- January 28, 2020
- Posted by: Rimal Patel
- Category: RCM
Making your practice financially healthy is not easy. Sometimes provider needs to revisit the coding with staff or medical billing company to see if there is anything which is falling in the cracks. Identifying significant areas which can help to increase the revenue and/or speed up the revenue cycle management. Here are few check marks.
1) Proper & effective coding
Coding is one of the major factors that impacts practice’s revenue. Effective coding contains few things.
Appropriate use of Modifiers
Missing or Invalid or Inappropriate use of Modifier can cause denial, delayed/decreased payment or loss of pay. At the time of coding, coders have to be more careful about putting or not putting modifier. At the same time, documentation must support the use of modifier.
Maximize the use of Operative Notes
Superbills and EMR bases coding captures most of(not ALL) the procedures & diagnosis. While coding procedures, operative notes is the key to capture each and every procedures & get 100% out of the procedure.
Proper use of CPT and ICD-10 codes
Correct use of CPT and ICD-10 codes are the keys to obtain maximum reimbursement for evaluation/management (E/M) and office visits.
Complete coding(i.e. cover all possible ICD-10 codes) is useful not only in reimbursement but it is mandatory to meet the quality measures.
2) Verify Insurance & Bill the right payer
A duck soup but it is one of the easiest mistakes to make.
Here are a few examples.
Example 1: One of your regular medicare patients, came to see the doctor. As usual, claims submitted to Medicare(of course without checking eligibility) & claim got rejected\denied considering the fact that patient enrolled in Medicare Advantage Plan like United Healthcare, Cigna etc. Now, after getting denial & delay in your payment, claim will be then directed to MCO.
Example 2: Complete opposite situation from example 1. The claim for patient’s last visit was submitted to Medicare Advantage Plan(let’s say United Healthcare). Patient came again after a few good months. Claim again went to United Healthcare & same result as example 1, it got denied as MCO terminated last month & patient is again on Medicare or another MCO.
3) Denial analysis & prevention process
Every practice gets some claim denied by payer. It is usual. But It is so important that you perform an analysis of the denials periodically. After analysis, you will find 2 types of denials.
These denials are nothing but the crack in one of your process like eligibility and benefit verification, coding and billing. We can bifurcate these denials into these process & identify the root cause. By fixing these cracks, we can avoid these denials by 100%.
Most of these denials are based on payer behavior. We should track these denials & try to learn their pattern so we can reduce these denials as much as possible.
4) Most common coding errors
Errors in coding lead to denials, loss of pay, unsatisfied patient (apparently leave the practice)Let’s look at the commonly made coding errors.
Diagnosis and Treatment mismatch:
This happens more when more than one service was provided or patient was seen for multiple diagnosis. This will make a huge impact on your monthly cash flow. Also, there are certain insurances who review the corrected claims manually & it is a time-consuming process compared to automatic processing of the claim. So, be on top of LCDs & LMRPs (at least which are related to your practice) & stop this from the start.
This normally occur when there is a billing of multiple procedure codes for a group of procedures normally covered by a single, comprehensive CPT code. Perhaps, experience and proper knowledge is the key to this issue.
Under coding or Over coding:
Overcoding is illegal and considered as fraud. So, please be very sensitive while measuring units of the service or billing the service(s). Undercoding is failing to report the full extent of services or procedures provided.
This is an equally unsound practice and a compliance risk. When we are in quality reporting, undercoding can have damaging effects on a medical practice, because proper coding speaks directly to the illness or injury of a patient and the method of treatment. Undercoding is also results into loss of pay against the actually performed services.
5) Scenario & prevention
Here is an interesting pain for all providers who see patients in the hospital. One of your payer always asks for the Medical notes for almost all hospital in patient visits. Looking for solutions, get a quote.