Monday, July 25, 2016

Top 40 Ideas to Improve Medical billing collection - Practice revenue

Many Medial billing company struggles or failed to increase the revenue of Practice or Hospital. Here we have listed top ideas can implement which really increase the revenue of provider , practice or hospital whether its in house or Outsourced Medical Billing.

1.Patient Eligibility Verification

Make sure doing Verification prior to face to face encounter would eliminate any non coverage problem and denial.

2. Reminder to Scheduled patient

Sending a remainder via text would be a good idea rather than billing no show fee which cause a problem patient goodwill.

3.  Collecting upfront

Doing prior verification would help us decide copay and other patient responsibility. Have a process of collecting copay from patient when patient comes in for visit by front office staff.

4. Coding review

Someone has to do the coding review takes a major part in submitting clean claim. Use appropriate modifier were ever is required. CPT and ICD combination has to be correct to avoid any Medical necessity or additional document record denial.

5.  Pre - Claim Edit

Most of the software and clearing house Pre - claim edit. Make full use of it.

6. Charge Entry Process

Has to be well trained person and should have basic coding Knowledge is important to entering charge as a clean claim


Improve Medical billing - Practice Collection

7. Claim Submission

Every day claim submission is recommended.

8. Working on rejection

This should be the top priority work by AR specialist on everyday.


9. Posting Payment

Convert as much as ERA that would reduce the time tremendously.


10. Denial Management

Have a dedicated time work on Denial , all the denial has be worked on the same week.


11. Re submission

Do the re-submission then there as corrected claim.


12. Getting payments on time

This point is very important factor as we need to download the payment EOBs on time to reduce the work on AR.


13. Patient statement process

Sending weekly statement is make huge difference is patient collection. Follow the cycle method.


14. Claim Follow up

We need to know the each and insurance response time period and start the follow up once it crossed that time. Now a days insurance started to respond within a week hence 15 -30 follow up would be a good practice.


15. Creating our own insurance login

This is very much helpful to check the claim status by online which is more time and cost effective.

16. Online checking

Do the claim follow up and verification through online as much as possible.


17. Call IVR/AVR

Make use of it


18. Calling follow up.

Provider Details required before calling the insurance. Provider Tax id, Provider ID, NPI and of course patient information and service information.

19 Fax follow up

Some insurance allow fax status claim follow up, we could use it for that too.


20. Appeal the claim

Group the claims which need to appeal and send it weekly basis that would be organized manner and time efficient too. Don't forget the follow up with appeal on time otherwise it would go beyond the time limit.


21. Timely filing limit.

Our Aim should be 100% submission and followup before TFL approaches. So there should be alarming method to if any claim approaches near TFL period.


22. Pre - Template appeal form

Always has Pre - template appeal for most often used reason and just fill up the insurance and patient information alone.


23. Pay to address

Always we make sure that any insurance has our pay to address and practice address right information.

24 Changes in address

If any changes in address in clinic, pay to address. Inform it to all insurance and all vendor like clearing house. Plan before to avoid any time delay.

25 Keeping old address Accessible

Even we moved to new address, we should have the access for old premises for at least 6 month. Maintain a good relationship with old address premises so that they would collect any letter behalf you.

26 Make it Electronic

Be it ERA, EFT, EMC. Going Electronic is far better than paper method.


27 . Secondary Claim Submission
Once we receive the primary insurance payment, we have to submit the  left over balance to secondary payer. People not giving much importance secondary claim but it should happen every week.

28 Identifying specific situation

Identifying specific situation and crate a separate rule is good option. Like some insurance require group number in CMS 1500 Claim

29 Organized Data

We should maintain our data organized by insurance and provide hence it would be ease to find it.

30 Inclusive code

Always have a update on inclusive code and non separately paid codes and take write off during payment posting itself. Make sure its 100% non paid procedure, some of the CPT can be paid by using modifier or difference in ICD.

31 High value claim

Our High value claim need to give more attention and follow up in every week.

32 Education

All staff has to educated every 15 days or a Month. All are has to be updated with current information

33 Billing Changes in claim format

Any changes in billing concept has to planned well and require follow up in every stage. Do the testing before claim submission and talk with clearing house and make sure changes are reflected in claim format.

34 Up coding or down-coding

Don't up-code which is not going to bring a revenue in the longer run. Always go by record and make sure we are not down coding as well.

35 Software database.

Always made changes in database like deleted code and use the date filter in software.

36 Fee schedule

Try to have a different fee schedule for patient biking and different insurances.

37 Collect patient e-mail

We can use it for Electronic patient statement and for communicating with patient.


38 Working on Clarification

Any claim which required clarification from provider or any other source would required immediate attention and work on it.

39  Find out top 10 denial

Find out Top 10 denial and have a plan of action in each department to reduce the chance of getting denied.

40 Authorization process

Identify the procedure requires Authorization and get it at least 3 days advance . If any changes in Authorized procedure and performed procedure required immediate intimation to insurance before submitting the claim.

Medical billing is ongoing learning process hence keep on update yourself to improve and increase the revenue of Practice. Use comment section for any other ideas and feedback.


Sunday, July 24, 2016

Threshold Times for Codes 99354 and 99355

 (Office or Other Outpatient Setting)

If the total direct face-to-face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, the physician should bill the evaluation and management visit code and code 99354. No more than one unit of 99354 is acceptable. If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, the physician should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration. Contractors use the following threshold times to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings including domiciliary, rest home, or custodial care services and home services codes.



Threshold Time for Prolonged Visit Codes 99354 and/or 99355 Billed with Office/Outpatient 

Code     Typical Time for Code    Threshold Time to Bill Code 99354   Threshold Time to Bill Codes 99354 and 99355

99201  10  40  85
99202  20  50  95
99203  30  60  105
99204  45  75  120
99205  60  90  135
99212  10  40  85
99213  15  45  90
99214  25  55  100
99215  40  70  115
99324  20  50  95
99325  30  60  105
99326  45  75  120
99327  60  90  135
99328  75  105  150
99334  15  45  90
99335  25  55  100
99336  40  70  115
99337  60  90  135
99341  20  50  95
99342  30  60  105
99343  45  75  120
99344  60  90  135
99345  75  105  150
99347  15  45  90
99348  25  55  100
99349  40  70  115
99350  60  90  135


Add 30 minutes to the threshold time for billing codes 99354 and 99355 to get the threshold time for billing code 99354 and two units of code 99355. For example, to bill code 99354 and two units of code 99355 when billing a code 99205, the threshold time is 150 minutes.

Friday, July 22, 2016

Billing tips for CPT CODE T1015

Clinic/Center-Federally Qualified Health Center (FQHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.


Service HCPCS Diagnosis Description Modifier Place of Service

Clinic/ Center -FQHC T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All FQHC clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider) 50



Clinic/Center-Rural Health Clinics (RHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.


Service HCPCS Diagnosis Description Modifier Place of Service

Clinic/ Center -Rural Health Clinics T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider) 72



Indian Health Center (IHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be
denied.

Service HCPCS Diagnosis Description Modifier Place of Service

Clinic/ Center -Indian Health Clinics T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider) 5

Tuesday, July 19, 2016

CPT CODE 99354, 99355, 99356, 99357 - Things to consider before billing

Prolonged Services With Direct Face-to-Face Patient Contact Service


A. Definition

Prolonged physician services (CPT code 99354) in the office or other outpatient setting with direct face-to-face patient contact which require 1 hour beyond the usual service are payable when billed on the same day by the same physician or qualified nonphysician practitioner (NPP) as the companion evaluation and management codes. The time for usual service refers to the typical/average time units associated with the companion evaluation and management service as noted in the CPT code. Each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99355.

Prolonged physician services (code 99356) in the inpatient setting, with direct face-to-face patient contact which require 1 hour beyond the usual service are payable when they are billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. Each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99357.

Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.

Code 99355 or 99357 may be used to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15 – 30 minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.



B. Required Companion Codes

The companion evaluation and management codes for 99354 are the Office or Other Outpatient visit codes (99201 - 99205, 99212 – 99215), the Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337), the Home Services codes (99341 - 99345, 99347 – 99350);

The companion codes for 99355 are 99354 and one of the evaluation and management codes required for 99354 to be used;

The companion evaluation and management codes for 99356 are the Initial Hospital Care codes and Subsequent Hospital Care codes (99221 - 99223, 99231 – 99233);
Nursing Facility Services codes (99304 -99318); or

The companion codes for 99357 are 99356 and one of the evaluation and management codes required for 99356 to be used.

Prolonged services codes 99354 – 99357 are not paid unless they are accompanied by the companion codes as indicated.



C. Requirement for Physician Presence

Physicians may count only the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable. In the case of prolonged office services, time spent by office staff with the patient, or time the patient remains unaccompanied in the office cannot be billed. In the case of prolonged hospital services, time spent reviewing charts or discussion of a patient with house medical staff and not with direct face-to-face contact with the patient, or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities cannot be billed as prolonged services.




D. Documentation

Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service.



E. Use of the Codes

Prolonged services codes can be billed only if the total duration of the physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes). If the total duration of direct face-to-face time does not equal or exceed the threshold time for the level of evaluation and management service the physician or qualified NPP provided, the physician or qualified NPP may not bill for prolonged services.

Sunday, July 17, 2016

Payment policy for Home Services (Codes 99341 - 99350)


A. Requirement for Physician Presence

Home services codes 99341-99350 are paid when they are billed to report evaluation and management services provided in a private residence. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home.



B. Homebound Status

Under the home health benefit the beneficiary must be confined to the home for services to be covered. For home services provided by a physician using these codes, the beneficiary does not need to be confined to the home. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit.



C. Fee Schedule Payment for Services to Homebound Patients under General Supervision

Payment may be made in some medically underserved areas where there is a lack of medical personnel and home health services for injections, EKGs, and venipunctures that are performed for homebound patients under general physician supervision by nurses and paramedical employees of physicians or physician-directed clinics. Section 10 provides additional information on the provision of services to homebound Medicare patients.

Friday, July 15, 2016

Provider Enrollment fee - who has to pay?

Who must pay an application fee?                                              

Institutional/facility-type providers newly enrolling in Medicaid or those adding a service location are required to pay an application fee. To determine if your provider type requires an application fee, please refer to the Provider Enrollment Matrix.

Is a fee paid to both Medicare and Medicaid?                                                

No, if you have paid the application fee to Medicare or another State’s Medicaid agency or Children’s Health Insurance Program (CHIP), you will not be required to pay an additional application fee to WV Medicaid. You may be required to provide proof of payment when enrolling with WV Medicaid.

Is the application fee refundable?

The application fee is non-refundable unless it was submitted with one of the following:
? A hardship exception request that is subsequently approved by CMS; or
? An application that is rejected prior to the fiscal agent’s initiation of the screening process.

When must the application fee be paid? If required, the application fee must be submitted with the provider enrollment/revalidation application. To determine when an application fee must be paid, please refer to the Provider Enrollment Matrix. An application fee is required for certain providers when initially enrolling in Medicaid and when those providers add a practice location. You may refer to Understanding the Application Credentialing Fee & Hardship Waiver Request for more information.



How do you apply for a hardship exception?

A provider requesting a hardship exception from the application fee must include, with the
enrollment application, a letter and supporting documentation which describes the hardship
and why the hardship justifies an exception. The hardship exception request and supporting
documentation will be sent to CMS for review and determination of whether to grant the
hardship exception. The WV Medicaid application will be placed on hold, and will not be
considered for enrollment until notification of CMS’ decision on the hardship exception
request is received. For further information regarding the application fee or hardship
exception requests, refer to Understanding the Application Credentialing Fee & Hardship
Waiver Request on the Provider Enrollment webpage at www.wvmmis.com.

Sunday, July 10, 2016

Payment guide for CPT 99324, 99334 - 99337


Home Care and Domiciliary Care Visits


Physician Visits to Patients Residing in Various Places of Service

The American Medical Association’s Current Procedural Terminology (CPT) 2006 new patient codes 99324 – 99328 and established patient codes 99334 - 99337(new codes beginning January 2006), for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services, are used to report evaluation and management (E/M) services to residents residing in a facility which provides room, board, and other personal assistance services, generally on a long-term basis. These CPT codes are used to report E/M services in facilities assigned places of service (POS) codes 13 (Assisted Living Facility), 14 (Group Home), 33 (Custodial Care Facility) and 55 (Residential Substance Abuse Facility). Assisted living facilities may also be known as adult living facilities.



Physicians and qualified nonphysician practitioners (NPPs) furnishing E/M services to residents in a living arrangement described by one of the POS listed above must use the level of service code in the CPT code range 99324 – 99337 to report the service they provide. The CPT codes 99321 – 99333 for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services are deleted beginning January, 2006.

Beginning in 2006, reasonable and medically necessary, face-to-face, prolonged services, represented by CPT codes 99354 – 99355, may be reported with the appropriate companion E/M codes when a physician or qualified NPP, provides a prolonged service involving direct (face-to-face) patient contact that is beyond the usual E/M visit service for a Domiciliary, Rest Home (e.g., Boarding Home) or Custodial Care Service. All the requirements for prolonged services at §30.6.15.1 must be met.
The CPT codes 99341 through 99350, Home Services codes, are used to report E/M services furnished to a patient residing in his or her own private residence (e.g., private home, apartment, town home) and not residing in any type of congregate/shared facility living arrangement including assisted living facilities and group homes. The Home Services codes apply only to the specific 2-digit POS 12 (Home). Home Services codes may not be used for billing E/M services provided in settings other than in the private residence of an individual as described above.

Beginning in 2006, E/M services provided to patients residing in a Skilled Nursing Facility (SNF) or a Nursing Facility (NF) must be reported using the appropriate CPT level of service code within the range identified for Initial Nursing Facility Care (new CPT codes 99304 – 99306) and Subsequent Nursing Facility Care (new CPT codes 99307 – 99310). Use the CPT code, Other Nursing Facility Services (new CPT code 99318), for an annual nursing facility assessment. Use CPT codes 99315 – 99316 for SNF/NF discharge services. The CPT codes 99301 – 99303 and 99311 – 99313 are deleted beginning January, 2006. The Home Services codes should not be used for these places of service.

The CPT SNF/NF code definition includes intermediate care facilities (ICFs) and long term care facilities (LTCFs). These codes are limited to the specific 2-digit POS 31 (SNF), 32 (Nursing Facility), 54 (Intermediate Care Facility/Mentally Retarded) and 56 (Psychiatric Residential Treatment Center).

The CPT nursing facility codes should be used with POS 31 (SNF) if the patient is in a Part A SNF stay and POS 32 (nursing facility) if the patient does not have Part A SNF benefits. There is no longer a different payment amount for a Part A or Part B benefit period in these POS settings

Thursday, July 7, 2016

Residential Habilitation and Respite Care CPT codes

HCPCS Modifier Description 

H2011 Community Crisis Supports (1 unit = 15 min)
H2015 Comprehensive Community Support Services; per 15 minutes
(24-hour/day unavailable under hourly services) for participants who live in their own home or apartment or live with a non-paid caregiver. This code requires PA.
1 Unit = 15 minutes
H2015 HQ Comprehensive Community Support Services; per 15 minutes
Supported living for two or three participants who live in their own home or apartment or live with a non-paid caregiver. This code requires PA. 1 Unit = 15 minutes
24 hour/day unavailable under hourly serviced.
H2022 Community Based Services, per diem 24 hours per day support and supervision. Provided through a blend of 1:1 and group staffing.
H2016 Comprehensive Community Support Services, per diem
24 hours per day support and supervision.
Typically requires 1:1 staffing but requests for blend of 1:1 and group staffing will be reviewed on a case-by-case basis.

Diagnosis Place of Service

Based on dates of service, enter the ICD-9-CM code V60.4 or ICD-10-CM code Z74.2 for the primary diagnosis.
12 Home (CFH, participant’s own home, or home of unpaid family)
99 Other (Community) This code should only be used when the participant receives hourly supported living to access the community. All other RES/HAB should be coded as Home.



HCPCS Modifier Description 
S5100 Day Care Services Adult; per 15 minutes
S5140  Certified Family Home Foster Care Adult; per diem
T2025 Agency - Certified Family Home Affiliation Fee DD Waiver Agency - Certified Family Home Affiliation Fee PA number must be billed on claim for payment consideration
Certified Family Home (CFH) - Agency Affiliation Fee

HCPCS Modifier Description Diagnosis Place of Service

T1005 Respite Care Services, up to 15 minutes 1 Unit = 15 minutes.
(CFH, participant’s own home, or home of unpaid family)
99 Other (Community)
This code should only be used when the participant receives hourly supported living to access the community. All other RES/HAB should be coded as, Home.

S9125 Respite Care, In the Home, per diem 1 Unit = 1 day

Maximum of six hours per day or 24 units.
Based on dates of service, enter the ICD-9-CM code V60.4 or ICD-10-CM code Z74.2 for the primary diagnosis.
For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements.
12 Home

Wednesday, July 6, 2016

How to bill Hospital Visits Same Day But by Different Physicians


In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.

If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.


B. Two Hospital Visits Same Day

Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.



D. Visits to Patients in Swing Beds

If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.

Sunday, July 3, 2016

How to Bill Hospital Visit and Critical Care on Same Day



When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.

Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.