Putting more oomph into your billing practices
Here are key billing oversights
Afraid of drawing the attention of the federal fraud police, more physicians are being extra-cautious when billing Medicare. Add to this a series of services that are often unknowingly undercharged by many practices, and the result can be a costly evaporation of legitimate payments.
While it’s wise to be prudent in today’s regulatory environment, there’s no reason you shouldn’t be paid fully for legitimate services. Next time you review your back-office practices, check to see if you are making any of the following common billing and coding mistakes:
• Underbilling for office visits.
Afraid of being red-flagged by government bean counters, more physicians are taking the cautious approach and downcoding office visits out of fear that claiming levels four and five services will prompt an audit.
Sadly, recent physician office experiences nationwide do partially bear out those fears. But auditors say the real smoking gun they look for is a constant billing of higher evaluation and management (E/M) services across a wide array of patients in a manner that seems inconsistent with normal practice patterns.
Physician offices are caught on the horns of a dilemma. If you do a properly documented multisystem exam of a moderately ill patient that requires multiple diagnoses but you only bill for a level three service instead of level four, you are just denying yourself appropriate payment, which can quickly run into thousands of dollars in a busy practice. On the flip side, billing a level four service for a hypertensive patient who comes in every month could get you into trouble.
• Mismatching ICD-9 codes and procedure codes.
Too many physicians simply mark ICD-9 and CPT codes on a superbill and assume the billing office will take care of the rest. However, this habit often means CPT and ICD-9 codes get mismatched or left off the bill altogether. And that’s a sure-fire way to get a claim questioned or denied.
One way to avoid this problem is to have the physician place a private code of his or her own (this could be a number or a letter) matching each diagnosis with the corresponding CPT codes on the superbill, to eliminate confusion about which ICD-9 goes with what CPT.
Some experts say it is easier for physicians to use a superbill or fee slip that already lists the practices’ most frequently used CPT and ICD-9 codes. Others, however, argue that offices should just do away with superbills and have physicians write out their diagnoses, while more experienced billers fill in the most appropriate diagnosis-related codes. Billers and coders should check with the physician when there are questions.
Are you forgetting the five-digit format?
• Not using the most specific and recent ICD-9 codes.
Despite the fact many four-digit ICD-9 codes have been replaced with more specific five-digit codes, many physicians still use the older four-digit format without thinking.
The trouble with that is that Medicare is now prone to challenge these four-digit claims, reports Chicago’s Karen Zupko & Associates. Some examiners, for instance, will question why a simple code for abdominal pain was used instead of a code specifying the exact location of the pain.
• Not using modifiers.
At first glance, coding rules prohibit billing a patient for an office visit and a minor procedure on the same day. But, it is OK to bill for both an office visit and a minor procedure, provided the physician justifies both charges, the services are properly documented, and a modifier "25" is used to let the payer know more was done than just giving the patient an injection.
The catch is this: if the patient was only scheduled to receive a joint injection, for example, and that’s the only service you provided, you cannot charge for both the procedure and the office visit.
• Not billing for injections.
According to the ProStat Resource Group in Shawnee Mission, KS, physicians often forget that they can bill for administering injections as well as the drug or vaccine itself.
For instance, while charging for both an injection (a minor procedure) and an office visit on the same day without using a modifier is generally prohibited, there are exceptions. When giving a vaccination for pneumonia, influenza, or hepatitis B, physicians can bill for the office visit, the injection, and the vaccine.
• Failing to distinguish between new patient visits and consultations.
A patient consultation pays more than a new patient visit. To justify billing for a consult over a new patient visit, the patient must have been sent to you for a consult by another physician, and you must provide the referring physician with an opinion or advice — preferably in writing — which should be included in the file.
• Overlooking payment for counseling patients.
When a physician spends more than half of his or her face-to-face time counseling a patient or coordinating care — such as calling other physicians, making arrangements for diagnostic testing, etc. — they can bill for a higher level of service. That’s true even if they don’t perform an exam or make a new diagnosis, says practice consultant Leslie Witkin in Orlando, FL.
For instance, if a physician sees a patient recently diagnosed with cancer and does nothing during the visit but counsel the patient, talk to family members, and make arrangements for further treatment, the physician still is entitled to code the visit as a level five if more than half of the visit — 20 minutes minimum, because level-five visits must be least 40 minutes long — was spent counseling the patient and coordinating care.
• Not charging for home care services.
Each time a provider talks to a home health agency or nurse about changes in treatment or medication for a patient receiving home care, the physician should make a note of when each instance of this communication occurred and exactly how long it took. If, at the end of the month, the physician spent between 30 and 59 minutes overseeing or coordinating care for that patient, the physician is eligible to be paid by Medicare.
• Forgetting to bill for the nurse’s time.
A level one code can be used for office visits if the nursing staff provide routine services when a physician is not present. However, it is best to only bill when the nurse does those small extra things like show a patient how to use insulin or gives some other kind of detailed instructions.