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    Welcome to the ClaimCare Medical Billing Blog. We strive to provide content that improves the overall quality of medical billing efforts across the US. If you have any specific topics that you would like to see addressed in this medical billing blog please post the topic in the Medical Billing Questions & Answers Forum. If you have an article that you would like considered for publication in the medical billing blog then please email your article to resources@claimcare.net.


    Accelerated Payment and Advance for Providers

    Posted by Carl Mays, ClaimCare President/CEO on Tue, Mar 31, 2020 @ 08:03 PM

    Accelerated Payment and Advance for Providers:

    How to get it and what it means for your practiceiStock_CashFlow2

    CMS has notified providers about the Accelerated Payment and Advance program available to Part B providers. This is a portion of the legislative CARES Act (P.L. 116-136).  Each Medicare Administrative Contractor (MAC) is required under this regulation to consider advancing payments at the request of a provider.  As we will explain below, this is NOT a cash influx without consequences. It is NOT free money. This advance can represent 100% of the amount typically paid to a provider in a 3-month period.   However, if you want to, you can request less than the                                                                   CMS calculated amount.


    ClaimCare advises you to be cautious when requesting this advance.  We completely understand that numerous providers and practices have been hurt by this horrific COVID-19 Pandemic.  However, we encourage you to look at what this would mean for your practice on down the road.  increase-cash-flow-medical-practiceThe amount of money received is not the issue. The issue is that you must carefully consider how the advance will be recouped and reconciled beginning 120 days after you have received it. It is still in flux exactly over what timeframe MAC will reclaim the advance through recoupments. MAC may take a little from every payment over a large number of months, or they may take a lot back from every payment over a shorter timeframe. It appears NOVITAS will be recouping a small amount over many months. However, no matter the timeframe in which the money is recouped, ultimately your future payments will be reduced until the full amount of the advance is paid.

    After you receive an advance through this program, you will continue to be paid as usual for your claims submitted in the normal course of business for the next 120 days.  However, after 120 days following the advance, ANY Medicare claims submitted for payment will be processed against the advance.  This means that after 120 days you will NOT receive full payment for claims submitted to Medicare until your advance is paid in full.

     ClaimCare is not suggesting that you do not pursue the advance. We are only saying that if you do accept it, do so with a full appreciation for the impact it will have on your monthly collections in four months.

    All providers are struggling with trying to provide continuity of care by using telemedicine and videoconferencing. We understand that if your schedules are not full, it is difficult to pay the bills and keep the doors open. If you need these funds, please be sure and submit the appropriate form as quickly as possible to your regional MAC. The forms have either been sent to your primary Medicare contact – OR – you can find them on the MAC website for your region. You should receive the accelerated payment advance in 7 days after your appropriately submitted form is received. This accelerated payment opportunity is only available if the nation us under a National Emergency.  Once this designation is over, the advance will not be available to providers.


    To qualify, you must meet the following requirements:  

    • Have billed Medicare for claims within 180 days of the signature on the form
    • Not be in bankruptcy
    • Not under medical review or investigation
    • Cannot have any outstanding Medicare overpayments

    After 120 days from the date you receive the payment, you will have 210 days to repay the advance, which will be offset against claims submitted.  If you do not submit a sufficient volume of claims in that 210-day period to replay the advance, then you will be expected to make a payment directly to Medicare for the difference.

    We certainly hope you and your staff are staying safe and healthy during this crisis. We encourage you to share with everyone, staff and patients, that they can keep updated on the news and recommendations on the government’s Coronavirus.com website.


    About ClaimCare

    ClaimCare Medical Billing Company is a 100% USA-based HIPAA-Compliant Medical Billing Company

    ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition.

    For additional information, contact sales@claimcare.net, or phone toll-free (855) 376-7631, or visit the ClaimCare Medical Billing website. We can assist your practice and/or facility in numerous ways.

    Tags: medical billing education, medical billing resources, COVID-19 Medical Reimbursement, Medicare Billing

    3 Medical Billing Tips Guaranteed to Maximize Your Revenue

    Posted by Carl Mays on Sat, Jun 01, 2019 @ 08:00 AM

    3 Physician Billing Tips Guaranteed to Maximize Your RevenueAccording to a Healthcare & Business Technology report regarding medical billing, almost $125 billion in uncollected revenue happens each year due to:

    1. medical billing errors, and

    2. failure to stay up-to-date on medical billing rules and regulations.

    This becomes even more alarming when realizing that a Modern Healthcare article stated nearly 80% of patients owe more than $500 to their healthcare providers while 51% owe more than $1,000.

    With this data to consider, maybe you should take a closer look at your medical billing situation to see if you have a mission statement similar to the one we have at ClaimCare Medical Billing, Inc.: “To collect the maximum revenue for your practice as fast as possible while helping to alleviate costs and hassle for your organization.”

    As you strategize to maximize revenue and alleviate costs and hassle, here are 3 medical billing tips that can help your billing process become more efficient.

    1. Create a clear billing and collection process

    Improve your revenue cycles through an established step-by-step billing and collection process. Do this by:

    • Establishing clear terms with your patients, which includes getting their permission to leave voicemail messages regarding billing matters, reminding them about co-pays, and discussing their different payment options.
    • Gathering and verifying patient information, which includes their phone number, email, workplace, and billing address. If you are not already doing so, require them to bring a photo ID to accompany their insurance card at their initial visit. This can be very helpful in case their bill has to go to a collection agency in the future.
    • Drafting a sequence of letters to remind them about their bills, which includes when their bill is due, when it will be overdue, and when it will be turned over to a collection agency.

    With these 3 bullet points above in place, you can experience a more efficient physician billing process with less delinquent payments.

    2. Properly manage your claims

    HealthCare & Business Technology revealed that almost 80% of all medical billing contains errors. When errors occur, the result is a longer cycle revenue for your claim collection process, which undergoes an initial submission, rejection, editing, and resubmission.

    Why go through this longer cycle if it can be done more efficiently by inputting the correct information and double-checking the claims before submitting them the first time?

    Ensure you double-check the following before submitting your claims:

    • Patient information
    • Provider information
    • Standardized medical codes
    • Insurance information
    • Duplicate billings
    • Documentations

    What if you still get a denied claim after verifying the above information? How do you handle this?

    Denied claims are often provided with claim number references or denial codes, together with an attached Explanation of Benefits (EOB). If you don’t receive these, it is best to contact the representative of the company to request the items. If they can't be provided, you may directly clarify the errors with them to ensure your claim will be accepted the second time around.

    3. Track pending accounts payable and identify problem accounts

    Aside from doing due diligence in performing tips no. 1 and 2, it is also important for your practice to track the following:

    • Pending account receivables
    • Problem accounts

    Why is this important?

    Tracking your pending account receivables helps you properly evaluate the efficacy of your collection procedure, while identifying problem accounts can help you create a better approach in handling their non-compliance to your billing schedules. As needed, you may either increase the billing reminders for these patients or choose an outsourced collector to handle the collection for you.

    About ClaimCare:

    ClaimCare is one of the largest medical billing companies in the United States. We offer a complete medical billing solution using the best-of-breed technology, actionable reporting, and airtight medical billing process to ensure you have increased revenue for your practice. For more information contact us by phone at (855) 376-7631 or subscribe to our Medical Billing Blog.

    Tags: medical billing education, medical billing, medical billing services

    Meet the Two Culprits Behind Your Medical Billing Mistakes

    Posted by Carl Mays on Tue, May 07, 2019 @ 11:03 AM

    Meet the Two Culprits Behind Your Medical Billing Mistakes According to a Healthcare Business and Technology report, almost 80% of medical bills contain errors. This results in approximately $125 billion of profit loss for U.S. practices. If you have in-house billing, it is important to identify these mistakes and the reasons behind them in order to fix and avoid them in the future.

    The Two Most Common Reasons Behind Medical Billing Errors:


    1. The Complexity of the Medical Coding System

    The International Classification of Diseases, currently in its 10th Revision (ICD-10), will present ICD-11 at the World Health Assembly in May 2019, which will come into effect on January 1, 2022. “A key principle in this revision was to simplify the coding structure and electronic tooling – this will allow health care professionals to more easily and completely record conditions,” says Dr Robert Jakob, Team Leader, Classifications Terminologies and Standards, WHO.

    Meanwhile, it is important to keep up to date on ICD-10, which has constant updates and changes, as exemplified on ClaimCare’s post: Impact of Medicare 2019 E&M code changes on a physician compensation package based on RVU.

    ICD was originally adopted by the U.S. to provide better data for research, a more efficient healthcare system, and quality, safety, and efficacy measurement of services - believing that it could reduce medical billing errors because of the specificity of services listed on each code.

    However, this has resulted in more errors for practices that have struggled to learn and remain updated with the coding system.

    Insurance companies have also become stricter with their medical billing and coding practices. The smallest mistake easily becomes a reason for your medical billing claim to be rejected.

    This results in a longer medical billing cycle, which may lead to several months of waiting before payment for services are released.

    2. Failure to Remain Updated with the Latest Medical Billing Rules and Regulations

    Another challenge facing medical practices is how to cope with the aforementioned constantly changing rules and regulations in the medical billing industry.

    The release of the Medicare 2019 E&M Code Changes meant another set of codes had to be remembered for your medical billing staff/personnel. The question arises, “Did your organization have the time and skill set to read and implement the changes?

    Kyle Haubrich, JD shared the following insights in his article, How the MIPS proposed rule could affect your practice:

    "Physicians are frustrated and are becoming burned out with all the regulations they currently have to comply with, so opting in might just be more frustration for them, and not worth the hassle."

    Are you feeling the same thing?

    Here's how you can get rid of these medical billing problems.

    Incorrectly, medical billing outsourcing may seem expensive to some practices and facilities that have never tried an efficient and effective medical billing company. However, the numerous benefits, including the reduced profit loss, will prove to be more beneficial than previously imagined for the practices and facilities that are hesitant to outsource.

    Teaming up with a medical billing company erases a need to worry about:

    • Changing medical rules and regulations
    • Medical claim submission and approval
    • Medical coding updates

    Most importantly, you don't need to spend on personnel:

    • Salary
    • Benefits
    • Taxes
    • Compensation

    You don't even need to think about turnover, training, and staff familiarization over billing software, procedures, and coding.

    With Medical billing outsourcing, you gain access to trained professionals, who only make money when you do.

    Reduce your profit loss. Consider your options and choose a medical billing company who can help you reduce these mistakes.

    Learn more tips and suggestions on how you can improve your medical billing process. Subscribe to our blog or call us toll-free at (855) 376-7631.

    About ClaimCare

    ClaimCare has over 80 years of combined medical billing experience in providing medical billing services to various specialties and states. This includes process engineering, information technology, accounting, and business management. Let's talk. Send us a message.

    Tags: medical billing operations, medical billing education, medical billing services, medical billing resources, Reasons to outsource medical billing

    Three Reasons You Should Outsource Your Medical Billing Services

    Posted by Carl Mays on Wed, Sep 26, 2018 @ 04:03 PM

    3 reason to outsource your medical billingThe majority of the chief financial officers (CFOs) involved in the 2018 CFO Outlook Performance Management Trends and Priorities in Healthcare listed cost reduction as their no. 1 priority.

    Among them, 50% expressed the desire for easier report creation, better dashboards and visuals, and enhanced ability to understand the report and data statistics. Also, a staggering 90% have shown their concern over the online payment security of their accounts. How can outsourcing your medical billing services address these concerns? Is this even possible?

    How Outsourcing Your Medical Billing Service Can Help Your Practice

    Outsourcing your medical billing services can bring numerous benefits to your practice including:

    Increased Revenues and Reduced Labor Costs

    Approximately, 8% to 10% of medical collections are spent on the medical billing process. However, with an outsourced medical billing, you can:

    • Reduce overhead costs
    • Increase reimbursements
    • Decrease claim denials and rejections

    In an orthopedic billing case study, the group reported a 73% increase with their billing revenue within six to eight months. This was due to the improved contracting and exiting unprofitable procedure lines implemented in their medical billing process.

    In most instances, physicians and office medical managers even realize a 96% claim payment upon the first submission in less than 45 days. All because they have moved their medical billing services to a third party provider.

    Easy to Read Dashboard Reports and Data Statistics

    Now you can focus more on your patients rather than spending long hours analyzing and interpreting your medical billing reports, with the help of an outsourced medical billing provider.

    Third party providers have medical billing online dashboards that easily show the issues with your medical account at a glance. Also, the data can be tracked on a weekly, monthly, or annual basis according to:

    • Patient volumes
    • Procedure mixes
    • Collections
    • Days in AR

    This makes it easier for your staff to handle your patients’ financial matters and results in a less time-consuming experience for them.

    Safe and Secured Data Infrastructure

    Last year, DataBreaches.net shared a data compilation revealing that 477 healthcare breaches affecting 5.579 million patient records were reported to the US Department of Health and Human Services (HHS).

    Choosing the services of a well established third party medical billing company can protect your patient records through 100% secure medical billing processes. These HIPAA-compliant providers offer a secure and transparent billing process that ensures your data remains confidential at all times.

    Now you can say goodbye to those unwanted cyber hack attacks without having to pay extra for cyber-security protection. These are all taken care of by your third-party provider. All you need is to find a medical billing third-party provider who can deliver the medical billing services you require.

    Why Choose ClaimCare for Your Medical Billing Services?

    ClaimCare has more than 25 years of experience in medical billing. It has a proven track record of increased customer collection reaching all the way up to 25% (the average increase is approximately 5%) and days in AR under 40 for your collectibles.

    Let's talk. Complete our online form or call us toll-free on (855) 376-7631, today.

    Tags: general medical billing questions, medical billing operations, medical billing education, medical billing companies, medical billing services, medical billing resources, Reasons to outsource medical billing

    Impact of Medicare 2019 E&M code changes on a physician compensation package based on RVU

    Posted by Carl Mays on Mon, Sep 24, 2018 @ 04:55 AM

    2018 09 22 - Imact of medicare changes on RVU based comp

    The Centers for Medicare & Medicaid Services (CMS) just issued a proposed ruling to the Medicare Physician Fee Schedule (PFS) last July 12, 2018. This will take effect on or after January 1, 2019.

    This article discusses the impact this will have on the physician's relative value unit (RVU) based on their practice (directly and indirectly), and a list of potentially misvalued services to watch out in 2019.

    Why is it important for physicians to know the upcoming RVU calculation changes in the proposed Medicare 2019?

    Physicians can earn up to 7% of their Medicare Part B payments in 2021 based on their Medicare 2019. Here is what the vice president of public policy of the American Medical Group Association (AMGA), Chet Speed has to say about it:

    "When you think about incentives, generally, you need both a carrot and a stick to make change. With Medicare moving to a value-based system, you need a carrot, in the form of higher payments for doing well, and you need a stick, if you don’t do well, you have less reimbursements. "

    How will this impact your practice? Here are some of the calculation changes and adjustments that will take effect on your RVU:

    Practice Expense Methodology Calculation Changes

    Medicare 2019 will be incorporating two new specialties, which will affect hospitalists and advanced transplant cardiology and heart failure physicians.

    Calculation Changes to Direct PE Inputs for Specific Services

    Standardization of the following specific services is expected in the proposed Medicare 2019:

    • Clinical labor tasks
    • Balloon sinus surgery kit comment solicitation
    • Scope systems' equipment recommendation
    • Existing direct PE inputs updated prices

    This includes an update on the prices of the following supplies and equipment:

    EQ370: Biopsy guidance software and breast MRI computer aided detection

    SA036: Transurethral microwave thermotherapy together with the kit

    SA037: Transurethral needle ablation together with the kit

    SK050: Neurobehavioral status forms

    SL140: Wright's Pack (per slide) and the stain

    Calculation Changes to the Indirect PE of Certain Office-Based Services

    The indirect PE RVUs for those working in a non-facility setting is expected to increase due to the direct PE costs applied to them. This is because the greater value between the clinical labor costs and the work RVUs in relation to the direct costs of these services will be the value selected in determining their RVU.

    List of Potentially Misvalued Services for 2019

    Aside from changes to the practice expense methodology calculation, the General Accounting Office and MedPac have also listed the following "potentially misvalued services." This is based on a high volume of codes submitted for review by their office to the CMS.

    • Colonoscopy w/lesion removal (45385)
    • CT head w/o contrast (70450)
    • EGD biopsy single/multiple (43239)
    • Electrocardiogram complete (93000)
    • Revision of heart chamber (92992)
    • Total knee arthroplasty (27447)
    • Total hip arthroplasty (27130)
    • TTE w/doppler complete (93306)

    An additional 72 separate code groups for specific codes are currently on review by the CMS. This is after it has taken a closer look at the rationale provided by the American Medical Association/Specialty Relative Value Scale Update Committee.

    Comments on these proposed new valuations are welcomed by the committee. You may submit yours on or before September 10, 2018 for it to be considered.

    Impact on Specialty Specific Health Sectors

    Those working on specialty specific health sectors, such as the following medical professionals, are also most likely to experience the following adjustments in their overall payment:

    • 3% increase for nurse practitioners
    • 4% increase for gynecology/obstetrics
    • 3% decrease for oncology/hematology
    • 4% decrease for dermatology

    Given these changes, surprise medical bills and price transparency remains to be the issues facing suppliers and providers.

    Would you like more updates about the Medicare 2019 E&M code changes?

    Subscribe to our blog to remain posted. Share the knowledge and hit the share buttons.

    Tags: medical billing education, medical billing resources, medical billing coding, 2019 Medicare Changes

    Buyer Beware: EHR System Vendor Agreements & Its Impact on Your Billing

    Posted by ClaimCare Resources on Thu, Sep 20, 2018 @ 05:06 AM

    Medical Billing Services


    Have you ever experienced signing an EHR vendor system agreement only to later realize you also transferred your medical billing tasks to the vendor? How about the nightmare of migrating your data from the previous system vendor to the new one? 

    This was experienced by Daniel Goodman, MD of Atlanta. He is a solo internist who had to pay approximately $10,000 to $12,000 just to get his data from the previous vendor into the new one. This is not to mention the 50% disruption of usual workload from his practice for an entire week.

    Learn the importance of thoroughly reading your EHR system vendor agreement before signing up to avoid these scenarios, surprises, and inconveniences.

    Basic Things to Consider Before Signing an EHR System Vendor Agreement

    Titus Schleyer, DMD, PhD, the director of the Center for Biomedical Informatics at the Regenstrief Institute in Indianapolis, Indiana gave a very interesting comment for anyone who wishes to sign a new EHR system vendor agreement.

    “Switching to a new system is a big investment, and you’re impacting practice viability if you’re laying out hundreds of thousands of dollars every few years for a new system. So, you need to be very careful and prepare for your switch well.”  

    You definitely need to do your homework before making that switch. To ensure you are making the right choice, include the following questions to your potential EHR system vendor:

    1. How will the data be migrated to the new EHR system?

    Migrating data from your current EHR to a new EHR system is a huge task.

    As Daniel experienced, he had to focus on manually encoding the data on the system for an entire week just to ensure it was accurately transferred. That meant temporarily closing his practice during that time.

    To prevent this from happening, properly plan for your data migration. Seek answers to the following questions in the EHR system vendor agreement:

    • How long will it take to complete the migration? Can the data be migrated in stages?
    • How does the system ensure that the data has been migrated correctly into the new vendor system?
    • Does the vendor have the capacity to integrate data from the billing system, LIS, RIS, PACS, and medical devices?

    If the answers are not clearly stated in the agreement, then it is best to clarify these questions directly with the vendor.

    1. How will the billing be done using the new system?

    A billing system is the heart of any practice. If it gets disorganized or disrupted, your entire operation may be in jeopardy. Thus, it is very important to know if the following items are clearly discussed in the agreement:

    • Billing capabilities
    • Training procedure
    • Data integration

    Software training and data integration are key factors in effectively using a new vendor system for your practice. If not provided, additional outside help from a software consultant may be necessary just to integrate the new EHR system and the medical billing system. This means more expenses for your practice.

    Think twice! Carefully read your vendor system agreement because...

    Some system vendors automatically assume the responsibility of handling the billing system of your organization after you have shifted to their service. Should you wish this to be handled by a different provider, immediately inform them upfront about it and amend the agreement stating such.

    What can ClaimCare do for your practice?

    ClaimCare provides various medical billing services. ClaimCare can work on yoru current Billing system or provide you with one if needed. For more information and how you can benefit from ClaimCare Medical Billing Services, contact us.

    Tags: general medical billing questions, medical billing operations, medical billing education, medical billing, selection process

    Top Three Impacts of Medicare ID Card Changes on Medical Billing Services

    Posted by Carl Mays on Mon, Sep 17, 2018 @ 07:05 PM

    ClaimCare Medical Billing LightsIn the interest of improving security, Medicare has released new cards meant to prevent identity theft among its users.

    The Centers for Medicare & Medicaid Services (CMS) have given physicians and medical billing companies 21 months to fully implement the necessary changes to their medical credentialing and medical billing services. The announcement was made to allow companies the chance to fully comply with the newly implemented Medicare ID card requirements.

    The question is, what kind of impact will these new changes have on your billing system and services? What would be the best way to go about this transition? Let’s start by understanding the major changes with the new Medicare ID card...

    There are three primary differences in the new Medicare ID card that should be taken note of:

    • The removal of the Social Security Number (SSN)
    • The replacement of the Health Insurance Claim Number (HICN)
    • The use of the Medicare Beneficiary Identifier (MBI)

    What’s the major difference between the Medicare Beneficiary Identifier (MBI) and the Health Insurance Claim Number (HICN)?

    Previous Medicare cards used to have the SSN based Health Insurance Claim Number (HICN) and used it as a primary identifier for card holders. However, due to rising incidence of identity theft and fraud risks, the Medicare Access and CHIP Reauthorization Act required the CMS to remove the HICN.

    Instead, Medicare cardholders will now be provided with a NEW Medicare Beneficiary Identifier (MBI) that features an 11-character-long combination of numbers and uppercase letters (except for S, L, O, I, B and Z), separated by dashes.

    It is a unique, non-intelligent and randomly generated sequence of numbers and letters that do not have any special meaning whatsoever.

    How will this impact doctors and medical office managers in billing and compliance services?

    Currently, the new Medicare cards are already being mailed and distributed to recipients. This means that cardholders will soon be visiting medical offices with their new cards, asking for further clarification about the changes, and seeking assistance for its use. It’s important,  therefore, that you are fully prepared to address their concerns, inquiries, and demands.

    With this in mind, here are the top three concerns or challenges that you need to take note of given this new policy:

    1. Eligibility Verification of the New Medicare ID Card

    With the new card, one of the primary concerns that you will have to face will be verifying its authenticity and validity. 


    The new card shares the same white, blue and red color like the previous one. However, take note of the new Medicare Number and how it is comprised of uppercase letters and numbers alone. Thus, it is most important for doctors and medical office managers to learn how to identify a valid Medicare ID card from a fraudulent one.

    This sounds simple, right? But wait a minute. This is just the tip of the iceberg. There is more information pertaining to the patient’s screening process that has to be verified. This includes:

    • Effective dates
    • Benefits and calculations
    • Administration, follow-up and plan execution

    Should there be a need to verify the validity of the card, doctors and medical office managers can check and verify using Medicare Administrative Contractors (MAC's) secure portal, beginning June 2018.

    2. Coordination of Benefits with the New Medicare ID card

    The major change happening with the new Medicare ID card is the use of the MBI number. CMS is not expecting any other major changes aside from this, unless there are disputes on an individual's account.

    Another issue you may encounter is your patients not being able to receive their new Medicare ID cards due to a change of address. How should you handle this if they visit your office and continue to hand over the old Medicare ID card?

    To that end, doctors and medical office managers should be proactive and update their records. This is to easily and quickly claim their payments while avoiding unwanted mishandling of client records in the future.

    3. Submission of medical claims using the MBI

    The issuance of new cards was driven by a need to protect users from potential identity theft and fraud. This basically means that the new Medicare IDs will still require doctors and medical office managers to thoroughly process claims. It’s important, therefore, to ensure that the process and submission of these medical claims are accurate, otherwise you will leave yourself vulnerable to payment delays.

    Bottom line…

    To help you with this transition, you need to have an efficient system set up that can handle new information, securely handle data, and manage operational efficiencies easily.

    ClaimCare provides doctors and medical office managers a complete medical billing solution to manage this transition.

    Claim Care:

    • provides the top service level guarantee in the industry
    • offers best-of-breed technology
    • is based 100% in the USA
    • an air tight medical billing process
    • provides actionable reporting and broad experience
    • 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 (855) 376-7631 or visit the ClaimCare Medical Billing Company website.

    Tags: general medical billing questions, medical billing operations, medical billing education, medical billing services, medical billing resources

    Big Medical Billing Changes Are Coming for Modifer 59

    Posted by ClaimCare Resources on Wed, Sep 03, 2014 @ 02:04 PM

    modifer 59 changesBig medical billing changes are coming for t
    he 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.


    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

    Tags: medical billing education, 2015 medical billing changes, medical billing coding

    Orthopedics Billing: 2013 Orthopedic Coding Changes

    Posted by ClaimCare Resources on Fri, Mar 29, 2013 @ 03:11 AM

    Orthopedic Billing and CodingMany 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.


    Tags: coding questions, medical billing education, orthopedic billing, 2013 medical billing changes, medical billing companies, medical billing resources, Medicaid billing

    Medical Billing News: You Are Probably Your Own Worst Enemy!

    Posted by ClaimCare Resources on Wed, Mar 27, 2013 @ 11:44 AM

    Denial ManagementMedicare 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.

    Tags: medical billing operations, medical billing education, cardiology billing, orthopedic billing, medical billing, improving medical billing, denial management

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