Coding and Billing Strategies to Boost Compliance and Revenue

by | Last updated Nov 15, 2023 | Published on Sep 23, 2019 | Medical Billing

Coding and Billing Strategies
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Staying financially healthy is not easy as practices transition from the fee for service model to value-based care. Many providers rely on medical billing services to overcome related challenges. There are many processes that can impact a practice’s bottom line. Physicians need to work with their medical billing and coding company to identify common areas that can have a significant impact on reimbursement. Here are some smart coding and billing strategies to improve compliance and ensure a better bottom line.

  • Coding compliance: Compliant coding is crucial to avoid audits and plug revenue leaks. Ways to avoid common coding errors that can cause billing mistakes:
  • Understand how to use diagnosis and procedure codes common in your practice: Correct CPT and ICD-10 codes are essential for obtaining maximum reimbursement for evaluation/management (E/M) and office visits. Coding completely and accurately is crucial not only for reimbursement but also to meet quality measures. Incomplete or inaccurate code descriptions on encounter forms, cheat sheets, and electronic charge systems are common errors. Take care to link diagnosis codes to the relevant CPT codes.
  • Use modifiers correctly: Modifiers can be used with CPT and HCPCS to inform the payer of special circumstances. Not using a modifier or using the wrong one can lead to billing errors and claim denial. Medical coding service providers ensure that their coders are trained to avoid these mistakes and use the right modifiers.
  • Know how to report telemedicine services: While telemedicine enhances patient access and satisfaction, experts say that getting paid for these services can pose problems ( Providers need to know the latest CPT/HCPCS codes applicable to telemedicine. Place of service code 02 should be reported to show that the professional telehealth service was provided from a distant site. If the services were furnished via a synchronous interactive communication, some payers may require modifier -95. Know Medicare and commercial payer rules for telemedicine.
  • Avoid chronic care management (CCM) denials: The common reasons for CCM denials are: several providers billing CCM for the same patient during the same 30 days, CCM billed more than once every 30 days by the physician, and inadequate documentation. To address the first two concerns, practices need to communicate with specialists as to who will bill for CCM and set up an alert in the practice management system to ensure that CCM is billed at the correct time, respectively. It is important to ensure that documentation describes the patient’s condition with as much specificity as possible and matches the intent of the code reported.
  • Code transitional care management (TCM) correctly: TCM is an area that auditors often target. To prevent TCM denials, practices need to ensure interactive contact (telephone, email, or face to face) with the patient within two business days of discharge. Admission discharge transfer (ADT) feeds and discharge summaries should be monitored and the information incorporated into the EHR system. This will allow the staff to engage the patient in the outpatient system quickly. The staff should document the date of discharge, the date of the call, and a very brief summary of the interaction in the medical record. High-complexity TCM (code 99496) would require detailed documentation to prevent denials.
  • Prevent Billing Mistakes – Follow best practices and keep track vital metrics. Here are some tips to prevent common billing mistakes:
  • Verify insurance: Medical eligibility verification and insurance authorization are critical to determine patient coverage and responsibility prior to the office visit. Lack of proper eligibility and benefit verification can lead to delayed payments, reworks, decreased patient satisfaction, increased errors, and nonpayment. A Physicians Practice article says that not verifying insurance can lead to billing the wrong payer.
  • Keep track of key metrics: While medical billing companies provide timely financial reports, physicians need to understand the information to make the right business decisions. Key metrics to track, according to Physicians Practice, are:
    • Net collections -the amount collected on the fees charged. Factors that can impact net collections include high deductibles that increase patient liability, procedures that are not covered, incorrect posting processes, etc.
    • Average collections per encounter: Keeping track of money collected per visit is important to understand yearly trends within the practice. Average collections per visit are influenced by patient liabilities and unworked A/R as well as changes in payer contracts.
    • Days in AR: This refers to the average number of days needed to get paid. Days in AR can increase due to rejections, coding errors, incorrect charge posting, credentialing problems, etc. Assessing days in AR by patient and insurance plan can provide a better understanding of where problems exist so that they can be addressed to promote speedy reimbursement.
    • Charge lag time: This refers to the number of days between date of service and claim submission. Improving your charge lag time can increase cash flow. According to Physicians Practice, the goal should be to reduce lag to less than 5 days for office-based services and 12 days for combined hospital and office-based services.
  • Double check claims before submission: Omitting even a small detail or making a spelling mistake in a claim can lead to denial. Practices need to ensure that all the fields in the claim are properly filled out.

Practices need to keep up to date on new coding rules and initiatives as well as payer rules to improve revenue and avoid potential compliance risks. Outsourced physician billing services are a practical way to achieve this goal. An experienced medical billing and coding company can efficiently manage time-consuming and complex revenue cycle management tasks, allowing physicians to focus on patient care.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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