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Tuesday, December 18, 2012

What is the Difference Between Medical Billing and Coding

Medical billing and coding are vital parts of the billing process. From the time a doctor sees a patient to when the paperwork is forwarded to the insurance company, there are important steps that need to be performed. Every doctor visit results in the utilization of medical coding and medical billing skills - both are necessary for doctors and health care facilities to be properly reimbursed for services.

Here's how it works:

Medical coding includes the process of using specific codes to identify procedures and services for private billing, health insurance companies, government health programs, workers' compensation carriers, and more. A coder reads all documentation, such as a medical chart or transcription of doctor's notes, and assigns the right universal code based on their coding knowledge. The codes are entered into a form on their computer system.

Medical codes are based on diagnoses and procedures. Codes exist for all types of services, tests and treatments provided by a healthcare provider in a medical office, hospital, or clinic. The diagnosis is translated into an ICD-9-CM code; while the procedure is translated into a five-digit CPT code. Medical codes can encompass anything from a stomach ache to a broken arm - there are codes for everything!

Once the diagnosis and procedure codes are determined, the medical biller transmits the claim to the insurance company for payment. Medical billing includes the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a health care provider. A billing specialist ensures that the patient and health insurance company are properly billed for all procedures. Approved claims are reimbursed, while rejected claims are researched and amended.

Under the Health Insurance Portability and Accountability Act (HIPAA), billing specialists are required to send claims for reimbursement via electronic means. This has resulted in faster, more accurate payments from insurance companies. The use of billing software has also enabled medical billers to perform accounting duties and manage billing practices more effectively. Patient records, open claims and outstanding invoices are a mouse click away!

Medical billers and medical coders ensure that the billing cycle is smooth - from patients being billed the correct amount to doctors getting paid. Without them, there would be no way to complete, track and manage medical claims. Both billers and coders are essential to the financial well-being of an organization and the health care industry as a whole.

Technology and Software in Today's Chiropractic World

In today's world technology is always changing. The evolution of technology is making its way into the lives of Chiropractors who now have new software to use in their offices. Billing services have taken the opportunity to use the software that has been born out of new technology.

The biggest rewards that the software used by billing services has given Chiropractors is ensuring the happiness of their patients and giving patients better results . By using new computer software, billing services have allowed Chiropractors to stay on schedule and not loose rack of their patients. The computer software used by billing services has the ability to check if patients are keeping up with their appointments and coming into the office regularly. This helps them maintain a healthy lifestyle and ultimately betters their life.

Because of the computer software used by billing services, patients feel taken care of. Chiropractors are able to stay focused on their patients and never loose track of a patient and their appointments. Patients are not going to get lost within a system because the computer software used by these billing services are keeping track of patients for Chiropractors. Technology is helping Chiropractors to stay focused with computer software.

Patients can be tracked throughout multiple offices with the computer software used by billing services. All of their information from their appointment time to an x-ray they have had taken is in the computer's system thanks to this software. Chiropractors now have an easier time knowing the care plans of patients and when their last care plan took place. A patients history is now easier to access and organized. Now chiropractors can click a few buttons and it is in front of them on their computer screen. It is also easier for Chiropractors to add or subtract information to a patient's care plan and keep up with that information to keep insurance companies satisfied. SOAP notes can be sent to insurance companies right away and Chiropractors will not have to worry themselves about whether or not they are done correctly.

Computer software used by billing services allows Chiropractors to work in real time. They can work on a patient and use the software at the same time to ensure that they are documenting everything at the right time and getting all of the details so they don't have to go back and try to remember them at a later date. Computer software allows a very thorough documentation of each patient visit.

As patients get better and see an improvement in their health, along with the attentiveness shown by their doctor, Chiropractors are seeing them continue to return. Patients want to stay with the practice longer and are bringing in more referrals for the practice. With more patients, revenues rise and practices blossom.

Computer software used by billing services is an easy solution for Chiropractors. This software will keep patients on track and therefore keep Chiropractors more focused. Technology is now helping secure healthy patients for Chiropractors and in turn healthy patients are helping practices to flourish and operate at their best.

Tuesday, November 27, 2012

Handling Denials For No Coverage or Coverage Terminated

One of the most important parts of billing is handling denials. Many providers' offices don't handle denials and end up losing thousands of dollars a year as a result. In fact, I saw a statistic once that said that 47% of denied claims don't ever get appealed. That is outstanding! Obviously based on that statistic the insurance companies have a great incentive to deny claims.

There are three reasons that denials don't get appealed. The first is that the denial is correct and there is nothing to appeal. In that case, there is nothing to be done except bill the patient if that is appropriate. The second reason is because the person responsible for handling the denials doesn't have the time to handle them. This problem can be rectified. If the right systems for handling denials are put into place then they can be handled in less time. Most time spent on denials is figuring out what to do about them, which brings us to reason number three.

The third reason that denials don't get appealed is that the person responsible doesn't know what to do about it. Many times they understand what the denial is for, but aren't sure what steps to take to rectify it. So over the next several months we are going to be covering the most common denial reasons and how they can be handled.

One denial that is very common is "denied for no coverage or coverage terminated." Seems pretty straight forward. But what do you do? There are actually a couple of things. First of all, receiving this denial does not mean that it is correct. Our local BCBS denies claims for this reason more often than I use a restroom. Many times it is just because BCBS issued the patient a new ID number or changed just the 3 letter prefix. It can actually be quite frustrating. If we receive a denial from BCBS for this reason we go to the BCBS website and do a search on the patient. In most cases we can pull up the correct ID number and resubmit the claim.

If the denial is for a company that does not have those issues, the next thing I do is look at the patient's claim history. Has the payor been making payments but suddenly stopped? In some cases the payor may have paid claims before and after the date of service they are denying. In that case a call must be made to the insurance carrier to question the denial. Hard to believe but they actually do make mistakes! (sarcasm)

Lastly, if the denial appears correct, or if we cannot find any additional information through the website or a phone call, then the patient must be contacted. Usually we send out a patient statement with the charges, and a note stating "Your insurance carrier states your coverage was terminated. Please contact

our office with updated insurance information." Many times patients forget to notify the provider when they do have an insurance change. Receiving a bill will prompt them to notify you. Usually they call us and give us the updated information over the phone and the claim can get resubmitted.

The most important thing here is that you come up with a system that you will use every time you receive this denial. That way you won't waste time trying to figure out what to do each time, and the denial will get handled promptly. If you do this for each denial you receive, all denials will be handled and it will cut down on losses.

How To Keep Up With So Many Changes in Medical Billing Maximize Your Medisoft! (Unknown and Underused Functions of Medisoft) Is the Job Growth Affected by the Existence of Software That Handles Medical Billing and Coding? General Overview of the Medical Billing and Coding Process

Checking Benefits and Eligibility on Patients

Whether you are working in a medical office or in a billing service you may be required to check with insurance carriers on eligibility or benefits on patients. Certainly in the medical office someone should be checking on the eligibility of each patient and what their benefits are or else that office is probably losing a lot of money. Some medical billing services offers this as part of their service. There are several ways this can be accomplished depending on insurance carrier and each individual office. And there are a few important questions to ask.

Generally when a new or returning patient comes to a medical provider they bring along their insurance identification card. The person responsible for checking them in should then check with the insurance carrier to insure the information on the card is up to date and correct. This can often be accomplished by checking the website of the insurance carrier or calling a representative of the insurance carrier. Some clearing houses are also capable of checking eligibility.

A primary care provider may be interested only in whether or not the insurance is in effect at the time of service and the patient's responsibility whether it be copay or coinsurance for a primary care visit; where a specialist needs to check to see if the copay for a specialist is different from the copay of a primary care physician. A specialist also needs to verify if their services will require a referral or pre-authorization.

Providers seeing Medicare patients definitely need to check with the carrier prior to seeing the patient as coverage with a Medicare Managed Care Plan can be very confusing to the patients. Many Medicare patients will tell you that they have Medicare and show you their Medicare ID card and not realize that they are enrolled in a Medicare Managed Care Plan. You can save a lot of delays in getting your claims paid by checking while the patient is there to see if they gave you the correct insurance information.

Appointments for new patients are generally set up in advance and the insurance information should be collected then. This gives the office time to check the information prior to seeing the patient. It is important to know what the patient's financial responsibility is before seeing the patient as it may be more than the patient expects and they may not be happy with a surprise. There are many things that can influence the patient's responsibility such as whether or not the provider is in network, is the patient has a deductible and the type of provider providing the service.

It is best to have a form in front of you when checking for eligibility and benefits so you make sure you don't forget an important piece of information. We have a form we have designed just for this purpose which you are welcome to download. This form can be stored in the patient's file for future reference. You can download our benefits and eligibility form at our website.

HIPAA 5010 - What It Is and How It Will Affect You

This is a basic breakdown of the HIPAA 5010. There are much more technical requirements, information and explanations.

Well, most of you should know what 5010 is and how it will affect you. If you don't you must have at least heard about it. It seems that all insurance carrier publications are overflowing with confusing information on this transition and the quickly approaching deadline. So we are going to try to break it down for those who still don't really understand what it is and if they need to do something.

First - what is it? HIPAA 5010 is a federal mandate that requires health plans, clearinghouses, and providers to use new standards in electronic transactions including claims, remittance, eligibility, and claims status requests and responses. HIPAA 5010 is an upgrade from the current mandate, or HIPAA 4010A. The new mandate is supposed to increase transaction uniformity and streamline reimbursement transactions.

The deadline for this new mandate is January 1, 2012. All affected organizations and providers should have long ago begun at the very least testing if they are not already compliant with the 5010 mandate or as Ingenix says "As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions." This means that if your current software is not compliant with 5010 then you will need to upgrade. And before we reach the deadline you will need to have tested your system to make sure it is compliant. Not doing so before the deadline may result in "operational disruptions" or in terms the provider will understand, mess up the accounts receivable.

So how do you know if you need to do something to prepare for HIPAA 5010? Well, if you submit all claims on paper and you don't receive any ERA's then you don't need to do anything. HIPAA 5010 is for electronic transactions only. That was pretty easy.

If you do submit claims electronically or do receive ERA's then you need to see if your system is compliant. Most people submit claims through a clearinghouse. If you use a clearinghouse then you need to check with your clearinghouse to make sure they are compliant or to see where they are in the testing phase. Most of the major clearinghouses are prepared. You should also make sure that the practice management system that you use to create your electronic batches is going to be compliant as well. Make sure there is nothing that you need to do on your end.

If you receive your ERA's through a clearinghouse, again you just need to make sure that they are compliant or are on track to be compliant. If you receive any ERA's directly from the insurance carriers you should check with them to see if there is anything that you need to do on your end.

Some providers or billing services submit claims using their own software as a clearinghouse. If you are one of these people you will need to make sure your software is updated by checking with your vendor.

Chances are by now your vendor should have contacted you with information but if they haven't you shouldn't wait. Contact them ASAP. Ask if there is going to need to be an upgrade to your system. Ask if the upgrade has already passed testing. Do not wait until you find out you are not compliant. Call and ask.

Don't be intimidated by all the confusing information that you are being bombarded with. If you receive something that you don't understand and you are worried that it does affect you, call the sender and ask for an explanation. Check your current system and make sure you are ready.

Proper Use of the 59 Modifier

Many people do not really understand modifiers and when they need to be used. A modifier should never be used just to get higher reimbursement. It shouldn't be just added on to get a code paid. Modifiers should be used when they are required to describe more accurately the procedure performed or service rendered.

The definition of the 59 modifier per the CPT manual is as follows:

Modifier -59: "Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries)not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. Unfortunately many times it is used to prevent a service from being bundled or added in with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier's edit system.

It should also only be used if there is no other more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed then that modifier should be used over the 59 modifier.

When using the 59 modifier to indicate a distinct and separate service, documentation should be in the patient's medical file to substantiate the use of the 59 modifier. The insurance carrier may request medical records to deem if the 59 modifier is being appropriately used. If a provider is going to bill using the 59 modifier they need to make sure they are documenting the services provided in the patient's file, showing that the services were distinct and separate.

Use of the 59 modifier does not require that there is a different and separate diagnosis code for each of the services billed. Also, just having different diagnosis codes for each service does not support the use of the 59 modifier.

An example of appropriate use of the 59 modifier might be if a physical therapist performed both 97140 and 97530 in the same visit. Normally these procedures are considered inclusive. If the 59 modifier is appended to either code they will be allowed separately. However, the 59 modifier should only be added if the two procedures are performed in distinctly separate 15 minute intervals. If the therapist does the codes simultaneously then the 59 modifier should not be used.

Another example would be if the patient is having a nerve conduction study with cpt codes 95900 and 95903 being billed. If the two procedures are done on separate nerves then the 59 modifier should be used to indicate that. If the codes were performed on the same nerve then the 59 modifier should not be used.

Billers should never add the 59 modifier to a claim even if they know that billing the services without the modifier will result in bundling or a denial. The 59 modifier should only be added by the provider or by a coder who has access to the patient's chart. If you are the biller and you believe that the 59 modifier would be appropriate but it was not indicated, you should go back to the provider to see if it was omitted by mistake. Don't just add the modifier to the claim.