Cracking the code on healthcare revenue cycle management topics for medical practice managers.
Revenue Cycle Decoded Gena Cornett, MBA, CPC, CPB
Cracking the code on healthcare revenue cycle management topics for medical practice managers.
Are Your Billing Errors Costing Your Patients?
Are Your Billing Mistakes Costing Your Patients Money?
Hi, everyone, welcome back to Revenue Cycle Decoded where we are cracking the code on revenue cycle issues. Today, I just wanted to riff a little bit on a topic that kind of chaps my hide a little bit, and that topic is billing errors that are costing your patients money or time.
So, let’s get started with this topic. The reason that I wanted to talk about this topic today is that I just received a bill from my dentist. Of course, dentists are not fun in the first place, at least not usually, but getting a bill is even more not fun. You want to be billed accurately from your dentist, and unfortunately, this bill was not accurate. So let me tell you a little about it.
I went to the dentist and had a cleaning and received the bill. I’m in network. My health plan is in network, the dentist is in network with my plan, I should say, and so they submitted the claim to the health plan. The EOB came back to the dentist with a denial for one of the services that was billed for the reason it cannot be billed on the same day as another service that they also billed for.
So, lets’ break that down. If there is an administrative denial on a claim because two services can’t be billed together on the same date of service – that's an administrative denial – you can’t then go and balance bill your patient for that according to your contracts with your payors. Unless, you know, it’s something that is not normally covered by the payor and you’ve received the patient consent to cover that, that’s a different story. You have to explain to the patient that this is a service that isn’t normally covered by the payor and therefore if the patient wants it to be performed, then they would be responsible to pay for it; they sign a consent stating that they are going to be responsible for that service and then you can balance bill the patient. But in this case, it was an administrative denial, the reason being that the code itself – the HCPCS code – specifically states that it cannot be billed with the other service on the same date of service. It’s the intent of the code.
So, they had seen the denial on the EOB but they had added back the portion for the denied service onto my patient responsibility and sent me a statement for that amount. Now because I am a certified coder and a certified biller, I immediately questioned, “why am I being billed for a service that was denied?” I looked up the codes so I understood exactly what I was being billed for, and I also looked up their professional association guidelines from the American Dental Association and found that there is indeed a specific guidelines for these two codes which states that because of the code definition of one of the codes, they cannot be billed together on the same date of service and it recommended other codes that can be billed for an exam, for example. Then, I also contacted my payer to make sure that this was an administrative denial and that I was correct that the dentist cannot bill.
So, the good news is, I did call my dentist and talked to their front office person who will forward my concern to her manager, but interestingly, when I discussed the issue with the claim, she stated, “We’ve never had somebody bring this up before.” Now that gives me a bit of a pause because that tells me they may be routinely billing these two codes together and patients who are not certified coders and certified billers may not understand the reason that they are getting balance billed and they may just be paying the bill. In other words, they may be paying something that they really, legitimately don’t owe and the fact is that the office is incorrectly billing them and it’s costing the patients money, or at the very least, time, as it did me, to look up the error and inform the office of the error.
Hopefully, the next statement that I get, the error has been corrected and the amount
Everything You Need to Know About the 2023 E/M Guidelines
Hi, everybody. In today’s podcast, we’re going to talk about the new 2023 guidelines for evaluation and management codes and how they might impact your providers and your practice. But first, Welcome to the Revenue Cycle Decoded Podcast. My name is Gena Cornett and I help medical practice managers like you get the revenue cycle edge in your practice. I am passionate about helping you learn the skills you need to be a revenue cycle hero, advance your career, and improve your financial results.
Let’s dive right in to the 2023 changes to the E/M guidelines. In 2021, AMA released changes to the guidelines for coding office and other outpatient evaluation and management services. The guidelines were intended to reduce the administrative burden placed on physicians. But, because the guidelines were only changed for outpatient visits, physicians and other qualified healthcare providers were faced with managing two sets of guidelines if they saw patients in other settings such as inpatient, critical care, emergency department, or post-acute settings. Now, for 2023, AMA’s CPT® Editorial Panel has approved revisions to the rest of the E/M code section, which will include E/M services provided in these other settings.
According to the AMA, the revised guidelines include:
New descriptor times (where relevant).
Revised interpretive guidelines for levels of medical decision making.
Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services).
Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam).
So to review the changes that will take place: Medical decision making or time will be used to level the E/M code for E/M codes that have levels of services. The provider must include a medically appropriate history and/or physical exam when performed, but the history and exam will not be used to determine the level, and the provider determines the nature and extent of the history and/or physical exam. This guideline brings the E/M codes for hospital inpatient and other settings in line with the guidelines for outpatient E/M leveling. This should, theoretically, lead to less time spent by the physician documenting history and exam and perhaps less cloning of information in the EMR, which is a practice the physician should avoid anyway, although with outpatient documentation in the specialty in which I practice, I have not seen a significant decrease in cloned or “pulled forward” information.
Within each category or subcategory of E/M service based on MDM or time, there are three to five levels of E/M services available, but you have to remember that you can’t interchange levels among different categories or subcategories. For example, a new patient outpatient E/M 99202 is not the same thing as an established patient outpatient E/M 99212 – you have to read and understand the definition for each level in each category or subcategory. And the concept of MDM does not apply to the outpatient visit code 99211, which is used most often for an incident-to nurse visit, or to 99281 which describes emergency department evaluation and management services that may not require the presence of a physician or qualified healthcare provider.
Medical decision making levels are either straightforward, low, moderate or high; and three elements define medical decision making:
The number and complexity of problem(s) that are addressed during the encounter;
The amount and/or complexity of data to be reviewed and analyzed;
The risk of complications and/or morbidity or mortality of patient management.
Let’s look at each of these elements:
The number and complexity of problems addressed is pretty straightforward. Keep in mind that just because the documentation includes a laundry list of problems, doesn’t mean all the prob
You Can't Afford Not to Invest in Yourself
Hi, everybody. In today’s podcast, we’re going to talk about how not investing in your professional development can hurt your career and how you can constantly improve your knowledge and skills as a practice manager. But first, Welcome to the Revenue Cycle Decoded Podcast. My name is Gena Cornett and I help medical practice managers like you get the revenue cycle edge in your practice. I am passionate about helping you learn the skills you need to be a revenue cycle hero, advance your career, and improve your financial results. [Opening music]
Let’s talk about continuing education and learning in this field. It’s important for anyone to continually learn and improve but it’s even more important in the healthcare space. A mistake you can make which will hold you back in your career and keep you from the success you could achieve is believing that it’s too expensive to invest in your professional development. Healthcare moves fast and compliance and regulations, billing and coding, reimbursement and payor policies are updated and changed all the time. It is a constantly evolving world, and if you’re not evolving with it, you will get left behind. The people who move up the career ladder are those who prove their value because they learn and develop and invest in themselves and their professional knowledge. There’s a reason highly successful practice administrators and healthcare executives join professional organizations, take courses, earn certificates and advanced degrees – they know that knowledge is power and every bit of knowledge and experience they gain gives them an extra edge on their career path over someone who is complacent, doesn’t improve, doesn’t update, and is willing to just settle where they are or who thinks they already know it all.
Being willing to be a lifelong learner and investing in your own professional development proves to your organization that you are coachable, that you have a growth mindset, and that you are going to bring your best game to the needs and challenges the organization faces. And you are opening up doors to advancement in your current organization and in future roles.
Many organizations are willing to join you in this investment in yourself, either through n-house training, tuition reimbursement, or paying for your continuing education. Explore opportunities through your supervisor and your companies' human resources department. But even if your organization doesn't currently provide financial assistance, it’s still important for you to invest in yourself, either in time or dollars or both. If money is an issue, there are many low cost and even free opportunities for professional development, and even more expensive offerings can often be financed or put on a payment plan. Where there is a will, there is a way.
Let’s talk about some of the opportunities to continue your education in healthcare practice management and, of course, my favorite, revenue cycle. One of those opportunities is formal education. When I began my career in healthcare many moons ago, it was as a pediatric nurse with a bachelor’s degree in nursing. After a detour to the mommy track that led to my nursing skills becoming rusty, I decided that the best way to re-enter the workforce and advance my career would be through healthcare management, so I went back to college for a master’s degree in business administration and I specialized in health organization management with an emphasis in medical group management. You may have come into practice management from a similar clinical background. Or you may have worked your way up in the medical office to a practice manager position. If that’s the case, a degree in healthcare administration can help to fill in the gaps between your clinical experience or hands-on experience, and the tools and skills you need to excel in managing the medical practice.
Teamwork Makes the Dream Work
Hi, everybody. In today’s podcast, we’re going to talk about one of the biggest mistakes practice managers make, and that is not involving their team in solving their revenue cycle issues. But first, Welcome to the Revenue Cycle Decoded Podcast where I help medical practice managers like you get the revenue cycle edge in your practice. I am passionate about helping you learn the skills you need to be a revenue cycle hero, advance your career, and improve your financial results. [Opening music] Today we are talking about teamwork in revenue cycle. You have heard the phrase, “teamwork makes the dream work” and it is just as true in revenue cycle as it is anywhere else. If you have a practice where you have an incredibly involved team in all aspects of managing the revenue cycle, congratulations! You probably have an extremely high performing team. However, some of you may be newer in practice management or newer in revenue cycle and you may be trying to take on everything yourself or solve all the problems yourself. First of all, this is a recipe for burnout. As a practice manager, you wear many hats, and you cannot do everything in the practice on your own. There just aren’t enough hours in the day. Secondly, if you try to solve all the problems, you are probably not going to come up with the best solutions. You may waste days or months researching when a team member may already know the answer or a potential solution that would solve the problem. Even if you do come up with a great solution, your team will probably not be invested in making the change, and then you set yourself up for a conflict with your team, or for your team to feel blamed or to undermine your solution.
If you manage a large practice or a practice with multiple locations, departments often function in silos. Departments may not talk to each other or may not share essential information that is needed to solve the issue. For example, you may have an issue happening in your front office processes leading to denials or rejections. The front office may not realize they need to obtain prior authorizations because the payor requirements have changed, but they weren’t made aware. Or they may have trouble getting authorizations, or payor gateways may not work properly, or payors may be slow to provide authorizations, but the information doesn’t get communicated to the clinicians and providers. It could be eligibility verifications; it could be new people not understanding what they need to do who are still in that learning phase. So, you have these denials and rejections coming across and your accounts receivable folks are seeing them but that information may not be getting communicated up to the front desk. We’re not necessarily closing that loop.
It could be middle revenue cycle processes such as physicians not understanding what is required in the documentation or not understanding a medical policy or not realizing why backend coders are sending queries, to get the most accurate information in the chart. Again, maybe that information is not getting communicated back to the physicians and the clinicians to close that loop and help them understand what they need to be doing to not get denied.
And, it could be your backend revenue cycle processes. Your accounts receivable or billing staff may be coming across an issue but like we said, it’s not getting reported across the organization and up to other departments so that they can take care of the issue or provide training.
So having department meetings bringing in the key team members together gives them the opportunity to discuss the issues and problems and to share information across departments. You’re also bringing in your problem solvers where they can brainstorm potential solutions, come up with ideas to solve the problems and then you can implement them to see how they work. Another benefit is that when the team is involved, they are invested in the solution
Front End Revenue Cycle - What Could Go Wrong?
In this episode, I discuss four processes that can break down in the front end of the revenue cycle that will cost you time and money.
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Making Sense of Medical Necessity
Hi, and welcome back to Revenue Cycle Decoded where we are making sense of revenue cycle for medical practice managers. Today, I’m talking about meeting medical necessity. So, what exactly is medical necessity and why does it matter when you are coding your claims? Well, our payers consider whether a treatment or service we provide is medically necessary for the patient’s condition on the date of service, and if so, the claim will be paid, assuming we submit a clean claim and everything else on the claim is correct, and the treatment is medically necessary to care for our patient on that date of service. In that case, we would meet medical necessity according to payer guidelines. However, payers also may decide that some treatments are not medically necessary for that patient on that date of service for a variety of reasons, and we’ll look at a couple of examples here in a minute. But for example, if a treatment is considered to be investigational or experimental, in that case, the payer likely will not consider the treatment to be medically necessary and they may not pay you if you perform that treatment for your patient. Another reason would be if we performed a treatment that doesn’t match up with what the patient’s condition is on that date of service. So how does a payer tell if a treatment or a service that we provided matches up with the patient’s condition to determine if it’s medically necessary. Well, the way is ICD-10 codes and CPT or HCPCS codes. As we know, computers understand computer language, they understand numbers. We submit these codes on our claims. Our ICD-10 codes tell the payer why we did what we did on the date of service. This is the diagnosis, or the diagnoses, of the patient’s condition or conditions. And then, the CPT or HCPCS code(s) tells the payer what we did. And so, if what we did matches up with why we did it (the ICD-10 code), that all links up and makes sense, then it meets medical necessity. However, if it doesn’t, then it wouldn’t. So, let’s look at an example here. In the first case, we have a patient who has presented to us with a displaced comminuted fracture of the left tibia. Now, one of the treatments for this, in addition to perhaps surgery, would be placement of a long leg cast. According to best practices, this would be one of the treatments provided for this condition. So, in this case, the ICD-10 code would match up with the CPT code that tells the payer what treatment we provided for the patient’s fracture. That way, the payer sees that this treatment is medically necessary, and they pay for the treatment. But if we submit on our claim an ICD-10 code, a diagnosis of why we did something, and a CPT or HCPCS code, the “what” we did, and it doesn’t match up or link up in the payer’s system, in this case, it’s going to not meet medical necessity and it’s going to get denied. So, what’s an example of this? In this case, we have a patient who has presented with a sprain of the left ankle, and we’ve applied a short leg cast. Well, that wouldn’t usually be the treatment for a sprain, a simple sprain of the ankle, where the physician may recommend wrapping the ankle or putting ice on it, but we generally are not going to cast a sprained ankle. And so, those codes don’t match up – they don’t make sense to go together. And so, your payer system is going to recognize that and deny that claim as not medically necessary if it was submitted this way. Now, what does the payer say? Well, we are going to have to check the payer policy to see what they consider to be medically necessary for a specific condition. And they may not have a policy for everything, but for the things that you are doing in your office, you certainly should be aware if they do have policies. For Medicare, this will be your Local Coverage Determinations or your National Coverage Determinations and also your Local Coverage Articles. Since 2019, Medicare has been moving the