Thursday, August 2, 2012

EHR Template Design

It is vital that the provider plays an active role in designing the templates that he or she will use for chart documentation.  However, many providers express that they don't know where to start.  It is important to have a strategy so that the templates are complete, flow, and don't become a hindrance to the provider's work flow.

Unintentional risks of poor template design:

1.  Higher Level E&M Codes
          -  Templates should represent all levels of E&M services for both new and established patients.

2.  Templates that are not customizable
          -  Include "other" fields or space for free text so that each note is personalized to the patient.

3.  Cloned Documentation
          -  Do not copy/paste an entire note.  Only copy/paste the data that will not change.

4.  Developing Documentation Bad Habits
          -  Documenting the same things on every patient; Using Copy/Paste from Previous Visits
             Incorrectly; Temptation of Shortcuts; Authenticating/Signing Notes without reviewing.

5.  Unclear Authentication of who performed which portion of the Patient Encounter/Chart Note
          -  All involved in patient documentation must list name/credentials/date/signature on the note.

Four Basic Principles for Good Template Design

1.  Contrast
          -  Use bold, italics, different font sizes, and different colors to differentiate headers from non-              headers and content.

2.  Repetition
          -  Consistency leads to organization and unity of your templates.  Have consistency in
             placement of visual elements, check boxes, etc.

3.  Alignment
          -  Nothing should be placed on the template just because there happens to be open space.
             Everything should be aligned, evenly spaced, and there should be visual connection from
             start to finish.

4.  Proximity
          -  Space to respond or elaborate via free text should be close to the template items that it
             relates too. 

One last helpful hint: 

Apply the 80/20 rule.  The most common content, which you feel is going to be used 80% of the time should be in the template.  The other 20%, that is only used a smaller percentage of the time should be free texted so that the note is personalized to the patient.

Remember not to let templates drive your documentation and E&M code choices.  Clinical judgement needs to be the driver!  The only person that can do that is the Provider!

Tuesday, March 6, 2012

Modifier PT

Modifier PT is a HCPCS modifier intended to be used when a scheduled colorectal screening test becomes a therapeutic or diagnostic service.  Why would this be needed?   Because a screening test has first dollar coverage and a therapeutic or diagnostic test will be subject to co-pay or deductible.  Medicare instructs medical practices to use HCPCS codes for colorectal screening (for example, G0105, among others.)  But if an abnormality is found and a biopsy is taken or a polyp removed, the surgeon uses a CPT® code in the family of codes starting with 37….  In that case, use the CPT® code, append modifier PT to the service and the patient will not be charged a co-pay or deductible.  CMS’s quick reference guide to preventive services states, “No deductible for all surgical procedures (CPT® code range of 10000 to 69999) furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services. Modifier PT should be appended to at least one CPT® code in the surgical range of 10000 to 69999 on a claim for services furnished in this scenario.

Thursday, February 9, 2012

Insurance Deductibles

Collecting deductibles is often a difficult task for any medical practice.  It is much easier to collect payment from a patient who is currently in the office to see the doctor, rather than a patient who receives a bill.  There are many patients who are unaware of what a deductible is, and refuse to pay the bill that they get in the mail, not matter what!  It helps to try to collect part of the deductible amount while the patient is in the office, and to have a notice placed in waiting room and front desk as to the practice's deductible policy.  Below is a notice that we gave to our practices to post in the waiting room/front desk area.


Welcome to the New Year.  As you know, with each New Year new insurance deductibles apply.  It is one of the more frustrating parts of medicine that with the arrival of each New Year, the application of deductibles replaces a significant amount of our insurance payments.  At this time of year, our cash flow is overly dependent on the collection of these deductibles.  As a practice, we utilize the best available online systems to determine our patient's individual obligations.  Unfortunately, this information is often incomplete.  It is the patient's responsibility to understand and honor this aspect of your insurance coverage.  Your deductible is due at the time of service.  If your insurance does not have a deductible, please be patient with our staff should they mistakenly ask you for a payment towards a deductible.

****Medicare Deductible for 2012 is $140.  Please be aware that many secondary insurance policies now have deductibles and/or do not pick up the Medicare deductible.

Tuesday, January 10, 2012

Surgical Global Periods

I am confident that all doctors have at least a basic understanding of the global package and what is expected of them during that time. However, what does and does not fall under the global period continues to be an issue for providers and medical billers alike.

Scenario #1: Provider performs pre-op visit and the subsequent surgery. Upon the follow -up visit, everything is found to be normal.

  • Since the provider has already been reimbursed for the entire global period, there is no additional reimbursement. The provider should bill a 99024 to create a permanent record that the patient was seen for post-op evaluation.

Scenario #2: Provider performs pre-op visit and the subsequent surgery. Upon the follow-up visit, Provider finds a postoperative infection that needs additional care.
  • The infection is unrelated to the diagnosis for which the surgical procedure was performed, therefore the provider should receive reimbursement for this encounter. The provider should code the encounter as they normally would for an office visit, but they must include a 24 modifier. Without the 24 modifier, the claim will be denied. 

A doctor can avoid a lot of denied claims by making sure that the biller includes the 24 modifier with claims such as in Scenario #2. If the modifier is not included, the claim will be denied and the biller will be left to try to figure out what caused the denial. The claim must then be appealed, where they will likely request chart notes. This requires an extensive amount of time and labor before the provider will receive reimbursement.

A good line of communication can avoid most of these denials on the front end.

Medical Billing Services & Solutions

Tuesday, December 27, 2011


The Office of Inspector General (OlG) has released its Work Plan for 2012.  The OIG sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities including CMS.

The OIG plans to initiate the following NEW activities related to physician services:
1)     High Cumulative Part B Payments – The OIG will review high cumulative Part B payments to determine if they are reasonable and necessary, adequately documented, and provided consistent with Federal Regulations.
2)     Incident-to-Services – The OIG will review whether “incident to” billing has a higher error rate than that for non-incident-to-services.
3)     E/M Services: Use of Modifiers during Global Surgery Period – The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period to determine if Medicare payments were in accordance with Medicare requirements.

To avoid potential penalties in 2012, be sure that all providers in your practice are documenting exactly what they are billing out to Medicare.  Remember, if it isn't documented, it didnt happen!!!

For more information on this topic, visit

Thursday, December 8, 2011


Beginning on January 1, 2012, a federal mandate requires providers, health plans, and clearinghouses to use new standards when electronically conducting certain health care transactions.  Included are claims, remittances, eligibility, and claim status requests and responses.  As of March 31, 2011, claims submitted using the current HIPAA 4010 standards will start being denied by CMS.  Commercial insurance carriers may deny claims as soon as January 1, 2012.
As the deadline approaches, providers and health care organizations need to upgrade and test their claims management systems to ensure that they are prepared to accommodate 5010.  The required upgrade to 5010 was prompted by the need for a comprehensive electronic data exchange for the expanded ICD-10 code set mandated for compliance by October 1, 2013.

For more information on this topic, visit

Medical Billing Services & Solutions

Monday, November 28, 2011

OB/GYN Billing

As you know, obstetrics and gynecology are technically two separate medical specialties dealing with the female reproductive organs, differentiated by whether the woman is in a pregnant or non-pregnant state.  However, the two specialties are usually combined to form a single surgical-medical specialty which enables the physician to care for his or her patients prior to, during, and after pregnancies.  This creates a broad range of conditions that the practicing OB/GYN will treat and many different procedures that the physician will perform.
As an OB/GYN medical billing specialist, knowledge of the specialty is vital to ensuring that the billing is being handled correctly.  The medical biller must play close attention to detail.  They must understand what is included in a global obstetrical package, and what can be billed separately…for all insurance carriers.  They need to be knowledgeable on how to receive full reimbursement for all medications, injectibles, and devices the physician may use.
The medical biller must also have a complete understanding of Well Woman Exam coding.  The biller must know which insurance plans will pay when a G0101 (Cervical or Vaginal cancer screening), Q0091 (Screening papanicolaou smear), S0610 (New patient-annual gynecological exam), or S0612 (Established patient – annual gynecological exam) is submitted.  Some pay for a specific code, and some with a combination of the codes.  Other payers will pay when submitted with a Preventive Visit (9938*-9939* codes), and others when included with an Office Visit (9920*-9921* codes).  The biller must also know what diagnosis codes are required to be submitted with the above Procedure codes.
The OB/GYN specialty requires knowledgeable billers that have both education and experience handling all aspects of the specialty.  If the medical biller doesn’t understand exactly what the insurance carriers require so that the physician can receive full reimbursement, then the denied claims can accumulate rapidly.  No physician can afford an interruption in cash flow, especially if it is due to inexperience.  Every OB/GYN desires full reimbursement for his or her services, and it is vital to have a qualified biller that is up for the task.