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Steps clinicians can take toward proper compensation
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Several times throughout European history, the law set limits on what medical services patients could be billed for and some clinicians could not bill for services at all or sue to collect fees, lawyers Mark A. Hall and Carl E. Schneider wrote in the Journal of General Internal Medicine, who added that such laws were never enacted in the United States.
The CDC website indicates there are nearly 72,000 ICD-10 codes. In the 2017 and 2018 alone, nearly 1,000 changes were made to the ICD codes. Next month, AMA will discuss more than 300 code changes in the new CPT edition, all to “capture and describe the latest scientific and technological advances in medical, surgical and diagnostic services,” according to an association press release.
Billing has been called “perverse” by Hall and Schneider, and coding was described as “complex” in a Family Practice Management article.
Healio Family Medicine interviewed AAFP members and other health care professionals about strategies that primary care physicians and other clinicians can use to minimize errors and maximize reimbursement.
Hire a scribe or coder
Several studies suggest financial and time management benefits to utilizing a scribe.
A report in the Journal of Family Practice found that physicians who hired a scribe spent 5.1 fewer hours a week on documentation, reported productivity increases anywhere from 9.2% to 28.8%, and generated $168,600 in office income annually. A second study which appeared in the Journal of General Internal Medicine found that scribes improved physician satisfaction without compromising patient satisfaction, and physicians reported satisfaction with the clinic workflow and the level of physician burnout did not change after using scribes.
Both studies also indicated that the patients’ level of satisfaction did not waver, suggesting scribes could be a win-win situation.
“In an outpatient family medicine clinic, the use of scribes substantially improved physicians' efficiency, job satisfaction, and productivity without negatively impacting the patient experience,” S.T. Earls, MD, of the department of family medicine and community health at University of Massachusetts Medical School, and lead author of the first study concluded.
Healio has previously reported that internal scribe candidates do not require a clinical background or professional certification. Transcriptionists could be retrained, especially because many of their jobs have been cut due to implementation of electronic health records and voice recognition. Administrative staff who are personable, have good typing skills and have a desire to learn also make good internal candidates. If hiring from the outside, consider looking at nearby medical schools.
Another option is to use a coder to ensure maximum reimbursements by reviewing charts and physician notes and staying abreast of new and changing codes, according to a health care finance analyst.
CMS estimates 60% of denied, lost or ignored claims will never be paid in full, according to Adrian Velasquez, president, CEO and co-founder of Fi-Med Management, adding that the Medical Group Management Association estimates that payers underpay health care organizations between 7% and 11%.
“Hire or outsource coders to code from physician notes, and have this person engage in ongoing physician documentation and coding education,” Velasquez told Healio Family Medicine.
Address EHR shortcuts
Physicians should create templates for exams such as the well-women exam, UTI exams and annual wellness visits, encouraged Lynn Rapsilber, DNP, APRN, ANP-BC, FAANP, a nurse practitioner and reimbursement specialist based in Connecticut.
“But do not clone your records,” she quickly added. “Every patient visit should look unique. If it looks like the information was copied and pasted from a previous report, it will not be seen favorably by an auditor.”
Incorrectly copying and pasting poses other possible risks, Sue Bowman, MJ, RHIA, CCS, a senior director of coding policy and compliance at American Health Information Management Association wrote in Perspectives in Health Information Management.
These include having redundant, outdated or inaccurate information, creating confusion over the author and intent of documentation and the initiation date of the documentation, propagation of wrong information, and unnecessarily long and inconsistent progress notes.
Donna Vanderpool, MBA, JD, and vice president of Professional Risk Management Services, Inc., offered other considerations in using EHR shortcuts.
“Do not allow prepopulated or auto-populated fields. Add space for free-form text and encourage the use of free-form text to individualize the record entry. Consider periodically printing out a record to see the completeness and consider whether another provider could understand what you did and why just from your documentation,” she wrote in Innovations in Clinical Neuroscience, adding that it is important to know what shows up in the record if information is not entered in the correct field.
Remember medical necessity
According to Emily Hill, PA-C, of the Catholic Medical Center in New Hampshire, Medicare generally considers medically necessary services as those that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
“Payers are becoming increasingly concerned about [this] issue, she wrote in Family Practice Management.
Hill added, even though many practices have staff members to help with billing and coding, the responsibility for meeting the medical necessity requirement falls to the physician.
“You are in the best position to identify the rationale for a test or other service,” she wrote. “In practical terms, that means selecting the ... code or codes that are valid for the visit or other service and linking them to the associated CPT code or codes. Incorporating this into your daily routine is simple once your encounter forms are up-to-date.”
However, a report from the Deloitte Center for Regulatory Strategies seemed to suggest ambiguity in what a clinician sees as a medical necessity vs. how a government regulator defines the term. According to the report:
- More than 1 million medical records were requested for review in the first quarter of 2013, 40% more than the fourth quarter of 2012.
- 38% of medical record requests were denied in 2012, up from 32% in 2011.
- The average dollar value of complex denials was more than $5,400 per medical record.
AMA’s website lists common mistakes made when billing to cut down on frustration and confusion among members, including: Unbundling codes and upcoding; failing to consult the National Correct Coding Initiative edits when reporting multiple codes; adding modifiers that may or may not be appropriate; overusing modifier 22–increased procedural services; and reporting codes improperly and unlisted codes without documentation.
Ask these questions
According to Jon Graham, PhD, and Cindy Acker, of the Claims Resolution Center in St. Petersburg, Florida, the person in charge of billing should ask him or herself these questions to ensure proper billing and reimbursement:
- How are services rendered verified for accurate billing?
- Are copays being collected?
- Are bills being sent out in a timely manner?
- Are payers paying the contracted amount?
- How quickly is the practice collecting what it is owed when bills go out?
- Are claims being collected?
- Is the practice taking part in all patient assistance programs?
“Exploring these issues and implementing the recommendations offered may cause some discomfort, but implementing them can help assure the financial viability of the practice and serve as a learning experience for all involved,” Graham and Acker wrote in the Journal of Oncology Practice.
Consult resources
Many medical societies have resources available to help clinicians through the billing and coding process.
For instance, AMA offers the CPT Assistant newsletter, said to provide the most up-to-date information on codes and trends in the industry on a monthly basis.
“[This tool] has been instrumental to many physicians in their appeal of insurance denials, validating coding to auditors, training staff and answering the day-to-day coding questions that arise,” according to AMA’s website.
AMA also has among its billing and coding arsenal an online database of frequently asked questions and a searchable list of codes.
The American Academy of Family Physicians, has a number of tools to help with billing and coding on its website, and recently developed paper flash cards to help its members, explained AAFP’s coding and compliance strategist Barbie Hays, CPC.
“Sometimes all the CDC does is remove a period and replace it with a comma. Or they may have removed a few words here and there. So, while a clinician may be thinking there are a lot of changes, it’s really not that bad,” she said in an interview.
AAFP’s billing and coding toolkit also includes occasional webinars to review ICD coding changes from time to time and offers tips on topics such as providing Medicare wellness and care coordination services to optimize fee-for-service revenue, improve quality, and decrease total cost of care as well as coding hierarchical condition categories and group visits.
Above all else, take your time
The adage ‘haste makes waste’ is true when it comes to billing, Hays told Healio Family Medicine.
“People think that they can just jump right in and look up a code. But if you don’t have the basis of what the codes are built off of, you’re likely going to be very confused. The very first thing we teach when we’re teaching coders, is to go to the guidelines first and read them carefully. Read all of the descriptions before assigning a code,” she said. – by Janel Miller
References:
AAFP. Medical Billing and Coding. https://www.aafp.org/practice-management/payment/coding.html. Accessed Oct. 2, 2018.
AMA. “8 medical coding mistakes that could cost you.” https://wire.ama-assn.org/practice-management/8-medical-coding-mistakes-could-cost-you. Accessed Oct. 2, 2018.
AMA. “AMA Releases 2019 CPT Code Set.” https://www.ama-assn.org/ama-releases-2019-cpt-code-set. Accessed Oct. 2, 2018.
AMA. “Finding coding resources.” https://www.ama-assn.org/practice-management/find-coding-resources. Accessed Oct. 2, 2018.
AMA. “Get support from CPT Assistant newsletter.” https://wire.ama-assn.org/ama-news/get-support-cpt%C2%AE-assistant-newsletter. Accessed Oct. 2, 2018.
Bowman S. Perspect Health Inf Manag. 2013 Fall; 10.
CDC. International Classification of Diseases, (ICD-10-CM/PCS) Transition – Background. https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm. Accessed Oct. 2, 2018.
Deloitte Center for Regulatory Strategies. “Balancing act: Can hospital CFOs square their medical necessity risks with revenue goals? Here’s how.” https://www2.deloitte.com/content/dam/Deloitte/us/Documents/risk/us-aers-balancing-act.pdf. Accessed Oct. 2, 2018.
Earls ST, et al. J Fam Pract. 2017; Apr; 66(4):206-214.
Graham J and Acker C, J Oncol Pract. 2007; 10.1200/JOP.0742504.
Hall MA and Schneider CE. J Gen Intern Med. 2008;doi:10.1007/s11606-008-0605-1.
Hill E. Fam Pract Manag. 2008 Nov-Dec;15(9):17-21.
Hill E. Fam Pract Manag. 2011 Mar-Apr;18(2):31-37.
Vanderpool D. Innov Clin Neurosci. 2015 Jul-Aug; 12(7-8): 34–38.
Disclosures: Healio Family Medicine was unable to determine relevant financial disclosures prior to publication.