By Delly Parham, CPC
Financial challenges are the top concern in practices today. One of these challenges lies in the obligations defined through physician contracts. Understanding the payer side of the industry better, so you can think like a payer, and knowing how they make money and set reimbursement rates, may help you to identify ways to prevent abusive payment tactics and improve your bottom line.
If you are one of those practices hard pressed to find a file drawer with all of the original agreements, addenda, and rates associated with reimbursement, you may end up with rates that do not even cover the cost of bringing patients through the door.
Tips for Overcoming Payer Challenges and Increasing Income
1. Be organized, consistent, and standardize your practice protocols.
- Compile and maintain all original agreements, addenda, and fee schedules in one place.
- Review your contracts with payers annually for rate changes, coding guidelines, policies, and pre-certification and authorization requirements.
- Stay informed of current CPT®, HCPCS Level II, and ICD-9-CM code changes and requirements. Submit timely, clean claims by using the appropriate codes and modifiers.
- Identify and bill the correct payer. Make sure the name and identification number on the insurance cards are the names and numbers submitted with the claims.
- Comply with all requirements for claims submission—including method and mode of submission.
- Evaluate Electronic Remittance Advice (ERA) and Explanation of Benefits (EOB) to detect processing errors, such as:
- Coding changes
- Reimbursement rates and adjustments
- Reason/explanation codes for denial of benefits
- Submit timely, formal appeal letters with supportive documentation.
2. Know your reimbursement rates and how these rates are determined. Your fee schedule is the most important factor in determining how much revenue your practice will generate.
You can better understand payers and how they make money if you understand how they arrive at the reimbursement rates paid to your provider. The reimbursement rates of payers vary in each geographic region and are usually determined by the number of providers in the same specialty in that region, the cost of living, and the product line. For example, a preferred provider organization (PPO) plan may pay a higher rate than a health maintenance organization (HMO) or Medicare replacement plan. This is because the premium your employer pays for a PPO plan is usually higher than the premium paid for an HMO plan.
Like all for-profit businesses, payers are in it to make money and keep it in their own pockets. It’s to their advantage to negotiate the lowest rates possible. If your provider specialty is needed in their network in that geographic region, you are at an advantage in negotiating a reasonable rate. Whereas, if there are a large number of providers in your specialty in your geographic region, negotiations become tougher.
3. Recognize the cause of abusive payment tactics and how to handle them.
The two most common payment tactics used today can best be described as delay of payment, and payment that falls short of the contracted rates.
Delay of payment may be due to a number of reasons, such as:
- Outsourcing by payers. This has increased over the past few years, and may take staff more than an hour to get through to a person who can help resolve a claims denial.
- Appropriate staff. Staff handling accounts receivables must be persistent and must follow through. Otherwise, deadlines for refilling claims may expire.
- Unclear reason codes for denials. A call to clarify the denial reason may be needed. For example, Blue Cross Blue Shield uses a denial reason that reads “OA-133: The disposition of the claim/service is pending further review.” If there is no follow-up, you may never know that this means Blue Cross requires a copy of the reports to review the claim before it’s paid.
Payment that falls short of contracted rates usually is discovered by evaluating the EOBs or ERAs for accuracy, and are usually an action taken by or omission of the payers, such as rate changes or coding changes. Or, the provider may not be linked to the contracted rates in the payer’s system.
Lastly, you may file a complaint with your state insurance commissioner for bulk claims that are delayed beyond state-required time frames. You may also involve your county and state medical societies regarding a pattern of delayed payment, or payment not adhering to coding guidelines or negotiated reimbursement rate.
May 23rd, 2013
Moving forward with implementation means your participation is vital.
If you thought the introduction of the electronic health record (EHR) would change coding, you were absolutely right. The days of sitting in the back office, appending ICD-9-CM codes to paper fee tickets and manually posting charges is, for some practices, in the distant past. Modern offices expect you to transform your coding knowledge into the fundamental tools used for EHR software development and compliance auditing. With a systematic plan, the right resources, and reasonably sophisticated EHR software, you can be a vital resource in their implementation.
Get Ahead of the Learning Curve
To participate in the development of compliant documentation templates, you must understand how an EHR is designed and how software is modified.
Overall, the EHR should interface with a billing or practice management software so patient demographics data attach to the medical record to avoid ‘wrong patient’ issues. Most EHR software is designed with pre-created templates used to capture patient medical data, document visits and procedures, order prescriptions, and document patient/provider communication—all seamlessly linked to the patient demographics. These templates are designed so providers can enter data through several methods. They can click check boxes or select radio buttons, and choose items from drop down menus to determine the information they want to document in the patient chart. The provider can type additional data within a text box, which displays this information exactly as it’s entered. Other patient data, such as chronic conditions, past medical history, and medication lists can be pre-loaded.
In some sophisticated software, templates can be set up to require some sort of action—almost like an internal email that alerts nursing staff to contact the patient regarding lab results. Other templates can be developed to order a prescription that automatically faxes to the pharmacy. These methods of selection and documentation are elements of a “user interface,” which is a behind-the-scenes mapping of how and where the information is displayed. Taking the time to learn about the behind-the-scenes default “language” that is all part of the EHR package’s user interface will help you determine whether there are options for clear and concise documentation, or if the documentation is limited to certain canned phrases and verbiage.
All EHR software arrives “out of the box” with default data lists that are used to populate the templates to drop pre-determined verbiage into a formatted document based on the provider’s selection. These data lists can include CPT® and ICD-9-CM codes, and place of service (POS) indicators, as well as more customized and editable lists such as office locations, special charges, and fee schedules. Data is typically selected through a drop-down menu.
In all cases, successful EHR implementation depends on the ability to understand, customize, test, and audit the capability and compliance of the EHR software. Coders, today, need to understand the concepts of a user interface, billing rules, and clinical documentation standards, and be able to translate coding and documentation guidelines for successful and compliant software development.
Test the EHR Before Going “Live”
A good software package will provide you with a test environment. When the practice decides to “go live” with a new EHR, there is a period during which the electronically-generated medical record should be systematically audited within a test environment to identify errors or bugs. These problems should be corrected prior to using the EHR in a “live” environment.
By comparing the computer generated notes against an approved audit tool, you can see where the software might be “double-dipping” (counting the same elements twice), pulling forward (bringing arbitrary documentation from another, unrelated note), or creating “bugs,” such as documenting both male and female system reviews for all patients. The completed EHR should meet all of the criteria for a legal medical document. This kind of testing is most effective if planned and implemented in a methodical manner, using test patients that you create, name, and run through the workflow process with varying visit types and medical scenarios.
Using a spreadsheet or database to capture and compare this analysis process is helpful, and can keep the project organized. Some scenarios to consider include:
- Are the templates for physical examinations age/sex appropriate?
- Are there opportunities to document all elements of the history of present illness (HPI)? The review of systems (ROS)?
- Are the examination templates set up to record based on 1997 or 1995 guidelines?
- Can your medical record be locked for security after a certain length of time? What is your addendum process?
- Can you import data such as lab results that are relevant to your current note? Is your note readable? Do consecutive notes appear to be copied, or cut and pasted?
- Do surgical/procedural templates allow for informed consent documentation?
- Is there space to document adverse effects or complications?
- Does your finger stick glucose lab template always default to a diabetes diagnosis? This should not be the case: Not everyone is diabetic!
- Does your wart destruction template allow for both benign and malignant lesion reporting?
Much of this developing and testing should be handled by your practice’s information technology (IT) department, but savvy coders, such as yourself, may want to develop super-user status. You can participate in pre-implementation activities, where you act as patients while the providers learn the software. During this time, make recommendations regarding coding compliance to the physicians, as well as the IT team.
EHR Software Works Best when Customized
The features that make an EHR easy to use, such as pre-filled templates, automatic code drop, and pre-determined diagnosis codes are the very things that cause compliance concerns. Think of the EHR as a tool that has to be sharpened and honed. It’s very effective if used correctly, but you have to learn how to use it safely, or you’re going to get hurt.
Most EHR software comes with pre-loaded E/M templates, which vendors probably will tell you are of the “plug and play” variety. Information systems experts and coders know that this is not necessarily the case. The Centers for Medicare & Medicaid Services (CMS) has not changed the E/M guidelines since 1997; however, the way the EHR captures data to support the levels of service has most definitely changed. Usually, the EHR configures the E/M templates in a manner similar to an audit tool, with a section for each of the key components: the chief complaint; HPI; ROS; past, family, and social history (PFSH); exam; and medical decision making (MDM). By working systematically, you and your IT staff can approach the development and customization of these templates in a way that ensures easy use and compliance within the final documentation.
Most EHR programs also have the capability to import documents. Scanning allows you to import a photo image of a document, to be stored in the patient’s chart. Establishing a direct interface between a lab or radiology department to import diagnostic results is a very efficient way to receive medical information into the patient chart. Having a consistent method of importing and cataloging these documents is important because it allows records to be easily identified and located at a later date. To meet compliance and patient care standards, all imported documentation must be reviewed and noted by the ordering physician before being stored in the electronic chart. Take it upon yourself to ensure that this is being done effectively and consistently.
Much of the custom work will be the IT department’s responsibility, with you acting as the compliance consultant. In smaller practice settings, your software vendor can be extremely helpful with the implementation process. Some EHR products offer users groups, which are online chat rooms offering a place for IT people, coders, and practice managers to post questions and discuss known issues. The bigger software companies provide seminars, conferences, and workshops on best-practice concepts and new initiatives. There is also an EHR discussion thread on the AAPC website where coders who are using the same EHR can “meet” and discuss.
Additional EHR Concerns to Address
Who Did What? Most EHRs have some “auditing” capability, where a behind-the-scenes look can identify which employee or clinician entered or edited which pieces of information. This allows you to see who is accessing the medical record (for instance, in case of privacy concerns), who is actually placing orders for medications and diagnostics, and where data entry errors might be occurring (to identify training opportunities). All EHRs should have signature and date recording ability for physicians and performing clinicians to meet the regulatory requirements of a legal medical record. This is one area where you can assist in workflow planning for compliance.
Procedure Templates: Most EHR software allows for easy documentation of office and surgical procedures. Templates should be designed to capture common elements of any given procedure, including anesthesia, informed consent, procedural elements, and follow-up instructions. When using these templates in a test environment, make sure the resulting procedure note makes sense, and your software default choices match the procedure that actually took place. For example, if your provider performs and documents a lesion excision, make sure your resulting note doesn’t document lesion destruction.
Annual Updates: Many of the EHR’s data lists, such as CPT® and ICD-9 codes, can be updated annually by the vendor, but often the vendor can provide only new codes. Frequently, the deleted and revised codes have to be edited individually and manually by you, or someone in IT, to ensure providers do not select invalid or deleted codes. One common issue in an EHR is that old diagnosis codes that are related to previous encounters remain in the patient’s list of chronic conditions, so the invalid codes can inadvertently be chosen again and again to appear on a claim form. Claim edits should be set up to prevent this from happening.
As you move forward with your implementation, other issues may present themselves. It’s critical for documentation compliance that you perform concurrent audits to review the EHR for completeness and accuracy as codes change, software is upgraded, and new providers begin to use the EHR. Having a comprehensive plan for EHR implementation that includes your participation in creating compliant EHR templates is essential. This implementation must include a comprehensive workflow evaluation to ensure that the EHR system your practice is using is configured in the best possible format as a legal medical record.
Pam Brooks, CPC, PCS, is physician services coding supervisor with Wentworth-Douglass Hospital in Dover, N.H.
April 4th, 2013
A physical therapy (PT) operation in Tennessee has agreed to pay the federal government for medically unnecessary services.
Therapists have struggled with payment policies over the last three decades as legislative efforts have employed methods that “supposedly” aim to bring the cost of services down by paying for the quality, rather than quantity, of care. Lynn S. Berry, PT, CPC, said “Therapists must juggle clinical concerns with documentation burdens to meet the challenge” of reimbursement.
While most therapists are meeting these challenges, a few have bent under the pressure of lowered payments. For example, Grace Healthcare, LLC and its affiliate Grace Ancillary Services, LLC (Grace) in Chattanooga, Tenn. On March 8, the Department of Justice (DOJ) and Office of Inspector General (OIG) announced that Grace’s therapy providers agreed to pay $2.7 million, plus interest, to resolve allegations of false billing for medically unnecessary therapy services.
According to the DOJ press release:
“The settlement resolves claims that in ten nursing home facilities in which Grace provided physical, occupational, and speech therapy for periods ranging from 2007 through June of 2011, Grace pressured therapists to increase the amount of therapy provided to patients in order to meet targets for Medicare revenue that were set without regard to patients’ individual therapy needs and could only be achieved by billing for a large amount of therapy per patient.”
Don’t let this happen to you. While waiting for more positive changes in the reimbursement system, there are things therapists can do to improve the current situation.
Properly Document when Using New G Codes and Severity Modifiers
To ensure you are compliant when rendering PT services, Berry’s recommendation is to “provide an audit trail by documenting in the medical record the G codes and severity modifiers, their rationale for use, and the pertinent tests provided. After the primary impairment goal is reached, a secondary impairment may be noted and treatment continued until the goal for that impairment is met or final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or secondary payer.” The G codes and severity modifiers for PT, occupational therapy, and speech-language pathology are noted in the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule.
Will Payment Challenges Get Better for PTs?
There is positive action taking place on the horizon. According to Berry:
“For PT, the American Physical Therapy Association (APTA) is already working on a new payment system. Their draft of an Alternative Payment System (APS), or the Physical Therapy Classification and Payment System (PTCPS), was released to members for comment March 15, 2012. The CPT® Editorial Panel in Memphis, Tenn., Oct. 2-3, 2012, fully supported their efforts. A workgroup will be started that is open to all advisors to rewrite the Physical Medicine and Rehabilitation Section of CPT®. This is a two-part, per session payment system: One set of codes for evaluations, and another set of per-session codes for treatments. Each combines consideration of the complexity of the visit and the severity or complexity of the patient’s condition. APTA expects this system to begin Jan. 1, 2015.”
When that system goes into effect, “therapists can then move forward to provide efficient, effective care for their patients and meet the challenge of high quality care at reasonable cost,” said Berry.
For more information on capturing proper reimbursement for therapy services, read the articles “Therapy Services: The Uphill Climb to Better Codes and Reimbursement” and “PTs Rise to 2013 G code Challenge” in March 2013 Cutting Edge.
March 14th, 2013
Both general ophthalmological services (92002-92014) and evaluation and management (E/M) codes (99201-99215) describe office visits for new or established patients. So, when should you apply the ophthalmological services codes rather than the E/M codes?
Generally speaking, ophthalmology services codes focus entirely upon the eye. If the provider is strictly evaluating eye function, report an appropriate code from 92002-92014. Although the eye codes won’t cover every situation, they will suffice for most exams. In addition, documentation requirements (especially the history) are less burdensome for the eye codes, relative to E/M services.
Revert to the E/M codes for services that don’t fit within the guidelines for eye codes. For complex or very difficult cases, you should use higher-level E/M codes. Similarly, lower level E/M codes will best describe follow-up visits and examinations for uncomplicated problems.
Like E/M codes, 92002-92014 distinguish between new and established patients. The rules for determining the patient’s status are the same for both sets of codes: A patient is established if any physician in a group practice (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months. The CPT® codebook contains a helpful “Decision Tree for New vs Established Patients” in the Evaluation and Management Services Guidelines near the beginning of the book, to help you select the appropriate patient status.
Additionally, general ophthalmological services—like E/M codes—are “leveled” to describe different service intensity. To report the evaluation of new or exiting conditions that have been complicated by a new diagnostic or management problem, use 92002 for a new patient or 92012 for an established patient. To report the evaluation of the complete visual system and treatment over the course of one or more visits, use 92004 for a new patient or 92014 for an established patient. These criteria are laid out in more detail in the CPT® codebook.
Note that individual payers may stipulate guidelines for reporting either 92002-92014 or 99201-99215. Although the above advice is generally correct, you must know your payers’ guidelines and follow their specifics.
March 1st, 2013