Codified billing: Software makes it simple

When it comes to Medicare billing, there is a seemingly infinite number of items that can go wrong. Resourceful companies looking to break into the health care market saw a way to not only provide a service but turn a profit at the same time, and so came the birth of billing and coding software.

Companies such as Burr Ridge, IL-based ADP Context set out to find automated solutions to medical coding, claims editing, and reimbursement issues confronting the health care industry. To date, the firm has more than 60 Knowledge Products — its software line — covering such areas as coding, fee management, and regulatory compliance.

Some software "actually looks at claims to see if you have the information required by your carrier in order for it to be accepted. It will check to see whether you have a primary diagnosis and the appropriate code," says Marge Klasa, DC, RN, manager of clinical content for ADP Context, of her company’s software.

"In the coding software, we have edits that indicate exactly what is allowed as a code. It doesn’t suggest which modifier to use, for example, but will alert the user to the fact that one is needed." she says.

Programs can be interfaced

To cut down on duplication, software can "interface with other programs so that it’s pulling a patient’s name and information, which will be reflected on an actual claim that is electronically sent to the carrier."

Even with a software program that seems to do the work for you, Klasa warns that there "should always be one person in charge so that someone can go back and review things and make changes if necessary. The only way for this software to really work for you is to have a certified staff member, whether it’s a registered health information technology person or a registered coder. They need to have the education and knowledge base in this area. I can’t emphasize that enough."

If your agency employs an experienced coder, you might be asking yourself what good software programs will do. "They can help reduce the number of errors, and anything that does that has to be helpful to a business," says Klasa. "Any time you don’t get reimbursed quickly you’re losing money, and sometimes you’re not even able to re-submit. You want all your bases covered when it comes to compliance so you know what you’re dealing with and you don’t waste time."

To that end, all software providers offer training classes, basic workshops, and more to help employees master the program, Klasa says. Additionally, they have seminars for correct coding.

In an article Klasa wrote for Health Care Innovations,1 she gives a brief rundown of just how coding software works in an agency context: Once a service has been rendered, the medical coder receives a summary of the services on an encounter form that is provided by the physician. This information is then entered into the system. The system will prompt the coder for the diagnosis and procedure codes and, as it does so, the software allows the user to identify the most appropriate code for that particular episode of care.

The coder will also be notified if there is an acceptable link between the diagnosis and the procedure codes. Once the proper codes have been entered, the entire claim and the patient history can be reviewed and compared to a particular payer’s rules. Should any errors appear as flagged, the coder can correct them on a real-time basis before the claim is submitted.

Check the facts first

But before you run out and buy the first program you see, there are a few facts you should know. First, prices should be comparable to what a practice management company would charge, says Klasa. Second, piecemeal plans are available if an agency only wants the software and a few other components. Then, too, there are a few shopping tips she offers. Any system you purchase should be able to:

- identify the appropriate procedure and diagnosis mismatches;

- identify whether the procedures are linked to the diagnosis code;

- identify unbundling occurrences;

- identify service violations and overutilization;

- flag users for overlooked charges (e.g. injections, surgical trays, etc.);

- have the ability to be integrated with a current practice management system;

- be easy to learn and use, particularly in light of high rates of staff turnover;

- have sources for payer rules disclosed by the vendor and updated frequently for users;

- offer a high-quality "help line" or other resource to provide assistance.


1. Klasa M. Automated billing — new generation of systems provides tools to improve compliance. Health Care Innovations 1999; 9:18-21.

Marge Klasa, DC, RN, Manager/Clinical Content, ADP Context, 241 S. Frontage Road, Suite 41, Burr Ridge, IL 60521. Telephone: (800) 783-3378.