MEDICAL BILLING BLOG

CMS announced on October 1^st that the 2013 PQRS (Physician Quality Reporting System) and eRx (e-prescribing) incentive payments are now available for eligible professionals and group practices that successfully submitted data for these respective Medicare Part B programs.  The payments will be paid based on services rendered and reported between Jan. 1, 2013 and Dec. 31, 2013. 

The incentive payments will be issued by MAC’s (Medicare Administrative Contractors) with remittance advices and identified as separate payments under these programs. MACs will use the indicator of LE ("Levy") to indicate federally mandated payments.

LE will appear in the PLB-03-1 segment of the 835 electronic remittance advice. In an effort to further clarify the type of incentive payment issued, LE will appear on the remittance, along with a 4-digit code to indicate the type of incentive and reporting year.

As medical billing reimbursement shrinks across the industry it is critical for practices to take advantage of the opportunity to participate in any of the CMS incentive programs.  It does take a great deal of effort, but the reward can be a great healing injection to your cash flow!

About ClaimCare, Inc.

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

Copyright 2014, Carl Mays II and the ClaimCare Medical Billing Company

 

Big medical billing changes are coming for the frequently used and often abused modifier 59. It is critical that all coders and providers be made aware of the changes to the utilization of Modifier 59 (Distinct Procedural Service) that will go into effect January 1, 2015. Additionally, as a medical billing company, we often find that clients will set up their billing systems to have an automatic default that adds Modifier 59 to specific codes. Starting January 1, 2015 that will no longer be the appropriate utilization and will no longer be applicable.

 

On August 15th, CMS released the final ruling for the appropriate use of Modifier 59 and the changes that will take effect January 1, 2015.  Transmittal 1422, CR8863 details new modifiers to be used in place of modifier 59.  The new modifiers will impact NCCI (National Correct Coding Initiative) edits utilized by CMS MAC Carriers. Studies have shown that the modifier 59 is both commonly used and commonly abused. According to the 2013 CERT report $2.4 BILLION dollars was paid on claims containing modifier 59 with a projected error rate of $450 MILLION. The error rate is not exclusively attributed to modifier 59, but if only 10% of those found to be in error were due to the modifier 59, that would represent a $45 MILLION dollar error.

 

CMS has established new HCPCS modifiers to define subsets of modifier 59 which was previously used to define a “Distinct Procedural Service” CMS will continue to recognize modifier 59, however due to the over utilization of Modifier 59, it should not be used beyond December 31, 2014. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X {EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. However, these modifiers are valid modifiers even before national edits are in place, so contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.

Thus, our recommendation for all providers, coders and medical billing companies is to prepare to replace utilization of Modifier 59 with the distinctive descriptors as follows:

• XE Separate Encounter:  Service That Is Distinct Because It Occurred During A Separate Encounter 
• XS Separate Structure:  Service That Is Distinct Because It Was Performed On A Separate   Organ/Structure     
• XP Separate Practitioner:  Service That Is Distinct Because It Was Performed By A Different Practitioner 
• XU Unusual Non-Overlapping Svc:  Use Of A Service That Is Distinct Because It Does Not Overlap usual components of the main service    

  

These modifiers, are referred to as -X{EPSU} modifiers, and define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. Our recommendation is to ALWAYS use the subset more descriptive Modifier EPSU’s. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific – X {EPSU} modifier for billing certain codes at high risk for incorrect billing.

WHAT THIS MEANS FOR YOU

All practices should monitor the utilization of modifier 59 to ensure that it is currently being utilized in the appropriate manner.  In light of this major upcoming change, we encourage all Practice Administrators to check with your certified coder or medical billing service to insure they are prepared for this modifier 59 alteration.  Inform your providers.  Make sure that there are no defaults set up in your practice management system that automatically default modifier 59.  And above all, ensure that you are properly documenting any distinct service.  January 1st is just around the corner.  Stay on top of continuing updates and changes by signing up for our medical billing blog. 
 

About ClaimCare, Inc.

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email atsales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

Copyright 2014, Carl Mays II and the ClaimCare Medical Billing Company

Please take a moment and look around you. 

Do you see a shred bin close to you?  Do you know where the shred bins are?  Have you been instructed by you Supervisor or Manager on what is to be disposed in the shred bins?  Shredding is a critical part of HIPAA Compliance.  Leaving documents where others can retrieve them, even if your intentions are good is a serious, and common, violation of HIPAA. 

Such was the case recently for a severe HIPAA Privacy Rule violation. In September 2008, Parkview Health Systems took custody of medical records pertaining to approximately 5,000 to 8,000 patients while assisting the retiring physician to transition her patients to new providers,
and while considering the possibility of purchasing some of the physician’s practice.

On June 4, 2009, Parkview employees, with notice that the physician was not at home, left 71 cardboard boxes of these medical records unattended and accessible to unauthorized persons on the driveway of the physician’s home, within 20 feet of the public road and a short distance away from a heavily trafficked public shopping venue. As a covered entity under the HIPAA Privacy Rule, Parkview must appropriately and reasonably safeguard all protected health
information in its possession, from the time it is acquired through its disposition.

Parkview cooperated with OCR throughout its investigation. On June 23, 2014, a settlement was reached. In addition to the $800,000 resolution amount, the settlement includes a corrective action plan requiring Parkview to revise their policies and procedures, train staff, and provide an implementation report to OCR. A card board box, full of patient information where the public could have retrieved it.  Pretty expensive box!

“All too often we receive complaints of records being discarded, left unattended, or transferred in a manner that puts patient information at risk,” said Christina Heide, acting deputy director of health information privacy at OCR. “It is imperative that HIPAA covered entities and their business associates protect patient information during its transfer and disposal.”

Have you made sure that you have pre-shred documents placed securely? Do you leave information sitting out where others could see it, take it, or use it in a manner that is not intended?  You may have a box near your desk where you put items that need to be shredded. Be diligent and make sure that those boxes aren't left for others to see. Empty it throughout the day.

The one thing no one needs is an $800,000 mistake wrapped in a card-board box.

Feed the shredder! 

About ClaimCare, Inc.

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

Copyright 2009, Carl Mays II and the ClaimCare Medical Billing Company

 

Practices and physician's constantly struggle with understanding how well their billing is working. This can be difficult to do because reliable medical billing benchmarks that can be easily applied are difficult to find. A great solution to this is the use of a Theoretical Yield (i.e., the amount you should collect for every dollar billed if your billing is working perfectly).

Understanding the concept of yield is the key behind assessing the billing performance using medical billing benchmarks.  From a medical billing standpoint, yield is the amount of a claim that should actually result in a payment versus a contractual adjustment. In other words, if your yield is 50%, then on a $100 claim you should received $50 in payments and will write-off the rest to contractual adjustments. In the first article in the series on allowables I discussed why you should set your fee schedule higher than your contractual allowables. Having fees higher than allowables is what results in yields that are less than 100%.

Calculating your practice's yield is straightforward. At its simplest level you take the allowable for a CPT and divide by the fee you charge for that CPT. Using the example above, if your fee for a given CPT is $100 and your allowable for that fee is $50, then your yield is $50 (what you should collect)/$100 (what you charge) = 50%.

This is a straightforward calculation. The complication arises because of the various payer contracts for a practice and the fact that the yield for a specific payer often varies by CPT (i.e., with BCBS you may have a yield of 50% for one CPT and 60% for another CPT).

This means that calculating your yield requires you to understand your procedure mix. To get a close estimate of your yield for a specific payer you can:

1. Take your top 20 CPT codes and calculate the yield for each of these codes; and then
2. Calculate a weighted average for the overall yield based upon the frequency of each of your CPTs;

To move from a close estimate to a more precise estimate your repeat the above procedure but instead of only using your top 20 CPT codes, you use as many as is required to cover at least 90% of your charge volume with each payer. Typically, however, the top 20 CPTs provide an accurate answer.

Once you have completed the above exercise for one payer, you need to repeat this for each of your top payers (you should do this for the payers that represent at least 80% of your payment volume). Once you have done this you can then get an overall yield for your practice by creating a weighted average yield for the practice based upon your charge volume (not payment volume) for the practice. The idea of a weighted average yield of the practice works well as long as your procedure mix and payer mix are stable.  If either changes significantly, then you need to recalculate your yields.

With a weighted average practice yield (or Theoretical Yield) in hand you can easily get an initial understanding of how well you medical billing is performing. This medical billing benchmark will provide significant insight into your true performance. If your practice theoretical yield is 50% and your actual performance is 42% - then you are leaving a lot of money uncollected (up to 8% of every dollar billed). There are a number of items that will keep you from achieving your full Theoretical Yield, but you certainly would expect to be within a few percentage points.

Although developing yields can be tedious work, it is critical to know your practice's yield and use this medical billing benchmark to understand if your medical billing is working well.

About ClaimCare, Inc.

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

Copyright 2009, Carl Mays II and the ClaimCare Medical Billing Company

Guess what day it is? No, it’s not hump day….it is HIPAA Day! Some providers are taken by surprise! Some practices are under the false impression that they are HIPAA Compliant.  Sadly, we are finding more and more that this is not the case.

September 23^rd is the deadline to ensure that your practice is prepared for the finalized MEGA RULE and HI-TECH Regulations. Numerous updates and changes are required of covered entities. Have you updated your manuals,
the NPP (Notice of Privacy Practices), and all BAA’s (Business Associate Agreements)? Are you aware that the rules governing notifications for marketing and fundraising requirements have changed?  Are you ready? Did you know that if you are found to be NON-compliant, there are strict fines and penalties? 

Are you ready to start the requirement for reporting disclosures to HHS? Do you know what limitations have been applied to that ruling? The HIPAA HITECH, Mega Rule comes with more audits, hefty fines and penalties and not only will it impact YOUR practice, but the impact reaches to all of your business associates. Do your providers use mobile devices such as laptops, I-phones, tablets, or other access that is considered remote access? Think about it!  September 23^rd is just around the
corner. So many questions!  Do you have the answers? If you do not feel prepared for the September 23^rd deadline or the new, stricter HIPAA rules, there are many resources available to help you get where you need to be. If you have questions or need assistance, let us know. We have a team that can help get you HIPAA compliant quickly.

About ClaimCare, Inc.

 ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

 

Many significant coding and billing changes have been introduced in 2013 for orthopedics. The ClaimCare Medical Billing Company has created a 13 minute training video to bring orthopedic providers and practice staff members up to speed on the key 2013 Orthopedic Coding and Billing Changes they need to understand to insure they have no compliance, billing or collection issues as a result of these new rules.

2013 Orthopedic Coding and Billing Changes - (13 minutes)

For more insights concerning orthopedic billing, please check out the following collection of articles: Orthopedic Billing Articles

 

About ClaimCare, Inc.

 

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

 

Medicare has over 200 reason and remark codes they use daily in the process of adjudicating claims. They have recently released the top reasons for medical billing denials and rejections.  Most practices may think the majority of medical billing denials and rejections are based on how the doctor or certified CPT coder chooses to code. This is incorrect. Of course, sometimes it is the case – but most times it is not.

You may be surprised to learn that the top denial and rejection reasons are caused by failures within the work flow of the practice’s office. It is easy enough to want to point fingers at Medicare in frustration, but quite often it is the little things that prevent a practice from being paid in as few as 15 days from submission.  So, if you are experiencing delays in receiving Medicare payments, the culprit may well be one of the issues listed below. Fixing these problems can dramatically speed up your payments from Medicare (and other payers). After all, the best medical billing denial management process is avoding denials in the first place.

2013 top 10 reasons for Denials and Rejections:

                1.   Claim submitted to the Wrong Payer/Contractor

                                a.  New Medicare Advantage programs

                                b.  Should be sent to Railroad Medicare instead of Traditional

                2.   Patient ID Number is Invalid

                3.   Patient DOB does not match Medicare Record

                4.   Patient Name does not match Medicare Beneficiary

                5.   Other insurance primary

                6.   Coordination of Benefits of the primary payer is out of balance

                7.   No Part B coverage (or Part A coverage only)

                8.   Zip Code of place of service invalid (requires 4 check-digit code)

                9.   NPI is invalid for the referring physician

               10.  Invalid Procedure Code for date of service.   

About ClaimCare, Inc.

 ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

Many significant coding and billing changes have been introduced in 2013 for cardiologists. The ClaimCare Medical Billing Company has created a 23 minute training video to bring cardiologists and cardiology practice staff members up to speed on the key 2013 Cardiology Coding and Billing Changes they need to understand to insure they have no compliance, billing or collection issues as a result of these new rules.

2013 Cardiology Coding and Billing Changes - (23 minutes)

For more insights concerning cardiology billing, please check out the following collection of articles: Cardiology Billing Articles.

You can download this presentation by visiting  the following page: 2013 Cardiology Coding Changes.

About ClaimCare, Inc.

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

Last spring, ClaimCare Medical Billing Company began notifying clients about inherent issues of the HIPAA 5010 mandate. We have continued working to guide clients through the standardized electronic requirements. Recently, many physicians with whom we have spoken have said they are only learning about these 5010 issues from ClaimCare. They are asking “Why isn’t there anything about these 5010 collections problems on the medical association sites?” It is understandable physicians ask this question. We have asked the question for almost a year. This is not an indictment against any state medical association, just an honest question.

The Texas Medical Association came on board February 1 to help distribute concerns, posting an article on its site about HIPAA 5010 potholes: Are Your Claims Being Rejected? Hopefully, other states that have not already done so will follow suit. This past December the Medical Group Management Association (MGMA) had issued a press release titled: Healthcare industry not ready for 5010; MGMA calls for 6-month contingency plan. Now, in a letter sent to U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius, MGMA President/CEO Dr. Susan Turney writes (click here for copy of the full letter):

“New federal standards designed to streamline electronic insurance claims are instead slowing them down, hurting physician cash flow and pushing some practices into financial distress... Many practices face significantly delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or even the prospect of closing their practice."

Medscape.com posted an article on February 3 about the MGMA letter titled: Physician Groups Say 5010 Standards Hurt Cash Flow. This was preceded by the Physicians Practice “dire situation” article in December to which we referred in an earlier posting: New Year Comes with New Challenges in Healthcare Reimbursement.

As we re-emphasized in our December 19, 2011 update to clients, and then again in January, the 5010 is a format in which all clearinghouses, payers and providers must submit claims. Unfortunately, not all parties have complied in a timely manner. As a result, 5010 has hit some with the fury of a hurricane. Delays in claims acceptance and payments from Medicare and other payers such as BCBS and Cigna are occurring across the nation, and your practice is most likely experiencing decreased collections.

The ClaimCare EDI team continues to work diligently (and literally around the clock) to help resolve these issues and insure that all claims and claim files are received and confirmed at each level of the submission process. This is one of the reasons that our clients are not among the unfortunate groups that have had no Medicare payments since November 2011! Many of the delays, however, are 100% with the payers. These delays will continue until the payers correct the internal system issues that are leading to erroneous claim rejections and general processing delays. This payer-problem is one of the situations we anticipated and to which we referred in the 5010 communications we sent clients in December and January.   

We continue to communicate with our clients on “known issues” at payer (CMS, BCBS, etc.) and clearinghouse levels. Most issues are being resolved by the payers and clearinghouses.  Many other file transmission issues have been resolved through recent upgrading or patching we have performed for our clients and their practice management systems and/or via a plug-in that is designed to help translate the transmitted data into the corrected formats.

If you are not getting the information you need about the impact that 5010 is having on your practice and would like to learn what ClaimCare Medical Billing Company can do to help you, we invite you to contact us at (877) 440-3044. As far as HIPAA 5010 is concerned, we remain on the forefront of testing and successful transmission and believe for practices that are prepared to take advantage of the opportunity, relief is in sight.

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