Strategies to Prevent E/M Mistakes and Denials

Strategies to Prevent E/M Mistakes and Denials

A large volume of the claims processed by medical billing companies are those for evaluation and management (E&M) services. The key to maximizing payment and avoiding risk of audits is proper documentation and coding of E/M patient visits.

The main reasons for the denial of E/M claims are assigning the wrong codes and reporting codes that do not support the services provided. Here are top strategies to prevent E/M mistakes and denials:

Choose the code that best represents E/M services rendered: There are different levels of E/M codes, which are governed by the complexity of the visit and documentation requirements, and certain other factors. According to CMS, the main variables that need to be taken into account when selecting E/M codes are:

  • Patient type (new or established) – New patients are those who have not received any professional service from the healthcare provider within the last three years; established patients are those who have received professional service from the healthcare provider within the previous three years.
  • Setting/place of service – The physician-patient encounter could take place in an office or outpatient setting, a hospital inpatient, an emergency department, or a nursing facility
  • The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (i.e., the number and type of the key components performed). Typically, the higher the complexity of the encounter, the higher the level of the code reported. Unless coding based on ‘time’, these three key components are enough to meet E/M documentation requirements.

Starting January 2020, evaluation and management (E/M) has new codes for e-visits that Medicare will reimburse.

Provide clear documentation for Level 4 Office Visits: When time is the main element in the patient’s visit, the appropriate time-based service code needs to be captured. However, choosing a , Level 4 E/M code based on time, proper documentation that clearly describes what was done and why is crucial, according to a 2018 Medical Economics article. The reason is that Level 4 E/M codes come under payer scrutiny as they are associated with higher payments. The report notes that if the physicians choose a Level 4 E/M code based on time, their documentation must clearly describe what was done and why. In the absence of proper documentation, the physician could come under the microscope if the payer suspects upcoding. The article notes that focusing on diagnosis codes can help justify the basis for E/M level selection based on time.

Another point to note is that time spent on extent of the counseling and coordination of care should also be documented. These services are above and beyond the E/M code and documentation must really reflect this fact.

Ensure services rendered are “reasonable and necessary”: According to CMS, when assigning an E/M level, medical necessity means “the service is furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition.” Medical necessity is determined by the severity of the patient’s presenting problem. To prevent claim denial, it should be ensured that the service provided was reasonable and medically necessary.

Follow documentation rules: If it wasn’t documented, then it wasn’t done. Physicians should ensure clear and legible documentation in the medical record. New documentation guidelines for office- and outpatient-based E/M services came into effect on January 1, 2019. According to these rules, the provider can reference previous information and document an update from the last visit. However, physicians should know the documentation guidelines followed by their non-Medicare payers as these may differ from CMS guidance.

Stay informed about updates: The AMA recently released CPT errata and technical corrections ( and knowing these changes is necessary to ensure correct coding. The Evaluation and Management section, under the Non-Face-to-Face Services heading, the Remote Physiologic Monitoring and Treatment Management Services introductory guidelines has been revised to specify that codes 99457, 99458 should be reported for the first completed 20 minutes and each additional completed 20 minutes, respectively, of clinical staff/physician/other qualified healthcare professional time in a calendar month. Other changes include:

  • Deletion of the second instructional parenthetical note following 99458 that states: “Report only 99457 if you have not completed 20 minutes of additional treatment regardless of time spent.” Do not report 99457 for services of less than 20 minutes.
  • Revision of the third instructional parenthetical note following 99458 to read: “Do not report 99458 for services of less than an additional increment of 20 minutes.”

These updates became effective Jan 1, 2020.

The best way to reduce claims denials is to outsource medical billing and coding to an experienced service provider. With proper clinical documentation of E/M visits, an experienced medical billing company can help practices reduce denials and increase revenue.

CMS to Expand Telehealth Coverage for Medicare Advantage Plans

CMS to Expand Telehealth Coverage for Medicare Advantage Plans

Telehealth can improve access to care. The original Medicare telehealth benefit includes restrictions on where beneficiaries receiving care via telehealth can be located. The proposed rule would allow Medicare Advantage (MA) and Part D plans to cover additional telehealth benefits starting in 2020, with which MA plans will have more flexibility than is currently available in how they pay for coverage of telehealth benefits. Physicians providing telehealth services can consider outsourcing medical billing tasks to ensure appropriate reimbursement. According to the CMS, Medicare beneficiaries are eligible for telehealth services, only if they are presented from originating sites approved by the agency such as –

  • The offices of physicians or practitioners
  • Hospitals
  • Critical Access Hospitals (CAHs)
  • Rural Health Clinics
  • Federally Qualified Health Centers
  • Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
  • Skilled Nursing Facilities (SNFs) and
  • Community Mental Health Centers (CMHCs)

Earlier, telehealth services were covered only for rural residents, who may need to travel considerable distances to receive in-person care. With its consideration to expand telehealth coverage, CMS believes that the additional telehealth benefits in MA will increase access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits. The proposed rule would give MA plans more flexibility to offer telehealth benefits to all their enrollees, whether they live in rural or urban areas.

The proposal would also allow Medicare Advantage enrollees to receive telehealth service from places including their homes, rather than going to a health care facility. CMS Administrator Seema Verma says, “I am especially excited about proposed changes to allow additional telehealth benefits, which will promote more access to care in a more convenient and cost-effective manner for patients.”

It is recommended that in the Medicare Open Enrollment for 2019 that is currently underway and runs through December 7, 2018, seniors can review their coverage options and decide how they would like to receive their Medicare benefits in 2019. With this proposed change, more payers are also expected to provide MA, thus expanding access to telehealth services. The rule would also help CMS recover improper payments made to Medicare Advantage organizations.

As these plans are reimbursed based on each member’s sickness level, the CMS uses its Risk Adjustment Data Validation (RADV) audits to make sure that the data submitted by insurers matches the patient’s diagnoses. According to the report from Fierce Healthcare, these proposed changes to MA audits could put insurers on the hook for billions. Insurance companies can consider comprehensive RADV audit services from professional medical billing companies to establish whether the diagnosis codes submitted can be validated by medical record documentation. CMS expects that, if finalized, these proposed changes would result in an estimated $4.5 billion savings to the Medicare Trust Funds over a ten year period, largely from the recovery of improper payments to Medicare Advantage plans through contract-level RADV audits.

Audiology Insurance Verification to Avoid Reimbursement Pitfalls

Audiology Insurance Verification to Avoid Reimbursement Pitfalls

Audiologists provide comprehensive hearing tests including vestibular tests, hearing aid services such as hearing aid evaluations, fittings, repairs and adjustments, sale of hearing aids, hearing aid fitting, and hearing aid counseling and aural rehabilitation. Outpatient audiology services are usually covered by health plans, but with limitations, making audiology insurance verification crucial for efficient medical billing. In fact, as a report in The Hearing Journal notes, for many audiology practices, coping with private insurance and other third-party payers has long been “more of a hassle than it’s worth”. Today, audiologists, physicians, non-physician practitioners (NPPs), and hospitals are realizing the benefits of partnering with audiology insurance verification companies to manage the patient eligibility verification and preauthorization process.

Audiology Insurance Verification

Audiology Services – Coverage, Limitations and Exclusions

According to the American Speech-Language-Hearing Association, 20 states require that their health benefits plans cover hearing aids for children, and in three of these states, health insurance plans are required to provide hearing aid coverage for adults. Understanding coverage, limitations and exclusions is crucial to ensure a smooth medical billing process:

  • Reimbursement for audiology services varies depending on where services are provided and the type of payment coverage that the patient might be eligible for
  • Evaluations to detect hearing loss and services related to degenerative hearing loss may or may not be covered by private insurance.
  • Almost all private health insurance companies cover audiological diagnostic services based on “medical necessity” as documented by the physician for an audiologic evaluation to test for a suspected diagnosis (e.g. hearing loss unspecified, sensorineural hearing loss, conductive hearing loss, etc.).
  • Hearing aids are covered by some plans when the hearing loss results from an illness or injury, but many private insurers exclude hearing aids.
  • Some private health plans may cover only a partial cost of the hearing aid or reimburse the patient for a set amount.
  • Medicaid covers hearing aids and other audiology services but coverage varies from state to state. Based on broad federal guidelines, each state administers its own program, and establishes its own income eligibility standards, type, amount, duration and scope of services covered.
  • Medicare covers certain diagnostic hearing tests and some Medicare Advantage plans include coverage for hearing aids. However, traditional Medicare does not cover routine hearing exams, hearing aids, or exams for fitting hearing aids. There is also no provision in the law for Medicare to pay audiologists for therapeutic services.

These exclusion policies and coverage restrictions pose significant challenges for billing audiology services. Audiologists and hearing instrument specialists need to consider each opportunity carefully before signing a third-party contract and verify patients’ hearing aid benefits prior to discussing device options with them. It is the patient’s responsibility to pay for audiology services that are not covered by the third party payer.

Prior Approval

Payers require providers to obtain prior approval before the provision of certain hearing and audiology services. If claims are submitted for such services without obtaining approval, these services will not be reimbursed as billed. Payers will not give prior approval for an item or service if a less expensive item or service is considered suitable to meet the patient’s need. When prior approval is given, providers should verify the patient’s eligibility on the date of service.

What Audiology Insurance Benefits Verification Involves

Insurance verification is a time consuming process that involves checking each patient’s hearing aid benefits eligibility, responsibility, and plan requirements before the patient comes in. The following patient coverage and benefits should be verified every time services are provided:

  • Patients name and demographic information
  • Policy number
  • Coverage – Primary, secondary, tertiary
  • Coverage for hearing aids, BAHA bone conduction hearing implants, cochlear implants
  • Participating provider / in-network provider
  • Patient policy status and effective date
  • If the patient allowed to share in cost of the device if they chose technology beyond their benefit
  • Out-of-network benefit (if not an in-network provider)
  • If the hearing aid benefit is monaural / binaural or annual
  • Provider discount if any and amount
  • Deductible and when it was met
  • Co-pay and coinsurance
  • Plan requirements (prior authorization, Medicare denial, referral, prescription, etc.)
  • Whether codes to be billed are covered, and if not, how uncovered codes are handled

Having an audiology insurance verification company handle procedures for collecting patient information and verifying insurance eligibility will support a smooth claims and billing process. Insurance verification specialists will have extensive experience in working with government insurance as well as commercial insurance companies. They will communicate with carriers regarding clinical information requested and strive to resolve coverage and payment related issues for specific patients and benefits. Partnering with an experienced service provider can promote streamlined insurance verification and prior authorization that can help reduce denials and drive higher reimbursement.

Read our FAQ on Hearing Aid Insurance Verification.

What Health Insurance Options will Consumers Retain in 2017?

What Health Insurance Options will Consumers Retain in 2017?

Health InsuranceWhat are my health insurance options in 2017? This is a question that many people are asking after the presidential elections and the newly elected government announced that it would repeal Obamacare. Healthcare providers, who rely on insurance verification services to check patient benefits before providing care, also need to know the answer to this question. Here is a list of the coverage options that physicians can expect their patients to retain in the coming year:

  • Medicare: As one of the country’s most important social programs, Medicare will continue providing health coverage for millions of Americans. However, in 2017, premiums are expected to rise for receipts that pay premiums for Part A coverage as well as for Part B coverage, which covers the costs of services and supplies needed to diagnose and treat diseases. Medicare recipients are also likely to see higher deductibles and copayments in 2017.
  • Medicaid: Medicaid provides health coverage to millions of eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. The Children’s Health Insurance Program (CHIP) covers eligible children, through both Medicaid and separate CHIP programs. Beneficiaries of these programs will continue to retain coverage in 2017.
  • Employer-sponsored health insurance: Nearly 60 percent of Americans are covered by an employer-sponsored health insurance plan. Under the Affordable Care Act, many workers enrolled in these plans to avoid paying a penalty. According to a report in the Houston Chronicle, health insurance paid by a company for its employees is expected to remain stable in the coming year – as long as the company remains in business and premiums are paid.
  • Private health insurance: There are several private health insurance companies operating in the US market today such as UnitedHealth, Kaiser Foundation, Wellpoint Inc., Aetna and Humana Group. Though the individual market is more complex than group insurance, consumers who pay the full price for private plans will most likely continue to be covered.
  • Health insurance exchanges under the Affordable Care Act: For those who enrolled in a plan offered by the Obamacare health insurance exchange by December 15, coverage will start January 1, 2017. The last day to enroll in or change a health plan is January 31, 2017. Health coverage obtained via is likely to be valid even beyond 2017, say experts.

Given the volatile health insurance scenario, the American College of Physicians (ACP) advises physicians to educate themselves about the coverage options available for patients. Many patients do not understand concepts such as deductibles and copays, which can pose collection problems. Physicians can direct them to consumer-assistance resources. The ACP also endorses patient benefit verification at the time of service and recommends that physicians tell their patients at this juncture what their cost-sharing obligation will be.

Many practices opt for comprehensive insurance verification services to manage this task. An insurance verification specialist contacts the insurance company directly to check patients’ coverage. Enquires are made about the patient’s un-met deductible, co-payment, and co-insurance responsibilities. A critical element of physician billing services, such support allows physicians to check patients’ eligibility ahead of their appointment and be transparent with them about their cost sharing responsibility. This will allow patients to make necessary financial arrangements to pay deductibles. In addition to avoiding surprise bills and increasing patient satisfaction, insurance verification helps providers improve collections and revenue cycle management.

To learn more about health insurance in 2017, see our new blog “How the New Senate Health Care Bill Proposes to Change Coverage“, published on 13 July 2017.

HHS Releases New Rules for Meaningful Use Stage 3 of the Incentive Program

HHS Releases New Rules for Meaningful Use Stage 3 of the Incentive Program

The United States Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) recently announced the release of the proposed rules for “Stage 3 of the Meaningful Use Incentive Program” for Medicare and Medicaid EHRs and the 2015 Edition of Health IT Certification Criteria to support the path to nationwide interoperability.

The two proposed rules aim to offer higher flexibility in healthcare operations by supporting better care provision, lowering costs and improving information sharing.

The proposed CMS rule of Stage 3 Meaningful Use specifies new criteria that eligible professionals (EPs), hospitals and critical care hospitals must fully meet in order to qualify for Medicaid EHR incentive payments. It also stresses on criteria that providers must meet to avoid Medicare payment adjustments based on program performance beginning in payment year 2018. In addition, the rule provides enhanced flexibility and simplifies requirements for healthcare providers by focusing on advanced EHR use and eliminating specific requirements that are no longer relevant. The 2015 EHR certification criteria include updated IT functionality and provisions that support the incentive programs.

As per the proposed rule, the meaningful use reporting period will be a full calendar year for both physicians and hospitals starting from the year 2017. The only exception will be made for Medicaid EPs and hospitals that are attesting to meaningful use for the first time, and these providers will have a 90-day period.

From 2018, CMS will promote electronic quality reporting for providers in the Medicaid incentive program. These providers can remain in either Stage 1 or Stage 2 or can attest even Stage 3 in 2017. However, from the beginning of 2018, all Medicare and Medicaid EPs and other hospitals will have to attest in Stage 3 (no matter which stage they were previously in). Furthermore, it is essential for all providers to adopt the 2015 edition EHR technology by 2018 (as they can use 2014 edition certified EHRs through 2017).

Stage 3 Meaningful Use – Ruling Highlights

  • About 25% of patients seen by eligible professionals (EPs) or discharged from a hospital or emergency department (ED) must actively engage with their EHRs.
  • About 35% of patients who get discharged from hospital emergency departments or are seen by eligible professionals must send a message through the EHR’s secure messaging function.
  • Healthcare professionals and hospitals must create a summary of care for patients (by using the electronic health record system) and electronically exchange it with other providers for more than 50% of referrals.
  • For nearly 40% of transitions of care, it is essential for the provider to include a summary of care from an EHR used by a different provider. In addition, for 80% of transitions of care, the provider must perform “clinical information reconciliation” that covers medications and allergies and problem lists.

Meaningful Use Stage 3 rules for the Medicare and Medicaid EHRs Incentive Programs are generally limited to the requirements and criteria for use in 2017 and subsequent years. CMS is planning to make additional changes to meaningful use beginning in 2015 through separate rulemaking. The comment period on the proposed “Stage 3 Meaningful Use” rule ends on May 29, 2015 and comments will be received on the certification criteria proposal until June 30, 2015.

The new Stage 3 rule features a more “simplified reporting structure,” in which all objectives and measures will replace the same in Stage 1 and Stage 2 criteria. However, the Stage 3 criteria will be relatively hard to achieve. Regardless of the severe complaints from physicians about the issues related to Stage 2 requirements for patient care summary and patient record sharing transitions, CMS is increasing criteria and adding new objectives that most physicians find arduous and time-consuming.

Failure to Submit Proper Documents May Result in Loss of Health Insurance Coverage

Failure to Submit Proper Documents May Result in Loss of Health Insurance Coverage

More than 5, 00,000 people who have not yet submitted proper documents to the US Healthcare agency may lose health insurance coverage or tax benefits that help pay for it. As US voters head to polls in the month of November, these issues are the most recent glitches related to health insurance sign-ups that may bring Obamacare back into the limelight.

Meanwhile, the officials from the Centers for Medicare and Medicaid Services have started sending legal notices to residents who have provided wrong or incorrect information on file about their level of income. In addition, the CMS has notified consumers who have not submitted details about their citizenship or immigration status within the September 5 deadline that they will lose their insurance coverage towards the end of this month.

The current deadline is applicable to people residing in those 36 US states and who have registered for health benefit plans via the federal site that suffered several technical glitches. This deadline is not applicable for those who have enrolled through state’s exchanges or through private brokers as there is no information about incompatible data reported till now. It is found that only 9% of those people who have submitted details under the marketplaces will fall short of coverage by these closing dates. Below mentioned are some of the key points about the income data mismatch

  • More than 360,000 people who have filed information about their income details do not match with the official records of the US Healthcare agency.
  • It is essential for such people to present additional supporting documents by the end of September.
  • Those citizens who fail to adhere to the specified deadline will subsequently lose their tax subsidies that help them pay for health plans. It is reported that the subsidies provided to about 8 out of 10 people that enrolled through federal insurance market places were initiated to help those families whose income is not low enough to qualify for Medicaid, but is still less than $94,200 a year. In addition, those who have qualified for tax subsidies are paying less than $100 per month for premiums.

As per the latest reports from the US healthcare agency, those people who do not submit the relevant additional documents for health insurance verification within the specified deadline will face penalties. An adjustment to the premiums will be done to replicate the income on records. Moreover, they will also face the liability or reconciliation process while filing for the taxes. On the other hand, those citizens who have submitted higher income information than what they were actually earning would benefit from amount recoup.