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Billing - Articles

Medi-Cal Coverage Criteria for Hospital Beds and Accessories
November 7th, 2018 - Raquel Shumway
Medi-Cal coverage of child and adult hospital beds and accessaries. What is covered and what documentation is required.
HCC - Acceptable Provider Interpretation for Diagnostic Testing
October 1st, 2018 - Wyn Staheli, Director of Research
The following table is taken from the Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance dated 2017-09-27 (see References). It is a listing of acceptable provider interpretation of diagnostic testing. Acceptable Examples include: Cardiology and Vascular Surgeons Echocardiogram (including Doppler, Duplex, Color flow of the heart vessels) EKG (electrocardiogram) – Stress test, Cardiac ...
Pricing for ASC’s and APC’s
August 27th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
Importance of Depression Screenings
August 16th, 2018 - Wyn Staheli, Director of Research
Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic ...
Dual Medicare-Medicaid Billing Problems
July 12th, 2018 - Wyn Staheli, Director of Research
It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added): A state plan must provide ...
Inappropriate Use of Units Costs Practice Over $800,000
June 11th, 2018 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?
June 8th, 2018 - Sharon Hoglund, CPC, CPMA, CEMC, CEMA
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed...
Three Ways Bundled Payments Can Be a Success
June 7th, 2018 - BC Advantage
Bundled payment models continue to attract interest for their potential benefits over traditional fee-for-service payment models. With bundled payments, also known as episode-based payments or packaged pricing, a group of providers is reimbursed based on a contracted price to cover all of the care and services related to a particular ...
Q/A: Coding for Lesion Removal and Repair
June 5th, 2018 - Chris Woolstenhulme QCC, CMCS, CPC, CMRS
The CPT book does not indicate repairs, measuring .5 cm and less, during lesion removal. Does this mean that...
Q/A: Modifiers for Injections
April 17th, 2018 - Nicole Olsen QCC
I'm currently receiving a rejection for my billing with BCBS. We've entered 20550 and 20600 as services for the visit....
Documentation for Enteral Nutrition
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for enteral nutrition. ...
Documentation for Negative Pressure Wound Therapy
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy.
Anthem Will Not Give Modifier 25 a Pay Cut
March 1st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Anthems original plan was to take a 50% reduction when providers reported claims using modifier 25, it was then lowered to a 25% reduction and has now been fully rescinded, to the relief of providers.  The policy was to go into effect March 1, 2018, however, due to strong opposition from ...
No HCPCS Code Available? Now What?
February 21st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
HCPCS level II codes classify products into categories for the purpose of claims processing. HCPCS level II codes are alphanumeric with a descriptive terminology that identifies the item or service used primarily for billing purposes. There are several types of HCPCS level II codes such as: Permanent National Codes Dental Codes Miscellaneous Codes Temporary National ...
Multiple Diagnostic Imaging Payment Reduction
February 1st, 2018 - Wyn Staheli, Director of Research
CMS and some other payers have adopted policies of reducing payments when certain multiple diagnostic imaging procedures (see Applicable Codes below) are performed in a single session by the same healthcare provider and/or group. They have done the same when there are multiple units for a procedure code. The rationale ...
OIG Reviews Medicare Advantage Claims
February 1st, 2018 - Wyn Staheli, Director of Research
On January 16, 2018, the OIG released a report of their findings on claims data for Medicare Advantage plans. While it appears that there were not significant issues, they did find that: "Types of potential errors included inactive or invalid billing provider identifiers; duplicated service lines; missing required data; inconsistent dates; ...
Physical Therapists: Rules For Nerve Conduction And Needle Electromyographic (EMG) Codes
February 1st, 2018 - Find-A-Code
According to Noridian L35081, nerve conduction code 95905 does not have levels of supervision 21, 22, 6a, 66, 77 or 7a assigned to it and is therefore not allowed by Physical Therapists. Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Tests Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law, ...
Reporting Tooth Numbers and Oral Cavity Areas
February 1st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
When billing for dental procedures you need to identify the exact tooth and/or location in the oral cavity. Qualifiers are used to report the location and tooth number. When billing procedures on teeth and the oral cavity, the JP qualifier is used to identify the tooth number(s) and the JO ...
Observation Z Codes
January 29th, 2018 - Find-A-Code
There are three observation Z code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected ...
Paravertebral Joint/Nerve Denervation
January 10th, 2018 - Find-A-Code
A facet joint is supplied by two medial branch nerves. Each medial branch nerve supplies sensation to one half of each facet joint above and below the spinal nerve of origin. Therefore, both of the two related medial nerve branches for each facet joint must be treated. The CPT codes 64635-64636 have a ...
Should ROM Testing be Reported with Evaluation and Management Services?
January 9th, 2018 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
Reporting the performance of range of motion testing (95851-95852) at the same encounter of an Evaluation and Management (EM) service, produces an NCCI edit resulting in payment for the EM service and denial of the ROM testing. Read the article to learn what other codes ROM testing is considered incidental to.

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Erythropoietin Stimulating Agents (ESA)
November 27th, 2017 - Wyn Staheli, Director of Research
Coverage ESA is typically covered for the following condition(s): Treatment of anemia associated with chronic renal failure (whether or not that patient is on dialysis) Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy Treatment of anemia due to AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) used in treatment of HIV/AIDS Treatment of selected ...
Escharotomy Procedural Cross-Walking CPT to ICD-10-PCS
November 10th, 2017 - Brandon Dee Leavitt CPC, QCC
An Escharotomy is used for "local treatment of burned surface" per the AMA Guidelines, when incisions are performed on the burn site. Notice, when cross-walking 16035 or 16036 to inpatient codes, Find-A-Code crosswalks lead to Body System H, Operation 8 - Division of the skin, and Operation N -...
New Payment Rulings Could Affect You
November 6th, 2017 - Wyn Staheli, Director of Research
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
Payment Rulings and Small Provider Practices
November 6th, 2017 - Wyn Staheli, Director of Research
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
Physicians Reciprocal Billing Arrangements
October 18th, 2017 - Chris Woolstenhulme, CPC, CMRS
A reciprocal billing arrangement is when there is an agreement between physicians to cover each others practice. A physician or his practice may set up reciprocal billing arrangements with one or more physicians to cover another practice or their own practice. There is certain criteria that must...
Dental Providers- So what are ICD 10 codes?
September 11th, 2017 - Christine Taxin
What has been your definition so far when asked about how they are different? What does an ICD-10 code look like? How does an ICD-10 code work? Have you seen commercials about medical coding schools and wonder if the profession is right for you? With the field expected to grow faster ...
Global Surgical Package: When to Bill and When Not to Bill, that is the Question
September 8th, 2017 - Stephanie Allard, CPC, CEMA, RHIT
The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.....
NEW Mandatory ABN Form to Take Effect June 21, 2017
August 17th, 2017 - Mario Fucinari DC, CCSP, CPCO, MCS-P, MCS-I
The Centers for Medicare and Medicaid Services (CMS) has revised the Advanced Beneficiary Notice of Non-coverage (ABN) Form. The revised Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be ...
If It’s Not a Consultation, What Is It?
August 16th, 2017 - Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
You thought you had a consultation supported in your documentation, and now you find out that you cannot bill the consultation codes (99241-99245, 99251- 99255). So, what are the top reasons for a consultation not to be supported? If the payer does not support these codes If the documentation does not support ...
United HealthCare Ending Consultation Reimbursements: Effective October 1st, 2017
August 15th, 2017 - NAMAS
While Medicare discontinued payment allowance for consultation services (ranges 99241-99245 and 99251-99255) in January 2010, many commercial carriers have continued to cover these services. United Healthcare is now joining Medicare's opinion on consultation services. In the June 2017 edition of the United HealthCare Bulletin, United Healthcare has announced that effective October ...
Requirements for Physicians Orders for DME/HCPCS
August 1st, 2017 - Chris Woolstenhulme, CPC, CMRS
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed may be denied ...
How to Bill a Dressing Change
August 1st, 2017 - Chris Woolstenhulme, CPC, CMRS
A dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602). Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable procedure code that, commonly but not necessarily, ...
Inpatient Compliance: Split-Shared Services
June 23rd, 2017 - Grant Huang
In the inpatient setting, a physician can combine his or her documentation with that of a non-physician provider (N.P.P.) to support an E and M service while billing the resulting code under the physician. This is called a “split-shared” service and allows physicians to bill at 100% of the fee ...
Modifiers: Reporting Wound Dressings
April 26th, 2017 - Chris Woolstenhulme, CPC, CMRS
When reporting dressings for wounds, it is important to indicate if the dressing is the primary or secondary dressing as well the number of wounds the dressing will be used for. Primary Dressing: May be therapeutic or protective coverings applied to wounds either on the skin or caused by an opening ...
Billing Dermal Filler Injections
April 20th, 2017 - Chris Woolstenhulme, CPC, CMRS
When billing dermal filler injections, separate payment may be made under the OPPS and ASC payment systems for HCPCS G0429- Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (lds) (e.g., as a result of highly active antiretroviral therapy). Use in addition: Q2026- Injection, radiesse, 0.1 ml, and Q2028 - Injection, sculptra, 0.5 mg With a diagnosis of B20 - ...
Treating TMJ
April 4th, 2017 - Chris Woolstenhulme, CPC, CMRS
Temporomandibular Joint (TMJ) Syndrome can include a wide variety of conditions that may be characterized as TMJ. Also there are a wide variety of methods for treating these conditions. Many of the procedures are excluded from coverage in the Medicare program for services or devices. There are other services and appliances ...
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
March 28th, 2017 - Chris Woolstenhulme, CPC, CMRS
Add the KX modifier to all claims for RADs and accessories for the first through third months if all thecoverage criteria have been met. Add the KX modifier to all claims for the fourth month and thereafter if all the coverage criteria have been met and if the physician signed and dated a ...
Devices Used for Treatment with TMJ
March 27th, 2017 - Chris Woolstenhulme, CPC, CMRS
Dynamic splinting systems or devices are used to assist in restoring physical function and are commonly used for treating TMJ. Injury or joint stiffness are diagnoses that may qualify for medically necessity. If physical therapy has proven ineffective to restore or improve range of motion, mechanical devices are often a next step. This ...
Reporting Unilateral Procedures
March 13th, 2017 - Chris Woolstenhulme, CPC, CMRS
Some procedures are unilateral such as D7840-Condylectomy. It is important to consult with your payer on reporting requirements. Some payers require two separate line items with a LT or RT HCPCS Modifier, while others require only one modifier to be appended to the claim. When billing a medical code for a Condylectomy, ...
New Taxonomy Codes Added for Glaucoma Specialists
March 8th, 2017 - Chris Woolstenhulme, CPC, CMRS
NUCC announced a new set of codes released 01/01/2017 with the effective date of 04/01/2017 for Allopathic & Osteopathic Physicians. For ophthalmology, the new taxonomy codes are specifically for Glaucoma Specialists in Healthcare. 207WX0009X Under the Allopathic & Osteopathic Physicians; Ophthalmology was added: Glaucoma Specialist - An ophthalmologist who specializes in the treatment of glaucoma and other ...
Alcohol and Tobacco Use During Pregnancy
March 3rd, 2017 - Chris Woolstenhulme, CPC, CMRS
If a mother uses alcohol or tobacco during pregnancy, be sure to assign O99.31 "Alcohol use complicating pregnancy, childbirth, and the puerperium." Document the time of the encounter (such as the trimester), during childbirth, or during the puerperium. NOTE: You also need to assign a secondary code from category F10- to identify manifestation of the alcohol use. The following ...
Care Plan Oversight Services
March 1st, 2017 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Care Plan oversight services is commonly done but rarely billed. The following codes can only be billed once every 30 days. The use of the following codes are determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period. G0179 MD re-certification HHA PT May be ...
Sleep Studies: Billing with Reduced Hours
January 12th, 2017 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
When using codes 95800, 95801, 95806, 95807, 95810, and 95811, and fewer than six hours of recording is performed, you must report the reduced services using modifier 52. Also, when using 95782 and 95783, and fewer than seven hours of recording is performed, modifier 52 would be appended to the appropriate code. 95805 would require modifier 52 if fewer than four hours of recording is performed. Medicare recognizes the ...
December 7th, 2016 - Wyn Staheli, Director of Research
All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing either Chapter 1.5-Fees of the Behavioral Health DeskBook or the Insurance and Reimbursement chapter ...
Dental Examination Prior to Kidney Transplantation
December 6th, 2016 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Despite the "dental services exclusion" in §1862(a)(12) of the Act (see the Medicare Benefit Policy Manual, Chapter 16, "General Exclusions from Coverage," §140), an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because ...
Billing for Prosthesis Designed and Prepared by the Dentist
December 6th, 2016 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
For maxillofacial services, if a prosthesis is provided, and is designed and prepared by the dentist, the Medicare Part B carrier may be billed with CPT codes 21076 through 21089. If the prosthesis is prepared by an outside laboratory, the laboratory bill goes to the Durable Medical Equipment Regional Carrier (DMERC), with Level ...
Shift Your Focus: The New Generation of Dental Billing
October 3rd, 2016 - Christine Taxin
More and more information emerges each day about the connection between certain serious medical conditions and poor oral health. Consider these headlines found in a recent dental journal: “Periodontal disease may have even more of an impact on overall health than previously thought,” and, “Biomarkers in Saliva Help Detect Early-Stage ...
10 reasons why medical practices prefer working with medical billing service companies!
September 29th, 2016 - Adam Smith
1. Training costs can save a healthcare organization over 8% of its operating expenses. A recent study states that teams who work with EHRs require an average of 53.5 hours of training at a cost of $3000. The cost of training a single physician amounts to $1540. That is a whooping amount for...
23 RCM questions you should ask when reviewing a medical billing company
September 29th, 2016 - Ango Mark
So, you have considered taking on the challenges of finding the best medical billing company for your medical practice. We should all by now know that the healthcare industry’s reimbursement laws aren’t going to stay put and be as they are. The changes they undergo are constant and...
Dental Offices - Billing Medical Insurance for covered procedures
September 12th, 2016 - Christine Taxin
If your dental office isn’t billing medical insurance for certain procedures, you’re missing out on an important way of serving your patients and expanding your practice. Currently, only about 64% of Americans are covered by a dental insurance plan. But the Affordable Care Act requires nearly 100% of Americans to be covered ...
1500 Claim Form Tips
August 3rd, 2016 - ChiroCode
The following rules for the 1500 claim form are excerpts from NUCC and Medicare instructions, but they are generally universal and apply to claims submitted either electronically or on paper. Please note that payment rules can change frequently for any payer, so consult with specific insurance payers for their adaptations. The ...
3 Steps To Be As Successful As University Of Virginia’s Medical Group Practice.
July 19th, 2016 - Adam Smith
How keeping track of the key performance indicators has given this group practice an edge over its competitors in handling the revenue cycle… The shift to value-based economic systems has de-stabilized many healthcare organization’s economic dispositions. Group practices endured...
6 Simple steps to create secondary claims using eClinicalWorks!
March 16th, 2016 - Victoria
With the help of web analytics , question and answer websites, forums, we came across the most searched queries . And, today we will discuss one of them. We reached out to Sophia Johnson,eClinicalWorks billing specialist at PracticeBridge to share her insights and she provided us six simple steps to...
How to submit Medicaid/Medicare secondary claims electronically using eClinicalWorks!
March 15th, 2016 - Victoria
It has never been a cakewalk working with an EHR. You know how tough it can be, if you don’t have an eClinicalWorks expert to help you with billing needs. What do you do when you are not aware of a certain feature or a procedure? We reached out to some organizations to know how what they did...
Net Collection Ratio
December 29th, 2015 - Codapedia Editor
The net collection ratio is a calculation that shows the practice how much money they are collecting of the money, which they could have collected after insurance adjustments. It is an excellent measure of how well the practice is doing in collecting accounts receivable.
Post-operative Hospital Visits
October 15th, 2015 - Betsy Nicoletti, M.S., CPC
In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and in a CMS Fact Sheet.
The Critical Role Of Hospital CFOs: A Data Driven Answer [Infographic]
October 6th, 2015 - Adam Smith
We know the evolving role of CFOs in the healthcare industry. There are situations which have forced the executives to make such decisions like changing the vendor, attritions and outsourcing one or more of their processes. There could be ample reasons like transition to value-based model, slow...
How to research coding questions
June 1st, 2015 - Christina Benjamin
How to Research Answers to Coding Questions Perform a search of the discussion board or listserv website prior to posting a new question. For your search terms, include specific words such as the diagnostic statement or procedure statement or the specific code number or ...
Money In Your Pocket: Balance Bill
December 4th, 2014 - Donna Weinstock
Do you routinely balance bill your patients? Do you send the statement as soon as you hear from insurance or do you wait until the end of the month? Balance billing your patients is essential for several reasons. First, it increases your revenue. It may not seem like a lot of money, but the...
CMS: Lot of errors billing psychotherapy services when E/M visit is involved
October 15th, 2014 - Scott Kraft
The Comprehensive Error Rate Testing (CERT) program Medicare uses to assess the accuracy of provider billing has uncovered a big source for mistakes – documentation problems when a patient is receiving psychotherapy services on the same date as an E/M encounter, according to CMS. There are...
Consult Documentation Guidelines
September 3rd, 2014 - Jeannie Cagle, BSN, RN, CPC
By Jeannie Cagle, BSN, RN, CPC For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following: · ...
The Benefit of Checking Benefits
September 3rd, 2014 - Donna Weinstock
Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure? In many cases outpatient procedures and...
‘Two midnight’ rule draws lawsuit – enforcement currently delayed
August 5th, 2014 - Scott Kraft
The American Hospital Association is leading the charge in a lawsuit against CMS’s controversial “two-midnight rule,” instituted last year to attempt to slow down the expanded use of observation status by hospitals by presuming that any stay intended to cover two or more midnights...
CMS NCD drops clinical trial requirement for FDG PET scans for solid tumors
May 6th, 2014 - Scott Kraft
Patients no longer need to be in a CMS-approved clinical trial for physician practices to get paid for doing as many as four FDG PET scans for solid tumors – one for an initial treatment strategy and three to guide subsequent treatments, according to CMS transmittal 8739 to its Medicare Claims...
Medicare fee schedule’s big pay cut probably temporary – big PQRS change likely permanent
January 3rd, 2014 - Scott Kraft
CMS released Medicare’s 2014 Final Physician Fee Schedule rule on Thanksgiving Eve, delayed from its usual November 1 release by the government shutdown earlier this fall. Fee schedule followers won’t be surprised to see CMS finalize a 20.1% average cut to payments next year,...
Bevy of changes make figuring out 2014 Medicare payments more complicated
January 3rd, 2014 - Scott Kraft
Some years, it is relatively simple to project how your Medicare payments will change for the services rendered. When the only factor in Medicare’s complicated payment formula that changes is the conversion factor, the percentage change in your payment is identical to the percentage change in...
Hospital discharge, nursing facility admit billable on same day by same provider in most instances
November 18th, 2013 - Scott Kraft
Medicare will typically pay for a hospital discharge service (billed with 99238-99239) and a nursing facility admission visit (99304-99306) when billed on the same date of service (DOS) by the same provider without the need for a modifier. As always, however, there are a couple of exceptions. The...
Look for standard use of remittance advice codes in 2014
September 6th, 2013 - Scott Kraft
Confusion over how to respond to electronic remittance advice (ERA) will hopefully decline in 2014, thanks to efforts from the Council for Affordable Quality Healthcare (CAQH) to streamline and standardize how payers use ERA codes to convey why your claims are being denied or rejected. These...
Hospital Observation Services
August 28th, 2013 - Dorothy Steed
Hospital observation services are considered outpatient services. They are typically used when a period of time is needed to evaluate the progress or regression. This may include effectiveness of medication/ infusions, results of diagnostic results or other reasons deemed as medically necessary....
Charging Medicare Patients for Missed Appointments
June 20th, 2013 - Cyndee Weston
Previously, each Part B office had their own requirements regarding charging Medicare patients for missed appointments. TRICARE (TriWest Healthcare Alliance) regulations required providers to establish office practice policies regarding "no show" fees and required beneficiaries to sign an...
Selecting a Third-Party Collection Agency and Choosing the Correct Collection Program
June 20th, 2013 - Frank Murphy
Increasing cash flow through the use of a modern, third-party collection agency is a must for practice survival. With states reducing government funding and third-party payers reducing allowables, more and more dollars are being transferred to patient responsibility. Practices now must trim...
How to Manage a Hospital, 101
May 1st, 2013 - Robert Jordshaugen
CEO - stop "Making decisions." If the data and metrics are correct, the decisions are self evident. Spend time instead developing your team, your culture of communication, and ensuring that you are measuring the right activities. Stop managing departments and start managing patients. The...
Charge capture: Paper and Electronic Encounter Forms
May 1st, 2013 - Codapedia Editor
Physicians and Non-Physician Practitioners (NPPs) may want to distance themselves from coding, but implementing an Electronic Health Record (EHR) moves them in the opposite direction. If using an EHR, after completing the note, the clinician selects the CPT® and ICD-9 codes (the procedure and...
Who Qualifies for TCM Services?
April 22nd, 2013 - Lacy Gaskins
Any patient post-discharge whose medical and/or psychosocial problems are complex enough to require TCM services qualifies for these codes. Here are the specifics:   1. Location: “TCM is for higher-risk patients being discharged from an inpatient or observation status to their home, rest home,...
Keeping Track of Your Surgeries
March 22nd, 2013 - Debra Sanders
When working my AR, I work my surgeries separately since that is my big money or bulk money. I want to make sure I get that money in as quickly as possible. For me, I created an excel spreadsheet. The columns are: DOS - PATIENT NAME/MRN - PROC NAME - CARRIER(S) - CPT® - MODIFIER - BILLED -...
No Claim Left Behind
March 22nd, 2013 - Shannon Bosley
Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims. Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons. I even have a little dance that I do! Why not? We need to get...
Why Get Into Medical Billing?
March 22nd, 2013 - Debra Sanders
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over 15 yrs and still learn something new every day. I even learn something I...
Graphical Coding as part of EMR clinical workflow
March 22nd, 2013 - Robert Jordshaugen
The way to ensure a high performing EMR implementation is to fundamentally rethink processes to match what is technologically appropriate, rather than automating existing workflows. Instead of using the existing HIT EMR systems from the major vendors as the workflow driver, start with a sample of...
September 18th, 2009 - Charlene Burgett
In an attempt to make the ABN more understandable for my physicians and staff, I developed this explanatory paper that is specific to our office; however, the basics apply to all offices. Charlene Burgett,MS-HCM,CMA(AAMA),CPC,CCP,CMSCS,CPM Administrator, North Scottsdale Family Medicine POMAA...
Modifier -24
June 21st, 2009 - Crystal Reeves, CPC, CMPE
Modifier 24 is used to indicate that an Evaluation and Management service was provided by the surgeon to a patient within the global period of a major or minor surgery. The claim must be accompanied by documentation that supports that the service is not related to the postoperative care for the...
Billing for no-shows
April 30th, 2009 - Codapedia Editor
CMS clarified in 2007 that a physician practice may bill Medicare patients for failing to keep an appointment. The CMS MedLearn matters article is attached as a resource. Check with your state Medicaid to see if you can bill Medicaid patients. If you are billing Medicare patients, this must be...
How to bill for Well Woman Exams (WWE)
April 15th, 2009 - Charlene Burgett
Well Woman Exam Coding There are options for billing pelvic exams and Pap smears for non-Medicare payers, albeit inconsistently by health plan. Some health plans will pay G0101, Q0091, S0610 and/or S0612. Some will pay one or another, some will pay a combination of two, others will pay certain...
Incident to Billing or Incident to Service
April 10th, 2009 - Jeannie Cagle, BSN RN CPC
By Jeannie Cagle, BSN, RN, CPC This question appeared in a recent list serve. My two responses are based upon two different assumptions: (1) both providers are physicians, and (2) one of the providers is not a physician. The principal points are that each physician has a unique National Provider...
Using denial tracking to improve collections
April 10th, 2009 - Codapedia Editor
Here are some examples of denials that a practice should track to be sure that they are paid correctly by the insurance company. Set up a denial type for each of these. Fee Schedule Issues: Wrong amount paid per the contracted fee schedule. May be too high or too low Modifier 80...
Using Modifer -59
March 31st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not...
Real Time Claims Adjudication (RTCA)
March 31st, 2009 - Codapedia Editor
Real time claims adjudication (RTCA) is a software interface between a physician's practice management information system and a payers claims processing system that allows the practice to submit a claim at the time of checkout, and receive a response from the insurance company while the patient is...
Denial tracking
March 30th, 2009 - Codapedia Editor
Claims denials have the following outcomes, none of them good: Collection of revenue is delayed Collection for the service never happens Staff members spend time and energy researching and resubmitting claims The denial is lost in the A/R system and never worked There are...
Copying insurance cards
March 30th, 2009 - Codapedia Editor
Is your office copying insurance cards? I have three words of advice: Just stop it. I am amazed at how often I see front desk staff doing this. They ask for the card. Get up from the desk. Walk to the copier. Hopefully, no one else is using it right then. Copy the front. Wait. Take the copy...
The cost of no-shows
March 30th, 2009 - Codapedia Editor
What is a no show in your practice? a huge relief: now we can get caught up lost revenue you can never make up Of course, the answer is both. From a financial perspective, it is critical to keep no shows to a minimum. It is a good idea to track no-shows, to see what they are costing...
Registration policies
March 30th, 2009 - Codapedia Editor
Years ago, we scheduled patient visits in a big book, penciled in the patient name, phone number and reason for the visit. We were done. Now, most practices are using a computerized scheduling system, that allows more than one person to schedule at once (remember passing "the book" back...
March 30th, 2009 - Codapedia Editor
One of the most common sources of denials in physician practices is "patient not eligible for this date of service." The patient presents with an insurance card, the office copies the card, and stores the information. The practice provides service, and perhaps collects a copay, and then...
How to analyze and diagnose a low collection rate
March 5th, 2009 - Elizabeth Woodcock
Woodcock & Associates has provided a diagnostic tool for you to download. Click the Resources link above to get the PDF file.
Accounts Receivable Benchmark Data
February 6th, 2009 - Codapedia Editor
Accounts Receivable benchmark data includes a measurement of the gross collection rate, the net or adjusted collection ratio, an aging report, or an aged trial balance and the total days in accounts receivable outstanding. It is critical for physician practices to measure and track this data on a monthly basis and to compare that data with national standards.
Completing encounter forms
January 29th, 2009 - Codapedia Editor
“Collecting the money is out of my hands.” How many times have we heard physicians express this sentiment, both as wishful thinking and as a statement of fact? Physicians often overlook the most important step in the billing and collection process: telling the billing office what...

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