coding Archives - Capko & Morgan

Time for a review of your E&M/office visit utilization? (DOWNLOAD free spreadsheet.)

Office visits represent a huge proportion of revenue for most practice types. It's easy for small errors in coding to become habitual, and the resulting inaccuracy can be costly for your practice. Under-coding can mean lost revenue -- multiplied by hundreds or even thousands of visits per year. Accidental over-coding can lead to revenue clawbacks that create accounting hassles and make it more difficult to accurately project revenue. Payers are very concerned about E/M accurate coding, too. That's why any variation (not just over-coding) can be a trigger for a payer audit. Checking your E/M coding patterns against Medicare's utilization data for your specialty is a quick way to spot possible problems. If your or your practice's code utilization differs significantly from national data and the reasons aren't immediately clear, it could be time for a closer review or internal chart audit. Getting your hands on the CMS data, then entering it into a spreadsheet, can be a bit time-consuming -- but we've taken care of some of the grunt work for you. Follow the links below to download a spreadsheet that already has the CMS 2017* data keyed. It includes formulas to calculate your clinicians' or your practice's utilization of each code, and compare it with the national averages. Just enter your data and get your results immediately. Allergy and immunology Cardiology Dermatology Endocrinology Family practice Gastroenterology General practice General surgery Internal medicine Neurology Neurosurgery OBGYN Orthopedic surgery Otolaryngology Psychiatry Pulmonary disease Rheumatology Urology Need a different specialty? Contact us and we'll pull it together for you, provided the CMS has published data for it. Besides comparing against the CMS numbers, we recommend you compare your clinicians' numbers against each other. Sometimes, differences in utilization make perfect sense -- such as when the doctors see distinctly different patient populations. But not always. If the variances don't look logical to you, it's time to take a closer look. You may find it's time to bring in an E/M coding expert for a customized refresher course and/or chart audit. (If you need this help, contact us.) *here's a link to

By Morgan|2019-02-27T15:32:20-08:00February 27th, 2019|

Distrust of medical bills: another obstacle in collecting from patients

Did you happen to catch this New York Times Magazine article last month? It begins with a moving story of an uninsured patient who suffers a terrible brain hemorrhage. Thankfully, she gets timely, effective treatment -- but her condition requires many expensive services, including an air ambulance. Her bills totaled about $500,000. Although the patient had assets like a vacation home and savings, the amount she owed was greater. As the article describes the patient's profound stress in dealing with huge, unexpected bills while recovering, it seems clearly headed toward a case for single payer. However, it takes a rather astonishing twist along the way. The twist? The piece proclaims that little-known villains are secretly contributing to skyrocketing patient bills and healthcare costs: medical coders. "The guerrilla tactics of providers' coders," the article argues, involve deliberately manipulating physicians' codes -- i.e., diagnosis codes -- to create higher bills. If you are a practice manager, biller, coder, or independent physician reading this for the first time while sipping your coffee, perhaps you just spit it out in shock (like I did). Because while there may be billers and coders out there who have been urged to make up diagnoses to generate higher bills, I've never encountered one. I can only imagine "guerrilla coders" are exceedingly rare. The billers and coders we work with have enough to do just trying to get their physicians properly paid for the work that they've actually done (!). Physicians, billers, and coders have to work with the codes our entire industry uses to determine payment based on services rendered. If they aren't careful and don't check that all services are properly coded, practices (and hospitals) will receive less than payers have promised them for the work that they do. This is the problem billers and coders are trying to solve: Making sure their physicians and organizations aren't underpaid for services performed. That a trusted voice like the New York Times is promoting such a sinister impression of medical coding (among other inaccuracies in the piece) really bothered me. But something else bothered me more. Among the

By Morgan|2022-01-01T22:51:51-08:00April 24th, 2017|

When did you last review your E&M/office visit utilization? (DOWNLOAD free spreadsheet.)

Office visits represent a huge proportion of revenue for many practice types. Consistently accurate coding of office visits is important to avoid costly under-coding or inadvertently coding above the level that applies, which could lead to revenue take-backs. Since the E/M range constitutes such a huge piece of the overall reimbursement pie, payers are very concerned about accurate coding, too. That's why E/M coding can be a trigger for a payer audit if your practice's utilization appears unusual. One way to check your office visit coding patterns to see how they conform to other practices in your specialty is to compare your utilization of each code to published CMS data. If you find that your clinicians' coding diverges noticeably from national data, and the reasons aren't immediately clear, it could be time for a closer review or internal chart audit. Besides comparing against the CMS numbers, you can compare your clinicians' numbers against each other. In our consulting, we often find that physicians in the same practice will gradually skew in different directions (some coding a little higher than the average, some a little lower) over time. Sometimes, differences in utilization make perfect sense -- such as when the doctors see distinctly different patient populations. But not always. If the variances don't look logical to you, it's time to take a closer look. You may find it's time to bring in an E/M coding expert for a customized refresher course and/or chart audit. (If you need this help, we can refer you to excellent resources. Just contact us.) Getting your hands on the CMS data, then entering it into a spreadsheet, can be a bit time-consuming -- but we've taken care of some of the drudgery for you! Follow the links below to download a spreadsheet that already has the CMS data keyed, plus is set up with formulas to calculate your clinicians' or your practice's utilization of each code, and compare it with the national averages. Allergy and immunology Cardiology Dermatology Endocrinology Family practice Gastroenterology General practice General surgery Internal medicine Neurology Neurosurgery OBGYN Orthopedic surgery Otolaryngology Psychiatry Pulmonary

By Morgan|2017-03-27T08:11:52-08:00March 25th, 2017|

Avoiding insurance errors, problems tops the list of medical billing priorities

Capko & Morgan has had the honor of collaborating with the MedData Group on several recent MedData Point surveys. This month, we worked together on one of our favorite subjects: billing and collections. The results may reflect some subtle but interesting changes to recent trends. For the past few years, it has seemed that the dramatic increase in patient payment responsibility was the focus for most practices. According to this new survey, patient payments are still a very pressing concern for most practices (53%). But this issue was edged out for the top concern by coding errors and other denial causes, which 59% of respondents considered very pressing. We wonder if this is related to narrowing of networks, increasing pre-authorization demands from some payers (mentioned by 49% as a pressing issue), lingering ICD-10 issues, or some combination of the three. Not surprisingly, AR and bad debt are still top-of-mind medical billing problems (49%). We were a bit surprised, though, that preparing for new payment models was only a pressing concern for about a quarter (28%) of respondents. But the CMS is also projecting that most practices will hold off on alternatives to fee-for-service payment, at least for now. Only 25% of respondents put adding or enhancing billing technology on the list of key concerns. We’d love to see more practices take advantage of the growing array of innovative, affordable tools to improve collections from patients and health plans alike. These results seem consistent, though, with what we found in another recent MedData Point survey: practices may not be aware of all the new front office solutions that can make their practices more efficient and profitable. Our consulting group is delighted when we get the opportunity to help practices get more from technology, including systems they've already invested in, especially to improve billing and revenue capture. Contact us if you'd like to explore how we can help.

By Morgan|2022-01-01T22:51:55-08:00July 20th, 2016|

Internal chart audits, the basics, part 2: conducting the audit

Conducting an internal chart audit require team effort to plan, execute and analyze the results. You will get far more out of the audit by involving team members from different departments and presenting it as an exciting time to learn more about the inner works of the clinic visit and their implications on practice finances. A team of five is perfect; a receptionist or scheduler, a biller, a nurse or medical assistant, a medical records or data entry person and a physician or other provider. Begin by gathering five random patient records per each provider and selecting one date of service for each patient; the date of service should be three to six months prior. This allows adequate time for insurance processing and receipt of third party payment on the records being reviewed. Staff should break into teams of two – preferably one administrative staff and one clinical staff person. Each team should review a minimum of five charts and document discrepancies. When the review is completed, they should analyze the results to determine if the same errors are recurring or if there are different areas of the practice or service where problems occur. They should then calculate the potential cost of the errors over a twelve month period. The next step is to make a recommendation on how to approach correcting the deficiencies for long term benefit. Common problems detected: Discrepancy in evaluation and management level of service (E&M code) Wrong diagnosis Missing dictation Incomplete charge slip Missed office charges: Procedures, lab, x-ray Missed hospital charges: ER visits, consultations Insurance write offs taken that are not justified (payment overlooked or discounted by payer) Patient balances written off on Medicare patients All of these problems have the potential to both cost your practice money in the short term (e.g., by causing denials or delays or down-coding) or in the long term by triggering an audit by Medicare or a private payer. By conducting your own internal audit, not only will your staff learn what kinds of mistakes you've unwittingly been making (and be able to correct them), everyone will understand

By Judy Capko|2022-01-01T22:52:09-08:00February 20th, 2014|

Internal chart audits: the basics, part 1

Auditing charts is nothing new; Medicare has been doing such audits for years. They are looking for coding irregularities within a practice to determine if they want to do a more extensive audit. That's when a practice gets the dreaded notice to prepare and submit charting documentation on a selected number of charts and submit them to CMS for a detailed review. Often when this happens the stakeholders in the practice have no idea what they have done to trigger the audit. We suggest you take a proactive approach to understand your coding patterns and whether you are coding appropriately based on the services rendered and the documentation essential to support the codes you billed for. Here are steps you can take to prepare for a practice-wide internal audit, which may help you avoid the dreaded Medicare audit – or at least be ready to pass with flying colors. Empower staff to understand the importance of their individual actions in helping the practice get paid for the services performed. A mini audit involves everyone in analyzing charge and payments for services rendered. The staff teams up to examine documentation of services rendered, diagnostic coding for encounters and the payment received for those services. Increase the staff’s awareness of the significance of accurate documentation and its relationship to revenue generated in the practice. By examining charts and billing information the staff will begin to understand how important it is to account for every single service rendered. With reduced reimbursement no office can afford to drop a charge or to neglect following up on an inappropriate reduction in reimbursement. For example if you missed charging for one EKG and one Urinalysis a day, it would add up to as much as $12,000 a year in lost revenue. If you missed charging for one hospital consultation a month per doctor in a four doctor practice, you would take an annual hit of $6,000. Increase the reimbursement IQ of reception and nursing staff, as they examine EOB’s and see a 30 to 40% adjustment in the payment rendered by third party payers. This will

By Judy Capko|2016-03-04T11:56:39-08:00February 14th, 2014|

ICD-10: The only thing to fear is fear itself
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ICD-10: The only thing to fear is fear itself

billing and practice management software (PMS), coding, EMR | EHR, finances, medical practice business, technology

ICD-10: The only thing to fear is fear itself

Did any of you catch the ICD-10 TweetChat Kareo hosted on Tuesday? I participated representing our team(@capkoandcompany); three other panelists from different segments of the medical management world joined in as well (@brad_justus, @modmed_EMA, @hitconsultant). Kareo does a wonderful job reaching out to its clients and the entire practice management community with events like these -- and we were delighted to have the opportunity to participate! (Kareo published a summary on its blog -- and you can also search all the tweets using #kareochat .) As expected, there were many smart, informed comments -- and some really good questions by the Kareo folks in particular. But, I was struck by the relative silence from people who weren't from the billing/practice management/technology expert community (i.e., from actual billers, coders and practice managers) -- especially because one of the themes that emerged from our chat was the sense that small and medium private practices (in particular) have been holding off dealing with ICD-10. Did the audience that could benefit the most shy away from the chat altogether? The drumbeat of journalists, bloggers and other experts about the need to deal with ICD-10 NOW (or face likely disaster!!) has gotten louder and louder in recent months, and I sometimes wonder if it sometimes has some negative unintended consequences. In our zest to create helpful urgency (and dispel the dream that ICD-10 will be delayed again), are we pushing people towards fear-induced denial and procrastination? Seemingly every week, we work with medical practices that have not begun to prepare for ICD-10 at all -- and they're scared. But while their foot-dragging has not been ideal by any means, it's also not a guarantee of disaster. Converting to ICD-10 is not going to be easy, but it's also not something that's beyond the reach of any practice to manage -- especially because so much help will be available from vendors and payers (provided you ask!). It seems from our vantage point that too many practice administrators, billers and coders have already decided -- without even really getting started -- that ICD-1o will be an unavoidable

By Morgan|2022-01-01T22:52:16-08:00September 13th, 2013|

Timely article about billing for locum tenens

Physicians: are you planning a vacation this summer, and worrying about coverage? Or, have you thought about bringing in extra help so you can take time off, but are worried about lost revenue? Hiring temporary physician help doesn't have to mean a deadweight loss of revenue for your practice. This helpful article from Physicians Practice spotlights billing for locum tenens help that you pay on a per diem basis. Take that much needed vacation! Get Revenue for Your Practice Even While on Vacation

By Morgan|2022-01-01T22:52:31-08:00June 21st, 2013|

13 for 2013 Tip #2: Analyze your E&M code utilization

For most practices, E&M codes represent a significant portion of billings -- and, for some practice types like pediatrics and other primary care, E&M codes can approach 100% of billings. Physicians and non-physician providers are often so sensitive to the risk of down-coding, denial or audit that they develop a bad habit of 'defensive' E&M coding -- i.e., sticking to the lower range of the codes for virtually every patient. Far from being an effective defense, though, this type of habitual coding may actually create more audit risk, since it leads to a distribution of codes that is skewed rather than the expected bell-shaped curve. And, it does so while also leaving thousands of the practice's dollars on the table! The end of one year and the beginning of another is the perfect time to analyze your practices E&M coding patterns -- and set new habits for the new year. Run a report for each physician by code for the full year, and you can create a table like this that totals how many times each provider used each code: code 99201 code 99202 code 99203 code 99204 code 99205 Total Anderson 12 252 900 12 24 1200 Buford 0 132 996 348 0 1476 Cochrane 12 996 96 0 0 1104 Delaney 0 36 732 432 120 1320 Elliott 12 48 1092 156 24 1332 From this data, you can easily calculate percentage utilizations to get a clearer idea of distribution -- and from there create a chart to spotlight any skewed coding: E&M Distribution Chart E&M Distribution Chart Notice the skewed utilizations of Cochrane, Anderson and Elliott? It's unlikely these codes are accurate -- especially Cochrane, who appears to be habitually and defensively under-coding. (Note, also, the addition of the CMS averages to the chart -- available from the CMS website. This is a great double-check to see the typical coding mix based on all practices billing Medicare -- and to get a sense if your coding patterns will look odd (or audit-worthy) to the CMS.) Next step: identify the number of instances of

By Morgan|2022-01-01T22:52:37-08:00January 8th, 2013|

New study claims ‘billions’ in Medicare costs may be due to questionable upcoding

A new study from the Center for Public Integrity has identified a trend towards higher coding of Medicare visits over the last decade -- and suggests this increased utilization of higher codes could signal increasing, habitual abuse. The study also notes that medical groups representing doctors assert that treating seniors has gotten more complex over the last ten years -- both because Medicare patients tend to have multiple, complex conditions and because EMR and coordination of care make treating them more time-consuming and make documentation and coding more accurate. A few tidbits from the report that stood out: The report cites the seemingly alarming statistic that "more than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade." But, 7,500 is less than 1% of the total number of practicing physicians in the US (829,673, per the Kaiser Family Foundation). Even if every one of these physicians is coding fraudulently, this is a pretty small proportion of physicians who are 'cheating' -- compare that with, for example, the 15% of Americans who've admitted to cheating on their taxes. The report reveals that the lowest code, 99211, typically pays only about $20. Will the reality of how paltry this is -- considering this figure not only compensates the doctor, but pays for the office, technology, clinical and business staff -- be lost in the outrage over more evidence of 'greedy doctors'? (If every single minute of an hour were dedicated to 99211 visits -- ignoring the need for administration, transition and documentation time between patients, late and no-show patients -- that still only amounts to $240/hour. Not much to pay a doctor, cover her overhead, and compensate staff.) The report also notes that, "the number of doctors who billed at least half of their office visits at one of the two most expensive codes more than doubled to at least 17,000 practitioners...[and] those who quit using the two least expensive codes rose 63 percent, climbing to more than 13,000 in

By Morgan|2016-03-04T12:10:30-08:00September 18th, 2012|

Another interesting (dispiriting) take on medical billing

A recent New York Times article and follow-up blog post discuss the challenges patients have understanding medical bills, through the eyes of a consultant named Jean Poole who has made a career of deciphering (usually highly erroneous) medical bills and helping patients recoup incorrect charges or reduce their outstanding bills. Billing is so challenging for practices -- even though specialized staff are usually handling the task, they have to contend with constant changing rules, reluctance of some payers to address issues, and the myriad of payment schemes with varying patient responsibility. But imagine how it is for patients -- who don't have any specialized knowledge to help them deal with the strange language and calculations of their bills. Ms. Poole's service would seem to be a godsend for patients who find themselves unexpectedly owing thousands of dollars (as the article points out, patient out-of-pocket obligations and opaque hospital fee schedules can lead to big surprises). It's great that she offers this service, for sure -- but how frustrating that it's so needed. The frequency of errors and lack of transparency in insurance company documents to patients is a big source of difficulty for practices. When patients feel they've been incorrectly charged or can't understand their bills, it undermines the trust they have in their physicians and other care providers. When your practice provides services in conjunction with a hospital, their billing clarity and accuracy (or lack thereof) can rub off on your patient relationships. While you can't control how hospitals manage their side of billing, you can at least make sure you're communicating as clearly and directly as possible with patients about what your practice will bill and how much of that bill their payer has declared to be the patient's responsibility.

By Morgan|2022-01-01T22:52:39-08:00June 27th, 2012|

The Time is Now for ICD-10 Planning

Regulatory requirements that affect the medical practice are changing rapidly. While the primary focus may seem to be on EHR systems and meaningful use to obtain those stimulus funds, there are other mandatory system changes that need to be addressed now, starting with the conversion to ICD -10 code set. The new code set represents an important advancement in diagnostic coding and conversion to it is required. Limitations of ICD-9 include limited descriptive reporting and inability to adapt to advances in medical procedures and technology. The new system promises more flexibility and descriptive capacity. As a result, more accurate healthcare data reporting is expected. Due to the significant structural differences between the existing ICD-9 diagnostic coding system and ICD-10 coding system, the transition to ICD-10 code set is one of the critical areas of change for physicians in the near future. Medical practices will be required to adopt the use of the ICD-10-CM code set by October 2013. Since the new system is relatively complex, you’ll want to make sure your entire staff receives the training they need as early as possible. One potential benefit for doctors that “under code” is that more precise diagnosis and procedure codes will enable more accurate reimbursement. Additional benefits include an improved ability to measure health care services, reduce coding errors, a decreased for supporting documentation with claims, and the ability to use administrative data to evaluate medical processes and outcomes. October 2013 may seem a long way off, but given the magnitude of this conversion it is important to address this change now in order to avoid severe work disruption and delayed or lost payments. The first step in planning for the conversion to ICD-10 is to assess the organization’s readiness for adapting the new codes and understanding the impact of the change on your practice. Practice leaders should meet with billing system IT representatives and develop an implementation strategy, time-line and budget to accomplish the conversion. The timeline should include adequate time for testing the system and it should contain a plan for providing essential education and training for the team members.

By Joe Capko|2011-10-27T16:54:55-08:00September 9th, 2011|