The trusted source for
healthcare information and
Afraid of drawing the attention of the federal fraud police, more physicians are being extra-cautious when billing Medicare. Add to this the fact that many practices often unknowingly undercharge for many services, and your practice may be leaving a significant amount of legitimate payments on the table.
Being cautious in today’s regulatory climate is prudent. However, there’s no reason you should not be fully paid for legitimate services. Next time you review your back-office practices, check to see if you are committing any of these common billing and coding oversights, which can choke off your practice’s cash flow.
Intimidated by the idea of being red-flagged by government bean-counters, more physicians are taking the cautious approach and downcoding office visits.
Sadly, there is a grain of truth at the center of the widespread physician fear of overzealous fraud cops. But the real smoking gun that auditors look for is a constant billing of higher evaluation and management-level services across a wide array of patients that seems inconsistent with normal practice patterns.
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. In a busy practice, that unbilled legitimate income can add up much faster than you’d think.
On the other hand, billing a level four service for a hypersensitive patient who comes in every month could get you into trouble.
At first glance, coding rules prohibit billing a patient for an office visit and a minor procedure on the same day. But it is acceptable to bill for both an office visit and a minor procedure provided that the physician does enough for the patient to justify 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.
There’s a catch: 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.
Also remember not to bill for injections. For instance, charging for both an injection (a minor procedure) and an office visit on the same day without using a modifier is generally prohibited. But, there are exceptions. According to the ProStat Resource Group in Shawnee Mission, KS, physicians often forget that when they can bill for injections, they can bill for both administering the injection and for the drug or vaccine itself. For instance, when giving a vaccination for pneumonia, influenza, or hepatitis B, physicians can bill for the office visit, the injection, and the vaccine.
It’s important not to confuse new patient visits with 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, and preferably included in the file.
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 or making arrangements for diagnostic testing — the physician can bill for a higher level of service, even if he or she doesn’t perform an exam or make a new diagnosis, says Orlando-based practice consultant Leslie Witkin.
For instance, if during a visit a physician sees a patient recently diagnosed with cancer and does nothing 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, provided that 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.
Another point to remember is that a level one code can be used for office visits if nursing staff provide routine services when a physician is not present. However, it is best only to bill this way when the nurse does those small extra things like showing a patient how to use insulin or giving some other kind of detailed instructions.