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!

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.

Medical Billing Services & Solutions

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

2012 OIG WORK PLAN

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 http://oig.hhs.gov/reports-and-publications/workplan/index.asp

Medical Billing Services & Solutions

PREPARE FOR HIPAA 5010 NOW TO PROTECT YOUR ORGANIZATION FROM FUTURE DENIALS

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 www.cms.gov/Versions5010andD0/

Medical Billing Services & Solutions

Maximizing Collection of Patient Debt

As a billing company, we are obligated to honor the patient collection policy of the practice and its physician owner/s.  Unfortunately, too often we encounter practices without written policy on this critical component of the practice income.  Front desk and billing staff need guidelines to follow.  It is imperative that the practice owner(s) be the one who establishes policy regarding patient responsible debts and then be consistent in support of the policy.  It is inevitable that patients are going to “forget their checkbook” or fail to inform the practice of a lapse or change in coverage.  However, at what point should the patient not be able to receive services if they have not paid their copay or deductible?  How many patient statements should be sent when the patient is not making any attempt to pay before the practice refuses to see the patient?  Unfortunately, most practices simply cannot afford to allow those patients to receive services without honoring the cost share associated with their health insurance contract.  Be sure to make every way to pay available to the patient.  Be sure to offer credit cards as a payment option.

To the best of your ability, the practice policy should be clear and give the staff the authority to enforce the policy.  Many staff members are uncomfortable asking for money and empathize with patients who perhaps are struggling financially.  The employees assigned to the front desk staff need to be willing to ask for the patient’s copay and should have accurate patient debt information readily available.  Staff can pull the patient aside and explain that as a participating provider, the practice has agreed to require patients to pay their cost share as defined in the insurance contract.  Failure to do so could result in being terminated as a participating provider.   Everyone empathizes with our patients who truly are struggling, but it should be the decision of the physician/owner to give away their money, not someone at the front desk who feels bad for the patient.

Consistency in the enforcement of cost share literally trains the patient population.  If your patients repeatedly come to appointments without bringing their check book or credit card and still receive treatment, they have the right to protest when all of the sudden payment is demanded.  Patients need to be gently trained by the front desk staff/practice manager that they are required pay whatever monies are due based on the insurance contract that “THEY” selected.  After all, the patient chose the insurance plan that they wanted, not the other way around.  Rules and procedures need to be put in place by the doctor and followed by the staff 100% of the time to prevent patients from finding a reason not to pay.  If there is confusion amongst staff members as to whether or not a copay is due, or whether or not the patient has had “Bad Debt Written Off” in the past, the patient isn’t likely to volunteer that information or offer payment while at the front desk today.

Procedures to increase patient collections:

1.       An eligibility report on each patient’s insurance should be run at the end of each day for the next day.  This will enable the staff to know exactly what copay is owed, before the first patient shows up at 8:00AM.

2.       Outstanding patient debt should be printed on the superbill or be readily available to the front desk staff.  If it does not appear on the superbill, at the end of each day, staff should look in the billing system to determine if there is a balance on the patient’s account.  If there have been more than two statements without payment, then the practice should designate an individual to meet with the patient prior to the physician encounter and review the unpaid balance.  If the patient cannot afford to pay the entire balance, then a payment plan can be set up.  The first installment needs to be due before the staff takes them back to see the doctor.

3.       Patients with a qualifying balance should receive a statement every month.  Patient statements should be sent out, from the billing office, at least 3 times per week. (We send patient statements EVERY DAY.)  This reduces the time between the patient receiving the EOB from their insurance company and receiving a patient statement from the practice.  It also evens out the number of phone calls from patients about their statement.  In order for this to be effective, the billing office must stay current with submitting charges and posting payments every day.

4.       Send patient a 2^nd statement 30 days later.  We most often see practices send 3 statements prior to sending the 10-day collections notice.

5.       If there is no payment after the third statement, a 10 day collections notice should be sent to the patient.  The patient should also be called by the front desk staff to alert them of the forthcoming “10 day collections letter”.  Patients that have not made a payment or addressed the balance after the 3^rd notice are unlikely to do so without something that catches his or her attention.  Some patients will respond before they are sent to collections.

6.       After the 3^rd statement/ 10-day collections notice letter, account balances above a certain amount should be sent to a collection agency.  A note should be made in the patient’s chart that a balance was sent to collections.  The smaller balances, perhaps $50 and below, should be written off, and put in the patient’s chart.  The small balances can’t be forgotten about, even if the patient isn’t seen for an extended period of time.  Balances above $50 can be sent to collections.

It is vital to collecting patient debt that guidelines, like the ones listed above, are implemented and followed 100% of the time.  A practice teaches its patients that they do or do not have to pay cost shares.  Once a patient realizes that debt will eventually be written off, never to be heard of again, the likelihood of them honoring their cost shares diminishes demonstrably.  Unfortunately, being sent to collections may sever the relationship with that patient.  If we are consistent in asking for payment and respectful of those who are truly struggling, we have to ask ourselves how many non-paying patients can the practice afford to carry.  When we reach that point, having a patient leave is not always a bad thing.


Medical Billing Services & Solutions

Send us an email if you have any questions.

Denial Management 101

Every medical practice experiences denied claims, however some experience a far greater number of denials than others.  The best performing practices can have denial percentages as low as 5%.  Other practices are seeing claims denied 25-30% of the time.  It is key to understand that once a Medicare claim is denied and appealed correctly, it will take at least 1-3 months before the provider receives payment.  In tough economic times, this cash flow delay is unacceptable for most every practice.  Healthcare professionals are always looking for ways to improve their billing performance.  The best way to improve billing performance is to prevent many of these denied claims before they happen.

For those that have been involved in physician billing for over 20 years, we know that there was once a time when claims were submitted to the payers and we subsequently received payments.  It used to be much less sophisticated than it is today.  An individual claim processor manually reviewed, processed, and paid every single claim.  Over the last two decades, much of that work is now being done by a computer.  Programs are written to make sure that the medical practice/medical billing service is "dotting their i's and crossing their t's".  If there is any doubt, they deny it.  They assume that most medical practices will not go through the trouble of following up on denied claims.  This saves the payers money.

To ensure that you, as a provider, are not leaving money on the table, it is vital to be proactive as to what the root of the denials is.  Keep track of how many claims are denied every month, identify the reasons for denials, and track your denial performance over time.

1:  Determine your Denial Percentage at the end of every month.

1. Total # (and charge amount) of claims filed to a payer.
2. Number (and dollar value) of denied line items.
3. Calculate Percentage by dividing "number of denied line items" by the "total claims filed to payer"

This will enable you to track from month to month whether or not your practice is improving.  This should be tracked as a complete practice, as well as by individual provider, location, and by payer.  This will give you insight as to where and why problems may be occuring.

2:  Determine the main reasons for the claim denials.

• Registration error
• Charge entry error
• Lack of referrals & Pre-authorizations
• Insurance Company needs info from patient
• Duplicates
• Medical Necessity/CPT Code does not match ICD-9 Code
• Documentation
• Bundled/Non-covered  {ex)modifiers}
• Credentialing

This information will enable your practice to understand why claims are being denied, and where on the job training needs to take place.

3.  Track your denial performance over time.



The details about your claims denials will allow you to focus your energy on the most frequent reasons that claims are being denied.  The provider/practice management staff will know the most efficient ways to address the problem if they know the root cause of the why claims are being denied.  Every time you reduce your denial rate you bring more money to the bottom line of your practice.  Not only do you get paid correctly and timely, you have eliminated all the labor hours involved in reworking denied claims.

Medical Billing Services & Solutions