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

If there is one thing that is certain in the healthcare industry today, it’s the increasing number of audits and recoupment actions. Every day my colleagues and I receive notices from CMS detailing new investigations and recoupment actions. Accordingly, many of our clients have become increasingly concerned about their actions, and how the actions of other practice physicians can impact liability for the practice as a whole. Their general concerns are not liability for fraud or illegal conduct, but simple, unintentional overpayments.
Below are some of our physicians’ most commonly asked questions and our answers related to these issues:
1. What liability does a practice have for recoupment of payment for services rendered by its physician providers?
Under Medicare, and assuming the services were billed under a number assigned to the practice, Medicare will look to the practice for the recoupment of payments for services rendered by its employed physicians. For independent contractors, however, Medicare can look to both the practice and the independent contractor for recoupment, as Medicare policies dictate that independent contractors only can assign their right to receive payment to the practice if they maintain “joint and several” liability for overpayments. If you’re an independent contractor physician, you should pay attention to the group’s billing practices to minimize your exposure.
For non-Medicare payments, the provider agreement with the payer controls recoupment. Generally, however, the payer will recoup payments from the party who received such payment. Accordingly, if the physician’s services were billed under the practice’s billing number, then the practice likely would be responsible for the recouped amount.
2. What happens if the practice no longer provides services and dissolves?
Medicare and other payers have no greater claim to recoup money owed to them than any other creditor upon dissolution. Once the practice dissolves and all assets liquidated, payers likely will not be able to recoup any amount from the practice. They may, however, attempt to collect through other methods.

If the physicians form a new practice after dissolution, a payer may successfully argue the new entity is a successor to the prior entity, and therefore, it should be able to look to the new entity to recoup the amounts due. Whether the two entities are so closely related as to be deemed successors is very fact-specific and varies from state to state. If your practice intends to defeat a recoupment action by going out of business, you should consult legal counsel to avoid successor liability.
If an overpayment is attributable to the services of an independent contractor of the practice, then Medicare can look to the independent contractor for payment as set for above. Again, a commercial-payer’s ability to act accordingly is dependent upon the specific payer agreement.

Under limited circumstances, a payer may attempt to obtain amounts owed by the dissolved practice from its individual owners. This concept is known as “piercing the corporate veil” and occurs when a practice-entity operates in such a way that it is not deemed separate and distinct from its owners. The ability for creditors to hold owners liable for the debts of an entity under this doctrine is uncommon, but still is a theoretical possibility. Accordingly, it is important to follow the advice of legal counsel when forming and operating your practice as a corporate entity.
3. If a physician is employed by two practices, can payers offset overpayments attributable to services provided by such physician on behalf of Practice A from payments attributable to services provide by physician on behalf of Practice B?

There is no clear law or policy allowing Medicare to recoup funds owed by one practice from another when the services were provided by the same physician. Any right a commercial payer has in this regard likely would be set forth in the payer agreement.
As illustrated by the foregoing, whether a physician is liable for an overpayment is not determined solely by whether such action is attributable to that physician. If you practice medicine through a group, you should always remain informed of the billing practices and actions of your colleagues to minimize your legal exposure.

By: Ericka L. Adler

– Source: http://www.physicianspractice.com/medical-billing-collections/three-facts-physicians-should-know-about-overpayment-liability#sthash.5A02n6sG.dpuf

A few weeks ago, I wrote about problems with the plans offered through the health insurance exchanges. The more we see how claims are processing, the more confused the entire system seems.
It reminds me of my high school computer programming class where I had to use “If/Then” statements:
• IF you have a contract with Blue Cross THEN you should be able to accept Blue Cross patients.
• IF this is a plan falling under the ACA, THEN that above statement is not necessarily true.
• IF the Insurance Exchanges get enough complaints from their new enrollees THEN they might consider adding you to their network honoring your current rates (and they lose money).
• IF they put you as in-network THEN you should be informed (but are not).
One of the big problems is that many physicians, labs, and private practices are not in these narrow networks found in the plans. This has resulted in the patient paying their monthly premiums, going to their doctors and receiving a large bill since it was processed out of network.
I actually have an employee who was looking for an exchange plan for her husband. A broker called her and pitched a Blue Shield plan (which we have been struggling so much with). He said, “I have not heard of any problems with Blue Shield.” She opted out of that plan since she is well aware of the problems patients are having due to the narrow networks.
One of our patients has switched plans three times in two months trying to find one where we are in-network with Blue Shield. He keeps striking out.
Brokers are making a commission in these plan “sales” and patients are paying the price.
A new plan emerged this past week: an EPO. We’ve had EPO’s in the past. Patients with EPO plans have very few out-of-network benefits except emergency and catastrophic. So, then we have to turn the patients into cash patients, and all of the money that they’ve spent to buy this plan means absolutely nothing.
They want to yell at us, understandably so, but this is our (and your) opportunity to take control. You know you are a professional who deserves to be paid for your services. This is when you train your staff to “sell your practice” to the patient. What sets you apart? What makes your practice worth the patient paying cash?
As more patients encounter out-of-network problems, your practice will need to educate them in what out of network and in network mean. These new exchanges and the brokers are not going to share this information with patients.
It’s not your fault, it’s not patients’ fault. This is your chance to retain that referral and prove your worth.

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/more-insights-health-insurance-exchange-plans-and-their-tricks#sthash.Hi78sXy0.dpuf

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

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

Author: Codapedia Staff

– Source: http://codapedia.com/article_672_New-CLIA-Waived-Tests.cfm#sthash.iMpf5SlG.dpuf

Whether it’s declining reimbursement or old-fashioned collections issues, the financial end of running a practice can trip up even the most highly skilled clinicians.
Spiraling overhead forced internist Sheila Bee and a partner, internist Anita Lane, into breaking away from a traditional multispecialty group in 2012 to form a direct-pay practice.
“We had central billing and contracting, a chief financial officer, and a chief executive officer, and then each site had its own overhead as well as the centralized services,” Bee says. “The more overhead you have the less you end up taking home, and it got to the point, with electronic health records and increasing costs from all the paperwork and collections, that our overhead was a very high percentage of gross revenues. As a working mom you start looking at how much you’re spending on childcare and wondering if it’s even worth it after you pay your sitter. I was having to see more and more patients every day and worrying that I was going to miss something [clinically]. It just became a situation where I didn’t feel like I was giving the care I wanted to give. It got to the point where I said, ‘I’m quitting or changing course.'”
Today the partners’ practice is a blend of a retainer and a fee-for-service model. It’s a direct-pay practice, but it produces appropriately coded forms for patients to submit to their insurance companies for possible reimbursement.
Eliminating the process of billing insurance carriers and instead requesting immediate payments from patients has enabled the partners to run their practice with just three staff members, down from the eight they had for themselves and another half-time physician when they were part of the larger group.
Saving that overhead means they can charge lower fees to patients, which they hope will help them retain their patient roster as healthcare reform matures.
“Our goal was to provide great care at a decent price for patients,” says Bee. “We now have time to really listen to our patients and address their problems.”
Choose smart alternatives
Immediate payment for service, as required at Bee’s practice, isn’t an option for many physicians who work under contract with insurers, but there are several things clinicians can do to keep the financial end of their practice running smoothly, experts say.
Outsourcing is an obvious answer, but isn’t always a panacea, says Grace Terrell, president and chief executive of Cornerstone Health Care, a North Carolina multi-specialty group that includes about 250 physicians.
She joined her in-laws’ practice in 1993, which merged two years later with several other practices to form the foundation of Cornerstone. One of the group’s first decisions was to outsource the billing function, which proved to be a mistake, she says.
“There were issues right away with accounts receivable. So we took that back in-house and were able to create processes that made sense for revenue cycle management from the very first time a patient interacted with our service,” says Terrell.
Most small practices can’t justify keeping all financial functions in-house, of course, so Terrell suggests putting all business decisions through a test.
“Are you going to buy it or build it? If you buy something, the question becomes, are you buying it at the right price? If you’re building it, what is the cost of that decision relative to your capabilities?”
And when it comes to purchasing new technology aimed at boosting efficiencies or generating new patient flow, she says, stay flexible.

By: Janet Kidd Stewart

– Source: http://www.physicianspractice.com/medical-billing-collections/small-ways-stay-top-medical-practice-finances#sthash.51QWjrrX.dpuf

Many physicians are familiar with the provisions of Stark Law and the Anti-Kickback Statute, and the requirement that physician contracts be at a price consistent with “fair market value.” This is aimed at preventing hidden kickbacks, in which the physician might be paid too much for services (or charged too little for things the physician must purchase, such as office space or equipment leases).
Less is understood about the requirement that contracts must also be “commercially reasonable.”
I asked Michael Heil, one of the founders of MD Ranger, about this. MD Ranger is a subscription service providing market benchmark data about hospital-physician agreements, Michael also leads the consulting firm HealthWorks, which provides valuation services to both physicians and hospitals for hospital-physician agreements.
Martin Merritt: How is “commercial reasonableness” defined?
Michael HeilMichael Heil: In CMS regulations an agreement is “considered commercially reasonable in the absence of referrals if the arrangement would make commercial sense if entered into by a reasonable entity of similar type and size and a reasonable physician (or family member or group practice) of similar scope and specialty, even if there were no potential DHS referrals.”
MM: That definition sounds quite subjective. Are there more objective standards?
MH: No, not really. The only additional sources are IRS guidelines that list a few factors for consideration (such as duties and responsibilities of the physician and economic conditions in the marketplace). Some additional clues can be found in a few court rulings where findings were made against hospitals when the issue was whether anything should be paid at all.
MM: Can you give an example of how commercial reasonableness is different from fair market value?
MH: A hospital considered paying for orthopedic spine surgery call at a rate that was well within fair market value. But it was already paying for restricted neurosurgery coverage. The neurosurgeons were fully credentialed for spine surgery. Based on commercial reasonableness requirements, the hospital shouldn’t contract with the orthopedic spine physicians at all: A reasonable entity would not pay for the same coverage twice in the absence of referrals.
MM: Are there any examples from case law?
MH: In Kaczmarzyyk v. SCCI Hospital Ventures, 2004, the court found an excessive number of medical directors in violation of the commercial reasonableness requirement. To help with assessments like this, MD Ranger provides data on the total number of medical directors for hospitals of various types and sizes.
MM: MD Ranger has developed a checklist to make the process more objective.
MH: We are happy to share it. As you said, the regulatory standard is quite subjective, but here are criteria that physicians and hospital administrators should consider that help make it more objective:

By: Martin Merritt

– Source: http://www.physicianspractice.com/blog/understanding-commercial-reasonableness?cid=related_teaser#sthash.S9hixaxP.dpuf

A few weeks ago, a billing staff member was subjected to a particularly difficult and demanding patient phone call. The patient took 40 minutes of her time insisting that billing was done incorrectly, which it was not, and was just really very rude. I decided subsequent calls would never last this long, and that I needed to provide the staff some autonomy and training from a call-center standpoint.
I started looking online for some suggestions for training. I found this website helpful.
The five of us spent a lunch hour going through the different situations and personality types, and then performed some role-playing exercises. We laughed a lot, and made it fun. By giving them this training, I enabled them to know when it’s OK to end a call with an angry customer, and how to troubleshoot those callers who really wanted help. They all walked away much more confident and happier from this training.
What has come from this has been a really amazing experience and transformation. The staff now feel more valued in their roles. They know they are not just the punching bags in the company, which is typically how billing staff feel; hence, the large turnover. Most often a patient will call and complain from something that happened at the clinic level, and really has nothing to do with the billing department or staff. They’ve historically always taken the brunt of patient dissatisfaction. Is this fair? Not in my eyes.
Since this training, calls are routed to the appropriate staff, or the patient’s frustrations are quelled, leaving a much happier interaction with everyone. We have even implemented a new system of patient callbacks with questions such as, “Were your benefits explained to you on your first visit?” and “Do you have any questions about your bill?”
You’ve read the Yelp reviews and seen, “Physician was great, front office staff was really helpful, billing was awful.” I never want to see that associated with our billing department. It’s been a challenge to really identify the “whys” of patient phone calls. But, once identified, you can take steps to stop those types of calls from even being made.
Remember that by empowering your staff, whether billing or front office, the results will make such a big difference in performance and job satisfaction. You can only benefit from providing this type of support. Your staff will thank you!

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/training-medical-practice-staff-deal-angry-patients#sthash.maLZnKEG.dpuf

Accepting insurance at your practice and signing a contract does not mean that you’ve opened your arms up to assume that financial risk. It is important that patients understand this concept.
One way to ensure patients understand your requirements is to ask patients to sign a payment policy.
Here’s a sample policy to consider adapting for your practice:
As a courtesy, (your practice name), verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.
It is the policy of (your practice name) that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. The office manager at your location will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.
If you are covered by health insurance with (your practice’s specialty) benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.
Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician’s referral and our verification of your insurance benefits are not a guarantee of payment.
We highly recommend you also contact your insurance carrier and check into your coverage for (practice specialty). Do not assume that you will not owe anything if you have more than one insurance policy.

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/sample-payment-policy-medical-practices#sthash.fudpO1sb.dpuf