All posts by david

Getting Paid for Value: Defining New Reimbursement Models

As payment for physicians’ services continues its steady decline, practices across the country are exploring new ways to thrive. For pediatrician Jesse Hackell’s five-physician practice, part of the solution was joining a large multi-specialty pediatric group.
“We found that payments were not keeping pace with inflation and hadn’t been for many, many years, and that was becoming an untenable situation,” says Hackell, whose practice is located in Pomona, N.Y. “What joining a large group enabled us to do was finally level the playing field a little bit in negotiating with the insurance companies. It gave us some strength by virtue of our numbers.”
But while partnering up might provide some practices with negotiating leverage, it may only be a temporary solution to a more permanent problem. The results of Physicians Practice’s 2013 Fee Schedule Survey indicate that the downward reimbursement trend continues. Between 2012 and 2013, average commercial payer reimbursement for all new and established office visits fell nearly 9 percent. That’s on top of a 10 percent decline that occurred between 2011 and 2012. (More in-depth survey data is available in the accompanying survey results and online at PhysiciansPractice.com.)
Editor’s note: The results of our annual Fee Schedule Survey are in. See where your practice stacks up when it comes to payment for top codes.
Eventually, even negotiating higher rates with payers won’t get practices very far.
But it’s not all bad news. As fee-for-service declines, more payers are exploring value-based reimbursement models, in which practices receive higher pay if they provide high-quality, low-cost care. And while many physicians are hesitant to embrace such models — only 16 percent of our fee schedule survey respondents said the shift in payment methodology would be good for their practices — experts say a proactive approach is the best course. “The world’s changing and the market’s changing, and I think that all too often physicians like it the way it was, and it’s not going to be like that,” says John Lutz, managing director at Huron Healthcare, a healthcare consulting firm based in Chicago. “I think that the sooner people start looking forward instead of looking in the rearview mirror, we’ll be better off.”
But finding the best path forward is not easy, and the broad array of emerging value-based payment models and incentives makes it even more difficult. Here’s a closer look at some of the most prevalent value-based models and incentives, and what the experts say your practice can do to get involved.
Pay-for-performance incentives
Getting paid for value does not mean your practice needs to jump headfirst into a full-fledged value-based payment model, such as an accountable care organization (ACO) or a bundled payment arrangement. Many payers are offering smaller-scale value-based incentives, such as pay-for-performance incentives, to practices that reach quality and/or cost targets.
Though pay-for-performance incentives are nothing new, the bonus targets set forth by payers are becoming “much more sophisticated” as the shift toward value gains momentum, says Randy Cook, president and CEO of consulting firm AmpliPHY Physician Services.
For example, in the past, a practice may have received a bonus if it prescribed generic medication to a certain percentage of its patients. Now, a practice may receive a bonus if a certain percentage of its diabetic patients have their A1C levels under control. “That’s what’s called an outcome measure,” says Cook, who is based in Columbia, Tenn. “[You] have to accomplish a whole lot of other things in order to create that outcome.”

By: Aubrey Westgate

– Source: http://www.physicianspractice.com/medical-billing-collections/getting-paid-value-defining-new-reimbursement-models#sthash.mllD9Yhe.dpuf

Merging E&M Guidelines; Screening Codes; Phone/Internet Consults

Merging E&M Guidelines
Q: My office manager told me that I can use parts of the 1995 E&M guidelines and parts of the 1997 E&M guidelines in the same note. I think that is not allowed. Who is right?
A: To provide you with some guidance, let me quote CMS from an announcement it made in September 2013. CMS stated: “For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after Sept. 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.”
This is the only aspect of the two sets of guidelines that CMS has specifically stated can “crossover” from one set of guidelines to the next. However, since there is no difference in the decision-making areas, and the exams are the component of E&M that is usually distinct from one set of guidelines to the next, this change corrects a long-standing audit problem with E&M. Prior to this ruling, even when a patient presented for chronic disease management and had no “complaints,” if a provider used a specialty exam from the 1997 guidelines, he needed to find the traditional HPI “elements.” This often hindered providers when billing new patient visits.
The only area that CMS should still improve in regard to crossing over between the guidelines is to recognize the “status of one or two chronic problems” as equivalent to a “brief” history of present illness.
Screening Codes
Q: I am an internist and I have patients who need me to fill out biometric screening forms. This consists of writing the values of cholesterol screening, fasting glucose, height, and weight. To do this I need the lab values.
I recently gave a patient a prescription for the labs using V70.3 as the billing code. Her insurance stated that it wouldn’t pay for the labs because I used the “wrong code.” It suggested using a code for, and I quote, “universal routine medical blood work.”
I have scoured the ICD-9 book without finding any mention of this code. Am I in the wrong for using V70.3? Am I missing the book carrying this and other mysterious “universal codes”?
A: There are no “universal” magical get everything paid codes, as I’m sure you suspect. V70.3 is specific to certain kinds of screening visits, such as those for marriages, prisons, school, sports, etc. This may be why that diagnosis code was denied.
V70.0 is the “routine general medical exam” code usually used. Maybe that’s what the insurer is looking for. It’s also entirely possible that the patient’s plan may just not cover screening, although the Affordable Care Act makes that unlikely.
Phone/Internet Consults
Q: There are new codes for physician phone/Internet consults in the 2014 CPT Manual. Can these be used in both an inpatient and an outpatient setting? Does a physician have to be on both ends of the conversation?
A: You are referring to the codes 99446-99449 for inter-professional telephonic/Internet assessment and management service provided by a consultative physician, including a verbal or written report to the patient’s treating/requesting physician or qualified healthcare professional. You select the codes based on time. Code 99446 is for five to 10 minutes of medical consultative discussion and review; 99447 is for 11 to 20 minutes; 99448 is for 21 to 30 minutes; and 99449 is for 31 minutes and more

By: Bill Dacey

– Source: http://www.physicianspractice.com/medical-billing-collections/merging-em-guidelines-screening-codes-phoneinternet-consults#sthash.YCWE95yf.dpuf

Eight Warning Signs Your Practice Isn’t Ready for ICD-10

1. Your practice hasn’t spent a dime to get ready.
There are a dozen excuses for this. “If I send her for training, she’ll just want more money or go to another practice.” Or, “We’ll wait and buy the final version of the ICD-10 book when it’s released. It’s still in draft form, you know.” While large systems and groups are well on their way to ICD-10 preparedness, some smaller groups have taken a wait-and-see approach. They hope that CMS will change its mind, and push back the deadline. Or, they tell themselves, “It will get quieter in the spring, we’ll do it then.” Lame excuses. Buy the draft version of ICD-10 and educate key staff members; plan physician training for closer to implementation, either in person or online.

2. Your software vendor tells you not to worry.Well, if your vendor tells you not to worry and has shown you their mapping program and has installed the latest software, then OK. Is your vendor well established and committed to the program you have? There is a shakeout going on in the EHR and practice-management world, partly related to meaningful use. Look in trade journals, talk to your specialty and professional societies, and be sure your vendor will still be in business, supporting your needs, in 2014. I’d still worry. Or better yet, prepare.

3. You’re using a paper encounter form and select diagnosis codes from it.
A long, laudable essay could be written about the benefits and ease of using a paper encounter form. It would need to end with “rest in peace,” however. Circling the most common codes and writing in a code that isn’t on the form — when a more specific code was available — has resulted in many unspecified codes. It wasn’t good practice in ICD-9 and will become impossible in ICD-10. ICD-9 had about 14,000 diagnosis codes and ICD-10 has about 70,000. It is the rare specialty practice that uses a handful of the same codes over and over. Groups using paper encounter forms for diagnosis coding will need a new system.

4. The software upgrade to an ICD-10 compatible version is scheduled for September 2014.
Be on the latest version of your software — get an early upgrade so you can try out the ICD-9 to ICD-10 mappings and begin to educate providers using your system. Worry if the vendor has a late implementation date. At the very least, ask for a test version.

5. Currently, you have claims denied as “not medically necessary” and/or pre-authorizations for diagnostic tests denied because there is “no covered indication.”
These are diagnosis-code problems in ICD-9 and they are only going to get worse in ICD-10, when the volume of diagnosis codes explodes to 70,000 codes. There will always be some of these denials in a practice: The patient may not have a covered indication or the payer policy changed. If your practice is experiencing these now, however, the problem will only grow. Expect some glitches as payers migrate their coverage policies from ICD-9 codes to ICD-10 codes.

6. No cash on hand or available line of credit.
Let’s say your staff is trained, your providers are scheduled for online specialty training, you own ICD-10 books, and your software has a mapping program that you’ve tested thoroughly. You’ve tested with CMS and all went well. There’s one more thing to do. Save some cash. One single fly in the ointment, one payer, one clearinghouse glitch, one binary 0 that should be set to 1 has the potential to slow your payments. For example, if one small insurance company that represents 7 percent of your revenue stops paying, how long can you make payroll and pay bills?

7. You never saw an unspecified diagnosis code you didn’t like.
It is easy to be complacent about diagnosis coding in a medical practice. After all, most ICD-9 codes support the medical necessity for an E&M service, specific or not. Many procedures have an obvious diagnosis: appendicitis for appendectomy. Diagnostic tests and procedures have always required more care in selecting the accurate code. But, if you run a report and find a high frequency of unspecified codes (codes ending in .9), pay attention. Start using specific ICD-9 diagnosis codes now to ease the transition to the more detailed and descriptive ICD-10 system.

8. A bonus worry. If your system allows users to change the definition of an ICD-9 code from the official ICD-9 language to words that are “easier to find” for the clinician, switch back to official ICD-9 language today. Don’t even think of converting to ICD-10 if your current diagnosis descriptions don’t match official language.

By: Betsy Nicoletti

– Source: http://www.physicianspractice.com/medical-billing-collections/eight-warning-signs-your-practice-isnt-ready-icd-10#sthash.CnePc3iP.dpuf

What to Charge at a Direct-pay Practice

While the decision to change to a direct-pay practice can be the most difficult one a physician can make, there is a second decision that is nearly as difficult: How to charge for services. This decision not only affects the bottom line of the practice, but can greatly affect the type of care that is given.
The main issues to consider are:
1. Do you charge a monthly “subscription fee”? If so, how much do you charge?
2. Do you charge a copay for office visits (or simply charge for visits alone, if you don’t do a subscription fee)?
3. Do you charge extra for labs, immunizations, and other services as an additional revenue source?
While I cannot expertly give all of the pros and cons of each of these options, I can explain how I decided on the route I took, as well as the consequences, good and bad.
1. Monthly fee
I charge a monthly subscription fee, ranging from $30 to $60 per month based on the age of the patient; that includes a $150 monthly maximum for families. I also have a one-time “registration fee” of $50 per person ($200 family maximum). I do not have any discount for people who pay for the year in advance, nor do I require people to commit to any more than a month at a time.
The main reason I chose this method was to keep it simple and affordable. I want it simple because I am a doctor who does not like accounting: I don’t want to chase down money I am owed, nor do I want to refund patients should I somehow not be able to provide the services they have paid for ― for example, if my office burns down or I get sick. The amount I charge is aimed at keeping my services affordable for my patients.
The consequences of this: This has really worked quite well. I have a reliable income that has grown each month I’ve been in practice. The growth of my practice, however, has not been too rapid, nor have I been overwhelmed with workload (so I think the price is not too low). Very few people have left the practice for financial reasons.
2. Copay
I do not charge a copay for visits. When I did the math, the difference between what even a substantial copay would contribute vs. no copay at all was quite small. The vast bulk of my income comes from monthly payments ― regardless of copays. I also felt that charging a copay would make my patients avoid care they needed, which sabotages my “high access” model.
The consequences of this: I was afraid that patients would abuse the no additional cost, open access, but currently (at 400 patients and growing) that has not been the case. The reality is that most people try to avoid going to the doctor, and the majority of their problems can be managed via telephone or secure messaging, so my office is often empty. Because of the monthly fees, I earn just as much with an empty office as I do with a full one. That’s a very welcome change.
3. Additional fees
I do everything possible to give services at, or near, cost to my patients. Immunizations, labs, office tests, and procedures are not marked up. I do this partly because, in the big picture, the income from them would be insignificant; but more importantly, I want to give my patients services they can’t get elsewhere. I want to raise the cost for them to leave my practice ― so they will keep paying me their monthly payment.
The consequences of this: The largest benefit is that my patients trust me much more than they did in my old practice. They know I am not going to “nickel and dime” them for every little additional service. Plus, the drop-out rate in my practice has been very low; indicating that I am giving my patients enough value to keep them paying me each month.
While I am still not certain of exact numbers, I am very optimistic about the straight, monthly fee-payment model I’ve chosen. I have a predictable monthly income (regardless of my patient volume). And more importantly, I am no longer dependent on sickness or clinical problems to get paid. I can now focus on treating patient problems when they are small and using education to help my patients spend their time where they want to be: away from the doctor’s office.

By: Robert Lamberts,

– Source: http://www.physicianspractice.com/medical-billing-collections/what-charge-direct-pay-practice#sthash.7ANIx0JY.dpuf

The Ongoing Evolution of Healthcare Revenue Cycle Solutions

As healthcare changes, the way many practices and health systems think about revenue cycle solutions will begin changing as well.

That’s according to Elaine Remmlinger, a senior partner and leader of the healthcare IT practice at Kurt Salmon, a global management and strategy consulting firm.
At this year’s Healthcare Information and Management Systems Society (HIMSS) Conference in Orlando, Fla., Remmlinger discussed the state of the revenue cycle solutions market, how it is changing, and how health systems can begin navigating this change during her session entitled “Next Generation Revenue Cycle — Is Now the Time?”
“This is not about just billing, this is about much more, “said Remmlinger. “Depending on your scope, these solutions can help to improve the patient experience, can help enable care coordination, provide the analytics and reporting that we’ve needed for so long, help you move towards your journey in new payment models … make you more efficient inside the business office, inside of the various areas that support the front end to the back end, and help improve your bottom line financial performance.”
Several factors are pushing revenue cycle management vendors to expand their capabilities, said Remmlinger. These factors include new payment models that reward high-quality, low-cost care; increasing integration between practices, hospitals and other health systems; the transition to ICD-10; and the pressure on practices and health systems to operate more efficiently. “The impact of all of this happening at the same time is tipping the marketplace to move forward with these projects,” she said.

Right now, many vendors are focusing on providing more of an “enterprise solution” to revenue cycle, one that can be applied and used throughout the continuum of care (such as within all of the practices and hospitals that are part of an integrated health system). In addition, vendors are exploring more data analytics capabilities and dashboards within their product offerings, said Remmlinger.

Other big changes to the product offerings and the overall market include: fewer add-ons within solutions (because “bolt-ons” are becoming part of the core system) and the push toward more modern technology platforms, she said. In addition, as more vendors provide enterprise solutions with more capabilities, health systems may be working with fewer vendors overall.

“As the needs become more integrated and the lines blur with the clinical environment, it’s clearly way more than just about billing,” said Remmlinger. Revenue goes from the front end to the back end, including patient management. It now includes care management.”

While the scope of revenue cycle solutions is changing, this change will be gradual, she said. Many health systems are reluctant to undergo a conversion due to the scope and financial commitment such a project entails. In addition, many are still focusing on the ICD-10 transition and meeting meaningful use requirements. On the vendor side of things, many of the products simply aren’t yet ready for implementation, said Remmlinger.

“While this transition has been occurring for probably a decade now, it’s probably going to go on for another five years before we see these next generation solutions replace the legacy systems and the enterprise systems mature,” she said.

By: Aubrey Westgate

– Soource: http://www.physicianspractice.com/medical-billing-collections/ongoing-evolution-healthcare-revenue-cycle-solutions#sthash.r5MzNKl1.dpuf

View Your Medical Practice Billing Department as a Partner, Not a Vendor

You know how your parents taught you to “Be kind to others and they will be kind to you”? Do you still use this philosophy in your daily living? It was a good lesson to learn, and I believe that if you carry it into your working life, you will really cultivate meaningful relationships that can carry on for years.
One such relationship is with your billing department. Whether it is in-house billing or outsourced billing, it is imperative that you build a strong, trustworthy relationship with those who manage your money. If you are looking down your nose at your billing department, you are looking at it as an untrustworthy vendor. If you change your thinking and your view of this area in your practice, you might be surprised at the results.
Think about your billing department as a business partner, because that is what it is in your big picture operations. If you laughed, scoffed, snorted, or otherwise said, “Not a chance,” then you need to move past that billing company, or update your staff in the department. Having to trust other people with making decisions about your money should not cause you to lose sleep or feel stress.
The billing department should follow very specific guidelines, and it should be monitored weekly, monthly, quarterly, and annually. A business partner is someone that you have very open communication with, and someone who understands that being monitored and allowing transparency is a good thing for everyone.
If you find that your billing staff is defensive, angry, unwilling, and unreliable, remember the phrase: “Be kind to others and they will be kind to you.” If your billing department staff members are always scrutinized, yelled at by angry patients, and not trusted by others, then they are going to take on those characteristics.
Approach your billing department differently. For instance, identify all of the steps one single claim makes in your practice before it is sent over to your billing department. Ask the owner or manager of the billing department to do the same. Now sit down together and make sure that all of your steps are compatible. Be friendly about it, and approach it with the attitude, “I think we can help each other.” If you approach the billing department head with this type of attitude, you will get a much better response.
It’s all about respect in the end, anyway, isn’t it? Everyone has a role in the clock. In order for all of the pieces to work, they all have to work together. Forcing one area to over-perform because of lack in another area, just wears the clock out. Really think about the business relationship concept.
Remember Einstein’s saying: The definition of insanity is “doing the same thing over and over and expecting different results.”
How does your billing department perform for you?

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/view-your-medical-practice-billing-department-partner-not-vendor#sthash.LDJQNFBK.dpuf

Why the Workers’ Compensation Reimbursement System is ‘Broken’

A week or so ago, I had the privilege of sitting in on a Friday morning meeting with a local senator. A group of us discussed our concerns over the Affordable Care Act, as well as workers’ compensation and its lack of reimbursement to providers. The meeting went well, and the senator provided some much needed insight into both areas.
Picture this: You are at a car manufacturing company observing the assembly line. Things seem to be going fine, and then one of the machines stops working. All of the cars start piling up on the back end. While the car manufacturer tries to fix the machine, you watch and realize that half of the cars that are considered complete have no paint on them, some are missing tires, and some lack window glass. These cars are loaded onto transport trucks and shipped to the dealerships that try to sell them as completed and fully built. You ask the president of the car manufacturing company, why this is happening. He responds simply, “Because we can. It would cost us too much to push out completed products because we keep having to fix our machines and those costs keep skyrocketing.”
This is exactly what workers’ compensation plans are doing in the state of California. Their processes are so broken, antiquated, and without transparency and accountability, that they are returning to you, the physician, half to no payments for your claims. The worst part is trying to follow up on unpaid claims. You can never get a hold of an adjuster or the bill review department. Plus, they tell you, “You need to allow 60 days from now for this request to process.” Sixty days later, you get the same denial because their process is still broken.
I’d love to know what kind of software they are using because quite frankly, I think it’s the old software I used in my high school computer courses back in the ’80s. They do not accept electronic claims, but require you to print out each claim with each chart note, authorization, and prescription. This is time consuming for the billing department, and even when everything is correct and you’ve submitted to the correct address, the claim still comes back denied. They provide no reason for the denial. Then the broken cycle starts again.
These workers’ compensation carriers are banking on the fact that at some point you will give up and walk away since you’ve already spent more money trying to recover the monies due than what the claim will actually pay.
Rest assured, there is a group of very intelligent and tenacious individuals who are fighting back. We believe it is time to stop the madness and get the appropriate individuals involved in order to fix this very broken system.
I will report back in a few weeks on the progress. In the meantime, keep an eye on that payer mix in your A/R. It can definitely get out of control very quickly.

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/why-workers-compensation-reimbursement-system-broken#sthash.7KjoP7bd.dpuf

Three Things Your Practice Needs to Do Now to Prepare for ICD-10

Like many in the healthcare industry, Angie Comfort was left bewildered following the U.S. Senate’s approval of HR 4302 on March 31, delaying the implementation of ICD-10 one year to at least Oct. 1, 2015. The extension was one line in a much larger bill delaying physician reimbursement under Medicare’s Sustainable Growth Rate (SGR) formula by one year.

As director of health information management practice excellence for the American Health Information Management Association (AHIMA), Comfort had spent considerable time preparing various medical practices for the move away from the ICD-9 coding system to its successor.

Angie Comfort”As anyone else who was prepared and really excited about the implementation being this October, I was shocked and saddened it got snuck into the [SGR] bill at the last minute,” Comfort told Physicians Practice. “I’m very disappointed. We were six months away.”

But now, Comfort and medical practices are at least 18 months away from using ICD-10 codes as CMS debates how it will move forward. On April 1, President Barack Obama signed HR 4302 into law, so the ball is now in CMS’ court on how — and exactly when — to enact ICD-10.

But just because the immediate future is uncertain, Comfort is secure in her belief that medical practices should not abandon all preparation for the new code set.

“We will go to ICD-10,” she said. “We just don’t know what that actual date is until CMS gives us the date. With holding off preparations, [medical practices] are only hurting themselves.”
So what should medical practices — whether disappointed that their preparations for this year are for naught or elated with the extra time — do in the immediate aftermath of HR 4302?

Comfort says there are three important steps:

1. Train

• If your practice was ready: If you’ve already put the time and energy into learning the new ICD-10 code set, Comfort says coders, physicians, and other practice staff who have the knowledge should put it to work. “Continue to dual code [using ICD-9 codes and their ICD-10 equivalents],” she said. “If you don’t use it, you lose it. We don’t want the people already trained and ready for ICD-10 to lose anything they’ve done.”

• If your practice wasn’t ready: If your practice hasn’t started training coders or anyone at all, Comfort advises to hold off for now. “If they do it now, and we don’t go live until [2015], it will be in the back of their mind, not in the forefront as they won’t be doing it every day,” she said. For these medical practices, Comfort said target the latter quarter of this year or first quarter of 2015 to start ICD-10 training for a fresh start.

2. Test

• If your practice was ready: CMS conducted end-to-end ICD-10 testing in early March and had planned to do more this summer. But now with the coding system delay, that future is uncertain. Nonetheless, said Comfort, if you were ready to test, then go ahead and identify key partners (clearinghouses, payers, etc.) who may also be in a position to test ICD-10 codes.

• If your practice wasn’t ready: If you weren’t in a position to test the new codes because you didn’t reach out to your partners yet, do so now, said Comfort. “[These practices] need to talk to their vendors about readiness,” she said. “Is their EHR going to be ready for ICD-10? What about their payers? Start discussing these things now” with future testing partners.

3. Talk

Looking for more information on improving your practice’s billing and coding and preparing for the ICD-10 transition? Learn from our experts at Practice Rx, a new conference for physicians and office administrators. Join us May 2 & 3 in Newport Beach, Calif.
• If your practice was ready: While you may be dismayed by Congress’ actions this week, Comfort said don’t let a speed bump derail your whole path to ICD-10. “Just stay the course. Continue to do what you are doing for your ICD-10 implementation as if it was happening in six months. You still need to know it; you still need to be training. If you’ve already learned it, you need to continue to use it, if not on a daily basis, then weekly. Keep it fresh in your mind.”

• If your practice wasn’t ready: First, notes Comfort, don’t get lulled into a false sense of security that Washington, D.C., just preserved ICD-9 for the long term. It’s time to focus on ICD-10 at your practice right now. “ICD-10 will eventually happen; it has to,” she said. “ICD-9 is totally outdated. There is not enough specificity … and we have to catch up with the rest of the world. Without a plan to train and prepare for the coding transition, when the coding system switch is made, “these [practices] could possibly go under because they are not billing correctly and getting paid correctly.” The one upside to the delay, Comfort added, is that practices — even those that have prepared — have additional time to reconsider budgeting for IT upgrades they could not afford in 2014. “Maybe they can find something to help them get ready for ICD-10 in 2015.”

By: Keith L. Martin

– Source: http://www.physicianspractice.com/medical-billing-collections/three-things-your-practice-needs-do-now-prepare-icd-10#sthash.7GO9IPeI.dpuf

CMS: Lot of errors billing psychotherapy services when E/M visit is involved

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 really two takeaways coders and billers need to have to get these services billed correctly on a consistent basis. A big part of it will also involve proper physician documentation.

First, there are two different sets of psychotherapy codes, one set that are add-on codes for E/M services and one that are not. When an E/M service is not billed on the same day of service, you bill these codes:
• 90832, psychotherapy, 30 minutes with patient and/or family member;
• 90834, psychotherapy, 45 minutes with patient and/or family member;
• 90837, psychotherapy, 60 minutes with patient and/or family member.

When an E/M service is being billed on the same date of service, you bill these codes:
• 90833, psychotherapy, 30 minutes with patient and/or family member when performed with an E/M service;
• 90836, psychotherapy, 45 minutes with patient and/or family member when performed with an E/M service;
• 90838, psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service.

A psychotherapy service that is less than 16 minutes long should not be billed.

The second element to the confusion is that issue of the length of the service. When you are billing the psychotherapy service alone, then the time should be documented for purposes of justifying the code chosen.

When you bill both services, the time spent on the psychotherapy service must be documented separately from the time spent on the E/M service. None of the E/M time can be counted toward the psychotherapy service and both services must be medically necessary.

Unlike in past years, the psychotherapy codes are no longer dependent on the place of service.

Author: Scott Kraft

– Source: http://codapedia.com/article_676_CMS-Lot-of-errors-billing-psychotherapy-services-when-E-M-visit-is-involved.cfm#sthash.QHJpfaUn.dpuf

New HIPAA rule gives patient the right to “refuse” to use insurance, receive PHI electronically

The HIPAA Omnibus Final Rule, known in the industry as the HIPAA mega rule, affords patients two key rights that your practice needs to be prepared to implement. Patients now have the right to request and receive their own protected health information (PHI) from your practice electronically and they also have the right to decline to use available health insurance and opt to pay out of pocket instead.
The mega rule was finalized in January, but key provisions took effect on Sept. 23, 2013.As you know, patients have long had the right to have access to a copy of their own medical records. Now, patients have the right to request and receive this information electronically. The only exception your practice has for not providing PHI electronically is if it is unable to do so because the records are not available electronically.When this is the case, your practice is still obligated to furnish records in a mutually agreed upon format, including paper or an alternative online format, such as a Microsoft word document or a PDF file with the information. As was the case before, you are permitted to charge a fee for furnishing the information. Make sure to check with applicable state or local laws on these charges.Patients now clearly have the right under HIPAA to request that your practice not file a claim with any insurance available to the patient for services rendered. Patients may have a variety of reasons for not wanting an insurance claim to be filed – the patient is under no obligation to specify a reason, but you are obligated to comply with the request.
When a patient opts to not use insurance coverage for a service, the terms of the insurance contract will not apply to the service. As a result, you are allowed to charge the patient your usual charge for the service – you’re not obligated to charge the allowed charge set by the patient’s insurance.
If the patient requests that a claim not be filed with insurance, but then fails to pay the bill for the services rendered, your practice is permitted to disregard the patient’s request and file a claim with the insurance company for payment after a reasonable amount of time and failed efforts to collect.
As with many regulations, CMS is not specific in the HIPAA mega rule on what constitutes a reasonable amount of time before a claim is filed. Your practice’s best bet is to institute an upfront policy in these situations. When a patient requests no insurance claim be filed, inform the patient upfront that the patient has a specified amount of time to pay for the services before a claim is filed and that you will send a specified number of requests for payment during that time.
Have the patient sign an agreement signifying that he or she understands the terms.

Author: Scott Kraft

– Source: http://codapedia.com/article_643_New-HIPAA-rule-gives-patient-the-right-to-%E2%80%9Crefuse%E2%80%9D-to-use-insurance-receive-PHI-electronically.cfm#sthash.jf8ddPQT.dpuf