Medical Billing Best Practices and Updates Blog

We are pleased to continue providing medical billing and office management support to our clients.  We founded our company during the early part of 2020 after spending many years gaining knowledge and experience in the field of medical billing and office management.  We have learned that successful medical billing doesn't happen without the input and support of committed health care practitioners and medical office management.  

It is our belief that every medical examination, treatment or procedure should generate income for the medical provider, unless the provider chooses to provide their service non gratis.  To obtain fair and appropriate compensation for every visit, the examination, treatment or procedure needs to be documented in accordance with generally accepted medical practice and consistent with the payor source's guidelines.  What are the payor source's guidelines?  It depends on the payor source.  This is where good medical office management comes in- determining whether prior authorization is needed before a visit or treatment is provided is essential to effective medical billing and revenue maximization.  While the medical provider's office professional is checking on the patient's payor source prior authorization, confirming the patient's deductible and co-pay amounts with the payor source representative and relaying to the patient the deductible/co-pay amounts before the visit or procedure helps the patient understand what is expected- no one likes to be surprised by the size of a bill.

Medical providers who document visits, treatments and procedures effectively that have been approved by the payor source (in advance, where necessary) and have collected the appropriate co-pays and deductible amounts should see the amounts of bad debt reduced or eliminated.  We at Western Slope Billing are here to do our part.  We take the clinical record information and quickly and effectively bill the payor sources on behalf of our clients.  Turn around time (from the time the medical record for the visit is complete to the date payment is received from the payor source) is minimized through our efforts to process the claim quickly and accurately.  Feel free to contact us with questions or to share your experience with medical billing.

So your practice has received a request for additional information such as medical records, clinician notes, lab results or procedure phots... how should the request be handled?  Below are a few tips that may make the exchange of information between medical providers and the various payor sources more timely and efficient resulting in fewer dollars returning to the payor sources due to claims process with insufficient supportive data -or- a denial of a previously paid claim due to untimely response to a request for additional information.

1.  Verify that the designated practice contact person's information is correct in the payor source's system.  Names, titles, email addresses, mailing addresses and phone numbers should all be verified to assure the practice receives any Request for Additional Information regarding a previously filed claim.  In the case of the Medicare RAC Auditing process, a medical provider has a limited number of days to respond to a request for additional information from the date posted on the request.  The RAC auditor will mail the request for additional information to the address included in the provider's profile in the Medicare system.  The provider is responsible for the accuracy of the information contained in their profile.

2.  Make certain that the person appointed by the practice to receive the request for additional information understands why the request for additional information has been received, and has a good system in place to respond to the request.  Let's face it folks- if you receive a request for additional information about a reviewed claim, the auditor believes the claim may have been filed in error and is contemplating denying the claim and requesting a refund from the provider.  A knowledgeable practice representative who receives the request for additional information timely and is able to provide documentation that supports the visit/evaluation/treatment within the prescribed timelines will have a positive impact on the amount practices are asked to repay.

3.  Have a claims review process that includes key members of the practice staff who review all requests for additional information- are there trends or lessons to be learned in regards to information that is provided to payor sources that may help reduce the frequency of requests for additional information and/or denied claims as a result of a look back audit?

Please share with us your thoughts on this topic!

​Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021
Dec 01, 2020 

• Physicians
• Policy

On December 1, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates on policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, on or after January 1, 2021.
The calendar year (CY) 2021 PFS final rule is one of several rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.
Background on the Physician Fee Schedule
Since 1992, Medicare has paid for the services of physicians and other billing professionals under the PFS. Physicians’ services paid under the PFS are furnished in a variety of settings, including physician offices, hospitals, ambulatory surgical centers, skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories, and beneficiaries’ homes. Payment under the PFS is also made to several types of suppliers for technical services, often in settings for which no institutional payment is made. For most services furnished in a physician’s office, Medicare makes payment to physicians and other professionals at a single rate based on the full range of resources involved in furnishing the service. In contrast, PFS rates paid to physicians and other billing practitioners in facility settings, such as a hospital outpatient department (HOPD) or an ambulatory surgical center, reflect only the portion of the resources typically incurred by the practitioner in the course of furnishing the service. For many diagnostic tests and a limited number of other services under the PFS, separate payment can be made for the professional and technical components of services. The technical component is frequently billed by suppliers like independent diagnostic testing facilities and radiation treatment centers, while the professional component is billed by the physician or practitioner.
Payments are based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for physician work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute.
PAYMENT PROVISIONS
CY 2021 PFS Rate setting and Conversion Factor
CMS is finalizing a series of standard technical proposals involving practice expense, including the implementation of the third year of the market-based supply and equipment pricing update, and standard rate-setting refinements to update premium data involving malpractice expense and geographic practice cost indices (GPCIs).
With the budget neutrality adjustment, as required by law, to account for changes in RVUs including significant increases for E/M visit codes, the final CY 2021 PFS conversion factor is $32.41, a decrease of $3.68 from the CY 2020 PFS conversion factor of $36.09. The PFS conversion factor reflects the statutory update of 0.00 percent and the adjustment necessary to account for changes in relative value units and expenditures that would result from finalized policies.

For more information visit: ​https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1

E/M CPT Changes coming January 1st 2021
 
Here’s a list of some of the changes that are coming soon that all providers must be aware of.

Reduction in the number of service levels to 4 from 5. New patients (5 levels of service are retained for Established Patients) 

• Elimination of History and Exam as required elements of code selection.
• Medical decision-making  or time will be used to determine the level of E/M visits.

• CPT 99201 will be deleted. Only 99202-99205 for new patients and 99211-99215 will be used for established patients. The time requirements for each of the levels has changed as well. Example: In 2020 CPT 99214 was typically 25 minutes spent face to face with the patient/and or family. That's changing to 30-39 minutes of total time is spent on the date of the encounter.

 
In terms of best practice, providers should still continue to perform clinically relevant H&Ps, but will NOT influence code selection.
 
Be prepared to continue to document to the highest specificity and make sure that time is documented appropriately. 
 
Keep in mind that AMA could always update and make additional changes as needed and you’ll want to make sure you’re informed when they do. If you’re interested in learning more feel free to contact us for quick step by step tools and additional information to help you along in these new changes.

Anyone who has taken on the responsibility of billing for medical clinics or practices probably understands the important role that billing and collecting payments for medical visits, procedures and treatments plays in the stability and viability of the medical practice.

An important question for anyone assuming the billing role and responsibility is "do I have the information I need to be successful?"  The question sounds simple enough.  To be successful, the biller needs to have a working knowledge of the Electronic Medical Record and the agency's billing software.  If additional important questions remain, the biller should seek out mentors or software training and support personnel to resolve questions before attempting to submit claims.  The initial time commitment to proper orientation to the Electronic Medical Record (EMR) and billing software will pay dividends in the form of fewer rejected or pended medical claims.

The biller must confirm the patient's information is correct, the ICD 10 code for the visit, treatment or procedure has been correctly identified and that all necessary clinician (doctor) sign offs have been secured, prior to filing the claim.  

Developing an effective working knowledge of the software(s) used for medical billing and assuring the patient information and coding information is correct will significantly improve the percentage of approved claims (the first time) and will reduce delays in payments received by the medical provider.