in a slowdown in claims processing. Practices can remove this variability and risk through outsourcing their billing and pushing the staffing burden to the third-party. Practices then rely on a team that can ensure the work of claim processing continues without interruption.

5. Are Staff Billing and Coding Skills and Training Insufficient?

Many practices take on the responsibility of hiring, managing and training Internal billing and coding staff. This works well in many practices. However, if billing and coding staff is under-experienced or not current on compliance and regulatory issues, practices must cost-effectively provide regular training to get and keep them current. Practices that prefer not to take on these burdens can find a simple solution in outsourcing.

​6. Has In-house Billing Become Too Expensive?

Considering the costs of hiring, salary, benefits and administrative costs of in-house medical billers, practices may find it costs less overall to outsource their billing.

In addition to employee costs, practices must purchase equipment, software, and more. In-house billing costs can quickly add up. Practices should compare internal costs to outsourcing to determine both the best operational and cost-effective methods for billing and coding management.

7. Do You Have New Providers or a New Practice?

Newer practices may find it difficult to navigate the complexities of medical billing and coding. These new practices or practices with new providers need to ensure they are focused on growing their business and providing a high level of care.

Delegating important responsibilities to a trusted third-party allows new practices and providers to do just that. Outsourcing your medical billing during this time can relieve the burdens of hiring, training or managing a team of new billing employees.

​8. Is Your Clinic Growing?

A growing practice can have similar challenges as a new clinic. Reputation is critical when growing your business and ensuring high-quality patient attention and care can become more difficult.

As your staff will likely be tasked with more responsibilities and duties during this growth period, why not ensure they can still provide meaningful services by taking some of those administrative duties off their hands. Your personnel will thank you for this by continuing to provide quality care to patients, which in turn will help you to continue growing.

9. Is Your Attention Divided Between Patients and Running a Business?

Overseeing internal billing and coding requires a substantial amount of effort, time, and expertise. Without dedicated staff to handle this, the responsibility can fall on the shoulders of clinic owners, physicians, or other administrative staff.

This can mean less time focusing on patients or other relationships and practice management responsibilities. When practices outsource the billing process, physicians and administrators are free to focus on providing quality healthcare services to patients.

If you found yourself nodding your head to one or more of these questions, it’s worth taking some time to learn if outsourcing would be better for your practice. NexTrust offers both patient and insurance billing services that not only improve revenue but allow providers and staff to focus on providing the highest level of care.

Free $25 gift card with RCM demo

Call NexTrust today 435-940-9123 or email us at rcm@billflash.com to learn how our Patient Billing and Insurance Billing services can improve the financial health of your practice.

Stay tuned to our blog for the latest information related to the medical billing field from EZClaim and our esteemed partners.

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