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

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• 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

Modifiers. They’re those pesky numbers that coders must append to a code in order to ensure proper reimbursement. What modifier is most appropriate? Does documentation support its use? Could the practice successfully defend its usage during an audit? These are just a few of the questions that coders regularly.

During AAPC’s 22nd annual HEALTHCON conference held earlier this month in Nashville, TN, two healthcare attorneys participating in a legal trends panel discussion cited modifiers as the top compliance concern facing today’s practices. They specifically flagged modifiers -25 and -59 as being particularly challenging.

Katherine Abel, CPC, CPB, CPMA, CPPM, CPC-I, director of curriculum at AAPC, talked about these and other modifiers during a presentation given to a room filled with dozens of physician practice medical coders. Following is some of the advice she provided.

Modifier -25
Modifier -25 denotes a significant, separately identifiable evaluation and management service that a physician or other qualified healthcare professional performs on the same day that he or she performs another procedure or service.

To correctly append modifier -25, coders must know the global period for each CPT code, including the typical pre-, intra-, and post-operative services included with each procedure, as these services are not separately billable, said Abel. Coders can easily search the entire fee schedule for this and other information about specific codes.

When coders append modifier -25 to an E/M code, carriers will pay for both the medically necessary E/M service as well as the procedure. Abel said coders should keep this in mind because the modifier can trigger overpayments if appended improperly. However, the modifier can also increase revenue if used correctly.

She urged coders show providers an example of how small overpayments due to this modifier can add up over time, resulting in thousands of dollars inappropriate payments annually.

For example, when coders report 20610 ($60.90) with 99213-25 ($73.08), they’ll receive a total of $133.98.

“A provider may look at an individual instance of $73.08, but if you annualize it an apply some of the penalties you can get from doing this, it gives [providers] a bigger picture to look at to help them understand what it is their doing and the risk they’re putting themselves at.”

Abel urged coders to keep in mind that E/M services performed on the same date of service as a minor surgical procedure (i.e., a procedure with a global period of 000 or 010 days) are generally included in the payment for that procedure. She cited this example of improper use:

A patient complains of left knee pain. A physician evaluates the knee and determines that the patient would benefit from arthrocentesis. The physician gives the patient an injection and schedules a follow-up visit for one month.

In this scenario, the evaluation and management is not separately billable in addition to the injection, said Abel.

However, she noted that payer policies pertaining to modifier -25 may differ. Each payer may have different criteria for usage as well as items that don’t meet those criteria. For example, BCBS of TN specifies that coders cannot append modifier -25 when a physician performs a minor procedure. BCBS of Alabama states that the decision to perform a minor procedure is a pre-requisite of appending modifier -25. Clearly, these two policies contradict one another.

Aside from checking payer policies, Abel also urged coders to literally separate the documentation of the E/M service from the procedure in order to better understand whether the E/M service could be billed separately. She suggested using a highlighter to identify documentation pertaining to one of the two services. Then ask whether there is enough documentation remaining to support reporting the other service.

“When you separate it out like this, it is very clearly seen,” she said. When appealing denials for modifier -25, coders can then attached this note with highlighted documentation to bolster support for their appeal letter.

Another suggestion was to simply ask physicians what pre- and post-operative services they normally include with certain procedures. This makes it easier to identify instances in which physicians go above and beyond what might normally be considered part of the procedure.

She referred coders to the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services (revised January 1, 2014) for more information and encouraged them to read through the general chapter. She also stated that coders should review the NCCI edits to determine whether modifier -25 may even be applicable. Download the physician—not hospital—version of these edits.

Modifier 59
Modifier -59 denotes a distinct procedural service, including a different surgical session, different procedure or surgery, different site or organ system, separate excision or incision, or separate lesion or injury.

In addition to reviewing NCCI edits and policy manual, Abel urged coders to review specific payer policies as well as Medically Unlikely Edits. Then ask these questions:

• Was the procedure performed in a separate setting, different time, or different encounter?
• Is there sufficient documentation to support the separateness and distinction of the two procedures?
• Was the procedure truly separate and/or is it unusual to perform these procedures at the same session?

As with modifier -25, Abel suggested using different colored highlighters to highlight documentation pertaining to each procedure to make it clear to the payer that each procedure is separate and distinct.

Author: Lisa Eramo

– Source: http://codapedia.com/article_706_Clearly-separate-documentation-when-appending-modifiers-25-and-59.cfm#sthash.Drby3E2A.dpuf

At the beginning of 2014, family physician Andy Pasternak’s two-physician practice braced for an influx of new patients. But while a few new patients who purchased insurance through the federal and state health insurance exchanges had trickled in by early March, new patient demand was far lower than what Pasternak expected.
“We had sort of been geared up for the large flood of people starting Jan. 1 because there was this whole, ‘Everybody’s going to get signed up and everybody’s going to have health insurance,’ and there was a lot of concern that there were people that maybe were going to have a lot of urgent needs,” says Pasternak, whose practice is located in Reno, Nev. “We’ve had some exchange patients, but it’s certainly not been the large overwhelming flood of patients that we were kind of concerned about.”
Pasternak is not alone in experiencing a slower than anticipated uptick in new patient demand. While several factors may be contributing, technical glitches in both the federal health insurance marketplace and state health insurance exchanges may be a key driver.
Still, by the deadline of March 31, just over 7 million Americans had signed up for health insurance plans via the exchanges, according to the Obama Administration; thanks to a surge in enrollment days before the end of the open enrollment period.
While it’s difficult to determine how this will affect your practice, it’s likely that many of you will begin encountering these new patients — and it’s smart to be prepared. And even if your practice does not experience a surge of new patients, brushing up on how you handle new patients is a smart move. As patient satisfaction plays a growing role in reimbursement, and as more payers ask patients to shoulder more of their healthcare costs, your new patient orientation policies and procedures should change accordingly. Here’s how to ensure that you are efficiently and effectively welcoming new patients to your practice.
Assess and update
Start by assessing whether your new patient orientation documents need to be updated or expanded. These documents should outline your practice’s basic policies — for example, how to schedule appointments, how to request prescription refills, and who to contact when questions arise, says Gail Levy, founder and president of The Levy Advantage consulting firm. They should also outline your practice’s payment policies, letting patients know if you require them to pay copays at time of service, how you handle past due balances, and so on, she says.
If your practice is encountering patients who are newly insured, consider adding a glossary of key health insurance terms to your new patient education materials. A December 2013 study published in Health Affairs found that fewer than 1 in 4 uninsured Americans understands key terms like deductibles, out-of-pocket spending caps, or provider networks. The more informed your patients are about how their insurance works, the easier it will be for your practice to collect what it is owed for services.
Distribute copies of patient orientation materials to your new patients by mail, e-mail, or in person, preferably prior to their first appointment, says Audrey “Christie” McLaughlin, of medical practice consulting firm McLaughlin Sales Group LLC. If you significantly updated these materials, distribute them to all of your patients at their next appointments. Also, post the materials on your website and/or your patient portal so they are readily accessible to patients, she says. “Now is the time, when you have this influx of new patients, to look back and review how you have been orienting new patients to the practice from the get go, and get that information out there.”

By: Aubrey Westgate

– Source: http://www.physicianspractice.com/medical-billing-collections/welcoming-newly-insured-patients-your-medical-practice#sthash.iPUQXiOk.dpuf

June of last year, we started reviewing every single statement prior to sending it out to the patient. We have pulled about 25 percent of those statements each month due to the patient payment and statement crossing in the mail; an incorrect patient cost-share implemented by the payer; coding or payment posting inconsistencies; or EHR issues. By pulling these statements, fixing any issues, and then re-running the statement, we have increased our customer satisfaction rate 10-fold. This was and still is the single greatest system that we implemented into our billing process.

If you have all of your claims clean and on track, a majority of your payers typically will pay you within 30 days or less. There are always the outliers like liens or Workers Compensation or HMOs. But the majority is paid quickly. This gives you an excellent customer service opportunity to capture. By reviewing how a payer is processing claims, you are able to immediately update and modify your front-office collection behaviors. Why is this important? We have found that approximately 30 percent of our insurance verifications are incorrect. Yes, that high. It could be as subtle as the insurance representative stating a $30 copay instead of a $40 copay. It could also be that specific appointment types are subject to a deductible, and that information is not provided to you on the initial phone call.
Regardless, once you are paid on a claim, and you know the patient is returning for more treatment, by reviewing how that payer paid versus how you collected in office is critical. Patient statements are generated from what payers do not cover. This includes misinformation provided to your staff. When the patient arrives back in your office, your staff are now armed with information on how the insurance company processed the claim, and can explain this to the patient, resulting in less patient balance looming on your A/R. Because let’s face it, you know you do your very best to treat patients. Your staff is top-notch in providing information and care. The fallout between your office and customer service typically falls under the “billing umbrella.” If you look up your Internet reviews, do you see things like, “Great clinic: clean, nice staff, billing sucked,”? It happens all of the time. Take this opportunity to fix that stigma of a poor billing-department experience.

Just a few simple changes in your systems can and will increase your customer service satisfaction. It really isn’t go

ing to take your staff more time, it’s really swapping time with another task, like spending time on the phone with the patient explaining why they owe more money.

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/poor-medical-billing-process-can-impact-patients#sthash.4qnCEcnU.dpuf

Reactions within the healthcare community to news of the ICD-10 delay to Oct. 2015 are akin to students’ reactions to a school teacher delaying the final exam: Students who feel unprepared are ecstatic and look forward to the extra time to study and prepare, while those who studied intensively and paid for tutors and other prep tools are frustrated.

Despite the delay, however, whether you are the 11th hour all-nighter or the semester-long studier, ICD-10 implementation is still coming. And though you may have taken a break from planning and prep when news of the delay first broke, it’s time to get back to work.

Here are 10 tips to help you get started:
1. Know what ICD-10 actually is and how it pertains to your specialty practice;
2. Review each compliance step and prepare a schedule timeline to meet each component;
3. Plan your budget for technology upgrades and resource investments;
4. Plan a schedule and additional budget allocation for training your staff because ICD-10 is more than just diagnosis codes;
5. Learn how the ICD-10 will integrate (or not) with payment scheduling and reimbursements to avoid claim denials;
6. Develop an internal process for ICD-10 across your workforce to simulate the process to be sure each individual understands what needs to be done
7. Know and identify all of the other regulations and changes so you don’t get behind as you approach ICD-10 implementation;
8. Make sure your EHR and practice management systems can handle the conversion.
9. Conduct external testing with your clearinghouses and payers to make sure you can send and receive transactions with the ICD-10 codes.
10. Filter out codes you use the most.

Following this checklist is important because of the very real changes in the move from ICD-9 to ICD-10. The current ICD-9-CM diagnosis codes do not provide sufficient clinical specificity to describe the severity or complexity of the various disease conditions. Hence, the current ICD-9-CM system is less effective for monitoring utilization of resources, measuring performance, and analyzing healthcare costs and outcomes.

ICD-10 will add over 65,000 new codes that describe medical conditions and treatments.

The major difference between the current ICD-9 codes and the new ICD-10 version include revisions to the structure of the codes themselves. Also, ICD-10-CM differs from ICD-9-CM in its organization and structure, code composition, and level of detail.

Since ICD-10 provides more specific data than ICD-9, it will refine and improve operational capabilities of clinics. Physician practices and healthcare organizations should be getting ready for this change using the above checklist, and clinical organizations need to move even faster to prepare.

Unlike a student pulling an all-nighter and acing a test — thoughtful ICD-10 prep and planning will be necessary for making the difference between a successful transition and missing the deadline.

By: Divan Dave

– Source: http://www.physicianspractice.com/medical-billing-collections/icd-10-delay-checklist-get-back-track#sthash.bPhnJZpN.dpuf

Don’t be surprised if you suddenly start to get persistent calls from home health agencies concerning patients you’ve referred for home health care.

Medicare has directed its supplemental medical review contractors (SMRCs) to crack down on the face-to-face visit rules required to certify home health care by auditing five records from every home health agency in the country to ensure they have the proper documentation of the face-to-face visit.

Because the face-to-face visit has to be done by the physician practice, expect the agencies to be calling to make sure they have the right documentation.

The face-to-face visit requirement to certify and recertify patients for home health care came about under the Affordable Care Act (ACA) as a means to reduce what CMS considered to be the overutilization of home health services believed to potentially be not medically necessary.

At the point of implementation, the provision that each patient referred for home health service have a face-to-face encounter for medical necessity challenged home health agencies and physician providers alike.

The agencies were concerned that their revenue was in jeopardy due to the added documentation requirement. Physician advocates were angry that they were being asked to complete yet another paperwork burden for no additional pay.

While a lot of those hiccups seemed to have gone away, an HHS Office of Inspector General (OIG) audit released in April showed that, of the 644 face-to-face encounter documents reviewed by OIG auditors, 32 percent did not meet Medicare requirements, which extrapolated to $2 billion in annual overpayments.

The face-to-face documentation essentially requires the physician to certify that a face-to-face visit related to the patient’s need for home health services took place, that the patient is homebound and that the patient needs medically necessary skilled home care. This must be communicated by the physician in a narrative specific to that patient’s need.

The physician may use a template for this, providing it is neither furnished nor completed by the home health agency. This visit must occur within 90 days prior to the start of home health care or within 30 days of it beginning.

Of the home health cases found to be lacking, 10 percentage points lacked face-to-face documentation and approximately 25 percent were missing one of the above required elements. The narrative statements by the physicians were found to be inconsistent.

Expect home health agencies to push on patient specificity, because that is the key to supporting their encounters. For example, a statement that it is taxing to leave home was found by OIG to lack specific patient detail about the need for home health. Instead, it just lifts a line from the CMS definition of homebound.

Examples cited that do not support home health skilled service include too weak to drive, family needs help, unable to furnish own wound care and diabetes. Examples that don’t support homebound status include unable to leave home, dementia, functional decline, weak and unable to drive.

OIG also challenged many of the uses of check boxes on certification forms, saying that CMS intended these only for limited situations when generated by the physician or the physician’s electronic health record system.

Four recommendations were made by OIG to CMS to reduce errors. First was that CMS use a standardized form for the face-to-face documentation. CMS agreed to consider it, though noted it would eliminate some provider flexibility to port information from the current medical record. Second was to require physicians to include their NPI, which CMS said would not add value.

The third, to provide more education, was agreed to by CMS. The fourth, more oversight, is why you might be getting more calls from home health agencies very soon.

Author: Scott Kraft

– Source: http://codapedia.com/article_712_It%E2%80%99s-a-home-health-crackdown-but-your-phone%E2%80%99s-going-to-ring.cfm#sthash.7FECerL6.dpuf