Charging for Missed Appointments

Does your practice have a policy in place for billing patients who miss their appointments?

Many practices already do reminder calls for upcoming appointments as well as follow-up calls on no-show appointments.

One solution for billing patients who missed their appointments was developed by the Healthcare Underwriters Group of Ohio. They suggested the following five necessary components to bill the patient for a missed appointment:

1. There must be evidence that the patient was informed of the physician's policy on missed appointments
2. The patient failed to cancel more than 24 hours in advance
3. The physician must have a 24 hour messaging service by which the patient can cancel their appointment (during and after office hours)
4. The physician must have been available at the intended appointment time
5. The charges must reflect the actual costs incurred

To download the full article, please click the following link: Charging for Missed Appointments

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Improving Patient Care

Need solutions on how to improve your patient no-shows?

In an article published by Family Practice Management, they offered tips on how to improve patient care as well as how to manage the "habitual" no-show patient.

Many practices do not have a policy to address the problem of missed appointments and cancellations. According to the article, only 46% had policies in place to address missed appointments and cancellations.

Some solutions mentioned in the article were as follows:

• Double booking patients
• This is not always the best solution
• "First-come, first-served" models
• Negative about this is the long wait
• Not a good solution for many of the problem patients
• Added a "new doctor" named Virtual Physician ("Dr. VP") 
• If they are a "habitual" no-show patient and schedule an appointment they were added to this doctors queue
• By doing this they do not effect the regularly scheduled patient
• 6-month alternative scheduling probation
• Contacted the patient by letter and phone
• If they made their scheduled appointments, they would return to the normal scheduling (and not Dr. VP)
• They could only see their primary care physician - unless their needs are for acute care
• If they did not make their appointments after 6-months, they could be terminated from the practice

To view the full article, please click the following link: Managing No-Show Patients

For additional billing and coding resources, please click the following link: Medical Reimbursement Resources Page

Hospital Medicine and the Health Care Crisis

Today's Hospitalist published an article on Hospital Physicians and management of their flat reimbursement from the CMS.

The article highlighted the following:

Medicare:

• Out-of-Pocket Increased 64% from 1997-2005
• One-quarter of people on Medicare spend 31% of their income on health care
• Analysis says Aging  will be responsible for 37% increased spending by 2035
• 46% of projected spending was attributed to "excess cost growth"

Hospital Care:

• Americans spent $2.6 trillion on health care in 2010
• Hospital care accounted for $814 billion (not including physician fees)
• Medicare and other fees accounted for 

Solution: 

• Control costs
• HCAHPS - Hospital Consumer Assessment of Healthcare Providers and Systems
  

To view the full article, please click the following link: Disappearing Dollars? Hospital Medicine and the Health Care Crisis

For additional billing and coding resources, please click this link: Medical Reimbursement Billing and Coding Resources

Meaningful Use: Stage 1, Stage 2 Comparison

EHR Intelligence published an article titled: "Meaningful Use: Stage 1, Stage 2 Comparison".  In the article they discussed the differences among Meaningful Use Stage 1 and Stage 2.

• Timing 
• Those beginning Stage 1:in 2011 have an additional year to prepare for 2014
• 2 Full years to manage technological and administrative requirements for Stage 2.
• Stage 3 Meaningful Use should begin in 2016.
• Objectives
• 20 and 19 Objectives
• Clinical Quality Measures: 
• Exclusions
• Can claim exclusions as long as they are applicable
• Reporting Period
• Stage 2: 3 Month Reporting Period
• Hospitals cannot choose their own 3-month period
• Batch Reporting
• Stage 2: Single File for eligible professionals

To view the full article and additional differences among Stage 1 and Stage 2 Meaningful Use, please click the following link: Meaningful Use Stage 1, Stage 2 Comparison

For additional billing and coding resources, please click the following link: Medical Reimbursement. Inc. Resources Page

Unclogging Patient Flow in the ED and Beyond

In an infographic published the HFMA (Healthcare Financial Management Association) offered the following tips on how to manage patient flow:

• Pre-arrival
• Reduce unnecessary volumes
• Avoid overcapacity/diversion
• Arrival
• Reduce wait times
• Enhance patient experience
• Triage
• Employ team-based, rapid assessment
• Segment patients for specialized care 
• Diagnostics/Procedures
• Synchronize/standardize steps
• Reduce hand offs/waste
• Bring care closer to patients
• Admission
• Commit to improving hospital wide flow
• Pull ED admissions
• Establish surge capacity tactics
• Discharge
• Avoid clogging ED with patients waiting to leave
• Prevent unnecessary future ED visits

To download the infographic, please click the following link: Unclogging Patient Flow in the ED and Beyond

For additional billing and coding resources, please click the following link: Medical Reimbursement Coding and Billing Resources

Ten Activities to Safeguard Patient Privacy in Urgent Care

The following tips were published in an article titled: "Ten Activities to Safeguard Patient Privacy in Urgent Care" from the Urgent Care Association of America.  The article was written for Urgent Cares, but could apply to any medical practice.

1. Conduct a Privacy Audit
• Verify a Notice of Privacy (NOP) is provided to every patient and it is posted in plain sight by the front desk.
2. Train Your Staff on HIPAA
• Provide refresher training every year after their initial training
3. Consider the Patient Sign-In Sheet
• Cross off checked-in patients with a black marker or keep the list behind the counter
4. Designated Staff-Escort and Staff-Only Areas
• To ensure patient privacy all workstations, file rooms, etc. 
5. Keep Patient Records, Papers and Computer Monitors Out of View
• To ensure patient privacy have computers and fax machines should be in a separate room with a sign that is "restricted area"
6. Have Electric Shredder of Locked Shred Bins Available
• Necessary so patient privacy is not recovered by "dumpster divers"
7. Limit Conversations About Patient Health Information (PHI)
• Don't "discharge" patients in the halls or talk about their account at the front desk
8. Verify Telephone and Fax Numbers; Mail and Email Addresses
• Allows improvements to billing and collection successes
9. Require Individual Passwords and Activate Screen Savers
• To prevent unauthorized use only give the password to the user of that particular computer
10. Consider and Act Upon Patient Comments
• If a patient has a complaint about their privacy, make the appropriate changes to your system

To view the full article, please click the following link: Ten Activities to Safeguard Patient Privacy in Urgent Care

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Collecting Copayments Can Generate High Returns

According to an article published in Emergency Medicine News - If Handled Sensitively, Collecting Copayments Can Generated High Returns, there are a variety of ways that hospitals have improved the collection of copayments.  The following bullets give some guidance on what Inova Fairfax Hospital in Falls Church, Virginia and St. John Northeast Community Hospital in Detroit, Michigan has done to increase copayments and revenue:

• Implement a discharge process
1. Employee verifies patient information (statistics show that 22% of patient records have the wrong information)
2. Asks if person wants to take care of copay or put a deposit down

• Have various payment options available to increase payments:
• Have an ATM available in the Emergency Department for copayments
• Accept credit cards
• Give patients self addressed envelopes to mail their payment in
  
• Be up front with your copayment collection process
• Having a sign such as "Your insurance requires $50 copayment" will cover any misunderstandings that patients may have

To view the full article, please click the following link: If Handled Sensitively, Collecting Copayments Can Generate High Returns

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Fewer Emergency Rooms Available as Need Rises

According to the article, "Fewer Emergency Rooms Available as Need Rises" published in the New York Times, many hospital emergency rooms are closing even though emergency room visits are increasing.

Some reasons for Emergency Rooms closing were a result of the following:

• They served large numbers of the poor
• Were commercially operated hospitals
• Were at hospitals with "skimpy profit margins"
• Operated in competitive markets

Closing other emergency rooms have an impact on the emergency rooms that are open as well. The following could effect the patient in a negative way:

• Take longer to get to another hospital
• There may not be enough beds
• Long waits to be admitted

To view the full article, please click the following link: Fewer Emergency Rooms Available as Need Rises

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources Page

Reduced Wait Times, More Efficient Emergency Departments

In an article published by New York City Health and Hospitals Corporation, Kings County Hospital Center implemented a reorganization of their emergency department.

Some of the changes to their emergency department were the following:

• They changed the greeter at the front door to a nurse instead of a security guard
• Triage nurse interviews a patient, performs an assessment, and identifies patient level of urgency - after this is complete their vital signs and a complete assessment are taken.
• They changed their department from staff-centered to patient-centered

Overall, the following improvements occurred at King County Hospital Center:

• Wait time had an improvement of 50% (from 31 minutes to only 15 minutes)
• Pediatric wait time dropped to 20 minutes from 52 minutes
  
• The article also shows success stories from 3 other hospitals in the New York area.

To view the full article, please click the following link: Reduced Wait Times, More Efficient Emergency Rooms

For additional resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Screening for Alcohol and Drug Problems in EDs

Published by the Physicians and Lawyers for National Drug Policy, "Screening for Alcohol and Drug Problems in Emergency Departments and Trauma Centers" highlighting the need for alcohol screenings in primary cares, emergency departments and trauma center visits.

• According to the American Association for the Surgery of Trauma, brief interventions in the trauma center decreased intoxicated driving.
• Alcohol exclusion clause (under the Uniform Accident and Sickness Policy Provision Law (UPPL)
• denies payments to doctors and hospitals that render care to patients
• discourages alcohol screenings in trauma centers and emergency departments.

Alcohol Exclusion Law

• 32 states and Washington DC explicitly allow insurers to use alcohol exclusions
• 9 states prohibit insurers from using alcohol exclusions
• 9 states implicitly allow insurers to use alcohol exclusions
• Many organizations support the real of the Alcohol Exclusion Law

To receive the full article in detail, please click the following link: Screening for Alcohol and Drug Problems in Emergency Departments and Trauma Centers

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

In-Network vs. Out-of-Network Care

Fair Health Consumer published an article on "In-Network vs. Out-of-Network Care".  The article discussed the differences between in-network and out-of-network care.:

Out-of-network costs by plan:

• HMO (Health Maintenance Organization or Exclusive Provider Network (EPO)
• The article stated you generally have to pay the full cost of any out-of-network care, except for emergencies.
• Preferred Provider Organization (PPO) or Point of Service (POS) Plan
• Higher deductible
• Higher percentage co-insurance, which is a percentage of the “allowed amount”
• The full difference between the allowed amount and your provider’s actual rate, which could be much higher

The article also has examples of In-Network and Out-of-Network Costs

Reasons for going out-of-network could be because of the following:

• You're referred to a specialist and they are out-of-network
• Providers who are at a hospital that is in-network, but the actual provider may be out-of-network

To view the full article, please click the following link: In-Network vs. Out-of-Network Care

To view addition medical billing and coding resources, please click the following link: Medical Reimbursement, Inc. resources page.

Creating an Efficient - and Effective - RAC Response

HFMA Published an article on "Creating an Efficient - and Effective - RAC Response" and how one hospital has designed an approach on how to manage their RAC audit activity.  The article stated that:

• RAC Spending has Increased from the end of 2011 to the beginning of 2012.  
• Hospitals needed a way to manage their RAC audit activities

The following are ways that Ministry Health in Wisconsin managed their RAC audit activities.

• Dedicate staff to RAC process management
• Manage the data flow related to RAC requests and meet deadlines for appeals with a tracking database
• Use a document management system to convert patient records into electronic files and scan documents for critical information.
• Track the time spent on RAC process management activities.
• Expand the team’s efforts to include review of audits from commercial payers.

To download the full article, please click the following link: Creating an Efficient and Effective RAC Response

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Obtaining, Uploading and Utilizing Your Contracted Fee Schedules

The American Medical Association (AMA) Published a step-by-step guide on "Obtaining, Uploading and Utilizing Your Contracted Fee Schedules".

The guide listed the following steps on how to obtain, upload and utilize your fee schedules:

1.  Gather your contracted fee schedules from the payers which you contract
2. Run an annual report on each CPT code and how many times it was used in that year
3. Determine your most frequently billed CPT codes from your annual report
4. Load all applicable information into your practice management system
5. Print and review your reports from your practice management system on your contract rates and payments (if applicable)
6. If you don't have access to reports from your own practice management system, create your own in Microsoft Excel.  

To receive the full step-by-step guide with Excel files included, please click the following link: Obtaining, Uploading and Utilizing Your Contracted Fee Schedules

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Bundled Payment Fact Sheet

A short fact sheet was produced by the Centers for Medicare and Medicaid Services on Bundled Payment Initiative.  The Bundled Payment Initiative allows providers flexibility in:

• Selecting Conditions to Bundle
• Developing the Health Care Delivery Structure
• Determining How Payments Will Be Allocated

The Bundled Payment Initiative consists of 4 separate Models:

1. Model 1 consists of the Inpatient Stay Only
2. Model 2: consists of the Inpatient Stay plus Post-discharge Services
3. Model 3: consists of the Post-discharge Services Only
4. Model 4: consists of the Inpatient Stay Only

To view the full fact sheet as well as a chart with the key features of each model, click the following link: Bundled Payment Fact Sheet (PDF)

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Moving Forward From the Sustainable Growth Rate (SGR) System

MedPAC  (The Medicare Payment Advisory Commission) produced a PDF on moving forward from the SGR, repealing the SGR formula and realigning fee-schedule payments to maintain access to primary care

In the PDF, MedPAC listed the following as recommendations:

1. Collecting data to improve payment accuracy
2. Identifying overpriced services
3. Accelerate delivery system changes to emphasize accountability and value over volume
4. Offsetting the cost of the SGR package

Figures on:

• Growth in spending for fee-schedule services
• Most-aged Medicare beneficiaries and older privately insured individuals
• Acceptance of new patients
• Potential Medicare offset options for repealing the SGR system

To view and download the fact sheet, please go to the following link: Moving Forward From the Sustainable Growth Rate (SGR) System

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Care Coordination in Fee-For-Service Medicare

MedPAC (The Medicare Payment Advisory Commission) published a data book in June 2012 on Health Care spending and the Medicare program. One section of this data book highlighted the following topics on Care Coordination in Fee-For-Service Medicare:

• Consequences of poor care coordination
• Reasons for poor care coordination
• Care coordination: Models and Types
• Illustrative models of care coordination
• Care coordination demonstrations in FFS Medicare
• Potential evidence of a reduction in hospitalizations in Medicare care coordination demonstrations
• Challenges of establishing an effective care coordination intervention
• Care coordination and Medicare payment policy

To view and download the full chapter, please go to the following link: Care Coordination in Fee-For-Service Medicare

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Medicare Beneficiary and Other Payer Financial Liability

MedPAC (The Medicare Payment Advisory Commission) published a data book in June 2012 on Health Care spending and the Medicare program. One section of this data book highlighted the following on Medicare Beneficiary and Other Payer Financial Liability:

• Sources of supplemental coverage among non-institutionalized Medicare beneficiaries
• Sources of supplemental coverage among non-institutionalized Medicare beneficiaries by beneficiaries characteristics
• Total spending on health care services for non-institutionalized FFS Medicare beneficiaries, by source of payment
• Per capita total spending on health care services among non-institutionalized FFS beneficiaries, by source of payment
• Variation in and composition of total spending among non-institutionalized FFS beneficiaries, by type of supplemental coverage
• Out-of-pocket spending for premiums and health services per beneficiary, by insurance and health status

* Additional web links on Medicare Beneficiary and Other Payer Financial Liability are also included in the data book. 

To view and download the full resource, please go to the following link: Medicare Beneficiary and Other Payer Financial Liability

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Quality of Care Statistics in the Medicare Program

MedPAC (The Medicare Payment Advisory Commission) published a data book on Health Care Spending and the Medicare Program.  A chapter in this data book was "Quality of Care Statistics in the Medicare Program". The following statistics (with charts) were discussed in the chapter:

• In-hospital and 30-day post-discharge mortality rates
• Hospital inpatient safety indicators
• Risk adjusted SNF quality indicators
• Home health quality measures
• Dialysis quality of care
• Medicare advantage quality measures

Additionally there are web links on the Quality of Care in the Medicare Program.

To view and download the full resource, please go to the following link: Quality of Care Statistics in the Medicare Program

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Medicare Advantage Program Payment System

MedPAC (The Medicare Payment Advisory Commission) published a fact sheet on payment basics for
Medicare Advantage Program Payment System. The fact sheet included the following topics:

• Defining the Medicare Advantage Products Medicare Buys
• Determining Medicare Payment for Local MA Plans
• Medicare Advantage Payment System for Non-Drug Benefits 2013
• Setting a Benchmark for Regional PPOs
• Determining Medicare Payment For Regional Medicare Advantage Plans

To view and download the full resource, please go to the following link: Medicare Advantage Program Payment System

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Guide on Medicare Beneficiary Demographics

MedPAC (The Medicare Payment Advisory Commission) published a data book: "Health care spending and the Medicare program" part of the data book includes a section on Medicare Beneficiary Demographics.

The data book highlights the following topics on Medicare Beneficiary demographics:

• Percent of beneficiaries and spending by age group
• Percent of beneficiaries and spending in poor health
• Enrollment in the Medicare program and growth in the next 20 years
• Characteristics of the Medicare population

The data book also has additional web links on Medicare beneficiary demographics.

To view the full resource, please go to the following link: Medicare Beneficiary Demographics

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Dual-Eligible Beneficiaries

MedPAC (The Medicare Payment Advisory Commission) published a data book in June 2012 on Health Care spending and the Medicare program. One section of this data book highlighted statistics on dual-eligible beneficiaries (those who qualify for both Medicare and Medicaid)

The data book discussed the following:

• Percent of fee-for-service beneficiaries
• Percent of fee-for-service spending
• Ages of dual-eligible beneficiaries and non-dual-eligible beneficiaries
• Health status of of dual-eligible beneficiaries and non-of dual-eligible beneficiaries
• Demographics differences among dual-eligible beneficiaries and non-dual-eligible beneficiaries
• Differences in spending and services use rate of dual-eligible beneficiaries and non-dual-eligible beneficiaries
• Medicare and total spending are concentrated among dual-eligible beneficiaries

In addition to these statistics, the data book has additional web resources on dual-eligible beneficiaries.

To view and download the full guide, please go to the following link: Dual-Eligible Beneficiaries

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Health Maintenance Organizations (HMOs)

According to the resource posted on Michigan.gov, Department of Licensing and Regualtory Affairs:

Health Maintenance Organizations (HMOs) provide preventive care and other services that are basic to good health. It is a health care system that joins together the financing and delivery of health care services to covered individuals by arrangement with selected providers who furnish a broad set of health care services

The HMO resource includes the following topics:

• The HMO Difference, Advantages & Disadvantages
• Primary Care Physician
• HMO Provider Network, HMO Service Area, HMO Eligibility
• Individuals Open Enrollment FOR HMOs
• HMO Coverage for Pre-Existing Conditions
• HMO Underwriting, Basic Health Services and Mandatory Coverage
• Services Not Covered By HMOs
• Emergency Services From an HMO
• HMO Prescription Drug Coverage
• HMO Deductibles, Copayments And Coinsurance
• HMO Claim Handling
• HMO Coverage for Family Members and Coordination of Benefits
• HMO Complaints and Grievances
• Medicaid HMO Clean Claims

To view the full resource, please go to the following link: Health Maintenance Organizations (HMOs)

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Making An Appointment for the ER, A Growing Trend

More and more hospital Emergency Room departments are allowing patients to make appointments to come to the Emergency Room according to an article published by the Los Angeles Times

The article described a system called InQuickER

• Patients schedule appointments online and are seen within 15 minutes of their scheduled time.
• Used at 15 different hospitals across the country
• Pros
• Doctors say patient satisfaction is higher
• Lower time spent in Emergency Room
• Patients wait in other area than the waiting room
• Cons
• Downside could be encouragement for people to use the Emergency Room who don't really need it Emergency Care

To view the full article, please go to the following link: Emergency Room Appointments

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

HIPAA in the Emergency Room

Posted on strategiesfornursemanagers.com, the article "HIPAA in the Emergency Room" discussed various topics in which those who work in the Emergency Room should consider when dealing with patients and HIPAA.

The article discusses the following topics:

• Why the ER is different
• Chaotic Setting
• Many Patients 
• Provisions for ER compliance
• Clinician can use their judgement
• Typical trouble areas
• Communication outside the ER
• Law enforcement officers’ access in ER
• Training tips for the ER staff
• Employee fears violation of HIPAA

To view the full article, please click the following link: HIPAA in the Emergency Room

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Cost of Canceled Outpatient Surgeries Can Climb Into Millions

In an article published by Outpatient Surgery Magazine, "Cost of Canceled Outpatient Surgeries Can Climb Into Millions.

• A study was done at Tulane University highlighting the cost of cancelled outpatient surgeries.
• The study found that 327 (6.7%) of the facility's 4,876 scheduled elective outpatient surgeries were canceled in 2009, which cost the hospital nearly $1 million in revenue over that 12-month span.

According to the article, the following were reasons why patients canceled their surgeries:

• No-shows were a common cause of cancellations
• Patient Transportation issues
• Uncertainty regarding the date of the procedure
• Forgetting about the appointment
• Lack of available beds or equipment

The study also found that: 

• The cancellations varied by specialty
• Improving equipment and resources and increasing efficiency help reduce the likelihood of having to cancel surgeries

To download the article, please go to the following link: Cost of Canceled Outpatient Surgeries
For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Medicare Physician Assistant Rules

In an article published by the Society of Emergency Medicine Physician Assistants (SEMPA) describes Medicare requirements and how they relate to Physician Assistants.

The article highlights the following:

• Physician Supervision
• Supervision between the Physician and the Physician Assistant
• Enrollment
• Must meet requirements to be a Medicare Provider
• NPIs
• "Incident To" Billing
• Must meet various criteria for services performed by a PA in an office or clinic setting
• Medicaid
• Billing for services varies by state
• Billing When Physician & PA Care for Same Patient

To view the full article, please click the following link: Medicare Physician Assistant Rules

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Hospitals Demand Payment Upfront From ER Patients With Routine Problems

Kaiser Health News published an article on payments upfront in the Emergency Room. The was article titled: "Hospitals Demand Payment Upfront From ER Patients With Routine Problems"

Article Overview:

• Growing number of hospitals have implemented the pay-first policy this was to reduce the number of individuals with routine illnesses from the ER.
• Federally required screening is done
• Half of all hospitals in the United States now charge upfront ER fees
• Emergency-room doctors and patient advocates blast the policy as potentially harmful to patients
• Hospitals turn away uninsured patients who often fail to pay their bills and are a drag on profits
• Dr. David Seaberg, president of the American College of Emergency Physicians, who estimated that 2 to 7 percent of patients screened in ERs and found not to have serious problems are admitted to hospitals within 24 hours.
• A 2010 Health Affairs study found that 27 percent of those visiting ERs could be treated more cost-effectively at doctors' offices or clinics.

Outcome of Payments Upfront:

• Decline in wait times since it implemented upfront payments.
• One hospital implemented a 24-hour on-call nurse triage system to assist the patient whether to go to the ER or a nearby clinic
• 75 percent of patients with non-emergencies left the facility instead of paying the upfront fee.

To view the full article, please go to the following link: Hospitals Demand Payment Upfront From ER Patients With Routine Problems

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

More Medicaid Patients Going to the ER, Study Finds

According to an article published by USA Today, increasing numbers of Americans (especially those who are on Medicaid) are using emergency rooms for their health care.

The article titled: "More Medicaid patients going to ER, study finds" used data from 1997 to 2007 to analyze Emergency Room visits.

• ERs are increasingly serving as "safety nets" (by law they must treat all patients regardless of insurance or their ability to pay)
• A "safety net" facility is described as the following:
• More than 30% of all visitors were on Medicaid
• More than 30% of visits were by people without health insurance
• More than 40% of visits were by Medicaid and uninsured patients
• Conditions could have been managed in a primary care clinic
• Treatment time increased from 22 to 33 minutes during the study since the volume was higher

To view the full article, please go to the following link: More Medicaid patients going to ER, study finds (USA Today)

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Health Law Guarantees Protection For Emergency Room Visits

Kaiser Health News published an article on a health law that went into effect on September 23, 2010 (six months after the law was enacted). This health law guarantees protection for ER visits.

According to the article titled: "Health Law Guarantees Protections For Emergency Room Visits"  the following occurs:

• Insurance companies must extend several new protections to patients who receive emergency care.
• Patients who need emergency treatment will have their costs covered at the same rate, regardless of whether they are treated at "in-network" or "out-of-network" hospitals. 
• The law also bars health plans from requiring prior authorization for emergency services. And it mandates that plans follow the "prudent layperson" rule. 
• For example, if a person goes to the ER with chest pain, but ends up being diagnosed with indigestion, the claim has to be covered because going to the hospital under those circumstances made sense.
• For years, insurance plans have been denying ER claims for a variety of reasons. 

• There is little data on the overall scope of the problem, a 2004 RAND Corp. study found that at least one out of every six claims for emergency department care was denied by two large HMOs in California. 

To view the full article, please go to the following link: Health Law Guarantees Protections For Emergency Room Visits

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Why More Primary Care Doctors Are Referring Patients to Specialists

KevinMD.com, published an article on "Why more primary care doctors are referring patients to specialists" more patients than ever are being referred to specialists.

The following are facts from the article on why more patients are being referred to specialists:

• Specialists are more expensive
• More advanced tests are done by specialists
• Primary care doctors see “failure to refer” as one of the leading reasons why they get sued

• From 1999-2009, the rate of referrals doubled

To read the full article, please click the following link:  Why More Primary Care Doctors Are Referring Patients to Specialists

For additional billing and coding resources as well as referrals to specialists, please click the following link: Medical Reimbursement, Inc. Resources

Increase in Health Care Advertisement Spending

According to the article in The New York Times, Health Care Ad Spending Rises, there has been a significant increase in the amount of spending hospitals are using towards advertising.

• For example, in the first six months of 2011, health care spending rose 20.4% (or to $717.2 million, from $595.5 million) from the same time period in 2010
• Popular Ad Topics:
• Patient Success Stories
• Catchy Headlines
• Patient Testimonials
• Accessibility of the Hospital
• Ads also may focus on the benefit of the hospital (we help you live longer) vs. the features that they have (great technology, world class physicians) according to Paul Amelchenko, the creative director at BFW Advertising.

To view the article, please click the following link: Health Care Ad Spending Rises

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Reimbursement and Coding Updates for 2012

According to ACEP's article, Reimbursement and Coding Updates for 2012, the following reimbursement and coding changes have occurred in 2012:

• 2012 Conversion Factor 
• Emergency Department RVUs 
• Telehealth Expansion (includes Emergency Department Services)
• Regulatory Update
• Physician Quality Reporting System (PQRS) 
• CPT Coding Changes for 2012 
• Changes to Observation Codes 
• Time Not a Factor in ED Code Selection
•  ICD-9 code changes for 2012  (effective October 1, 2011 - relevant to Emergency Medicine)
• Chart with the following:
• ICD-9 codes detail influenza with other specific respiratory manifestations
• ICD-9 codes detail causes of anaphylactic shock and other reactions
• V codes expand the list of factors influencing health status and contact with health services that could help explain the reason for an ED visit
• Additional Resources

To view the full article, please go to the following link: Reimbursement and Coding Updates for 2012

For additional billing and coding resources as well as referrals to specialists, please click the following link: Medical Reimbursement, Inc. Resources

Improving Patient Satisfaction Rates by Posting Wait Times

According to the solution titled: "Improving Patient Satisfaction by Posting Wait Times", 50% of the hospitals’ revenue begins with the ED. That being said, the following three hospitals implemented a solution in order to improve patient satisfaction rates:

• Middlesex Hospital in Middletown, Connecticut
• Middlesex Hospital Marlborough Medical Center in Marlborough, Connecticut
• Middlesex Hospital Shoreline Medical Center in Essex, Connecticut

The Goal and Results of the Solution were as follows:

• To determine if different factors influence what Emergency Room patients went to as well as make patient volume more manageable in the process
• The Hospital utilized a simple way to posting wait times from the ER every 5 minutes on their website
• Results of the solution led to:
• Better patient quality
• Left-without-being-seen rates decreased
• Higher satisfaction scores on the Press Ganey scale
• Middlesex Hospital Marlborough Emergency Department was ranked #1 in the state
• Middlesex Hospital Shoreline Emergency Departmentt was ranked #2 in the state

To download the full solution, please click the following link: Improving Patient Satisfaction By Posting Wait Times

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Patient Safety and Quality of Emergency Care

Since Emergency physicians are dedicated to providing the highest quality of emergency care it is important to stay-up-to-date on various issues that affect patient safety and the quality of  Emergency care.

In an article published by ACEP (American College of Emergency Physicians) the following points are addressed regarding patient safety and the quality of Emergency Care:

• Overcrowding
• The on-call specialist shortage
• Use of technology to improve patient safety
• Pay-for-Performance measures is to improve quality of care
• Mandatory reporting of medical errors

To view the full article, please go to the following link: Patient Safety and Quality of Emergency Care

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Implementing a Bedside Registration Process

Looking to improve your Emergency Department's triage process and reduce the time patients spend waiting for treatment?
Described below are the problems before implementation and what the hospital achieved after implementing a bedside registration process.

• The solution, Bedside Registration, was created at Cape Canaveral Hospital in Cape Canaveral, Florida and has an ED volume of approximately 33,000 visits annually. 
• Before implementing this solution, the hospital incurred long wait times and had difficulty increasing patient volume, bottlenecks, overcrowding as well as patient, staff, and physician dissatisfaction.

Results:

• After the solution was implemented, there was an 85% reduction in wait times (from triage to treatment rooms) would equate to an 11 minute wait.
• The wait times decreased as the patient volume had increased to 15%.

To download the full solution as well as view other solutions for your Emergency Department, please click the following link: Implementing a Bedside Registration Process

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources

Handling Electronic Submission of Medical Documentation

The Department of Health and Human Services and the Centers for Medicare and Medicaid published a manual on the Process for Handling Electronic Submission of Medical Documentation (esMD)

Overview of the Process for Handling Electronic Submission of Medical Documentation is as follows:

• Centers for Medicaid and Medicare Services (CMS) developed a mechanism to electronically receive medical documentation from providers. 
• This project is called Electronic Submission of Medical Documentation (esMD). 
• Medicare Review Contractors have requested an electronic mechanism to receive imaged medical documentation. 
• Electronic mechanism is used submit imaged medical documentation upon request.

The manual also includes the following submission time frames:

• Prepayment Review Time Frames
• Postpayment Review Time Frames

To download the full article, please click the following link: Electronic Submission of Medical Documentation

Implementation of National Recovery Audit Program

Published by the Centers for Medicare and Medicaid Services: "Implementation of Recovery Auditing At The Centers For Medicare & Medicaid Services", discusses the Medicare Fee-For-Schedule Program

The guide includes the following topics:

• National Recovery Auditing Program - 4 Regions in the United States (A, B, C, & D)
• Medicare FFS Claims Processing
• Improper Payments in the Medicare FFS program
• Medicare FFS Recovery Audit Program Contract Awardees
• Implementation of the FFS National Recovery Audit Program
• Status of the Recovery Audit Program for Medicare Advantage, Medicare Prescription Drug, and Medicaid Programs
• FFS Recovery Audit Review Process
• Key Program Components
• FY 2010 Results
• Corrective Actions
• Continuous Improvement

To view and download the full PDF document, please click the following link: Implementation of Recovery Auditing

How to Handle ED Patients Who Do Not Need To Be Admitted

Do you need a solution on how to handle your Emergency Department patients who do not need to be admitted to the hospital, but are not ready for discharge from the ED?

William Beaumont Hospital in Royal Oak, Michigan implemented a solution that they have found to work well in their emergency department. The solution was titled: "Clinical Decision Unit". This solution was suited for those patients who need to still be monitored without using valuable inpatient space by admitting them to the hospital.

• Guidelines for the Clinical Decision Unit were developed based on best practices from hospitals around the country. 
• The support of physicians and hospital leadership was critical to the success of the Clinical Decision Unit.

The reasons they implemented the Clinical Decision Unit were because of the following:

• The hospital was missing myocardial infarctions (MIs) and admitting patients with chest pain who did not have acute coronary syndrome
• Bed availability was an issue, hospital occupancy rates routinely over 90 percent (where they remain today)
• Lack of bed availability triggered ambulance diversion

To view and download the solution for your emergency department, please click the following link: Clinical Decision Unit

Medicare Overpayment Collection Process

Need information on the Medicare Overpayment Collection Process?

A 3-page fact sheet was developed by the Centers for Medicare and Medicaid Services highlighting the following information about the collection of Medicare physician and supplier overpayments:

• Definition of an overpayment and why the overpayment occurs:
• Duplicate submission of the same service or claim
• Payment to the incorrect payee
• Payment for excluded or medically unnecessary services
• A pattern of furnishing and billing for excessive or non-covered services.
• The Overpayment Collection Process
• The recovery process is used when Medicare discovers an overpayment of $10 or more
• Steps in the Overpayment Collection Process include:
• Demand Letters
• Repayment Plans
• Rebuttals
• Appeals
• Additional Medicare Resources and links

To view and download the fact sheet, please go to the following link: Medicare Overpayment Collection Process (PDF)

For additional resources, please click the following link: Medical Reimbursement, Inc. Resources

How to Avoid Ambulance Gridlock

Reducing the amount of gridlock caused by multiple ambulances waiting to transfer patients to hospital care results in a decrease in the amount of treatment wait time and faster turnaround.

An example of a strategy to decrease ambulance gridlock was developed at Valley Hospital Medical Center in Las Vegas, Nevada. The strategy was named "EM Xpress".

Some facts about EM Xpress:

• Simlar to a car racing model comparing the pit crews to the Emergency Department staff
• Reduces the Emergency Department wait time from 19 minutes to under 10 minutes
• Increase of around 75 ambulances a day up from 52 ambulances a day
• Runs from 11am to 11pm

The strategy works in the following way:

1. Bring your patient to Valley Hospital
2. Check-in with the Transfer of Care software
3. Give report to the Charge Nurse or the EM Xpress personnel
4. Offload your patient
5. Done - the Charge Nurse will check you out – drive safely

To download and view the full strategy, please follow this link: How to Avoid Ambulance Gridlock

Other resources are available to assist you at the following link: Medical Reimbursement, Inc. Resources

*We are not affiliated nor endorsed by Valley Hospital Medical Center. The Urgent Matters article is used with permission on our website*

Guide on Medicare Physician Fee Schedule

Need information on the Medicare Physician Fee Schedule?

The Centers for Medicare and Medicaid Services published a short fact sheet on the Medicare Physician Fee Schedule.

The fact sheet covers the following topics:

• Physician services
• 7,400 uniquely covered services
• Therapy services
• Medicare Part B pays for the services of physical therapists, occupational therapists, and speech-language pathologists based on the Medicare PFS.
• Medicare PFS payment rates
• The Medicare PFS is based on the following three components: 
  • 1) Relative Value Units (RVU)
  • 2) Conversion Factor (CF)
  • 3) Geographic Practice Cost Indices (GPCI).
• The Medicare PFS rates formula
• [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF
• Additional Resources

To view and download the fact sheet, please click the following link: Medicare Physician Fee Schedule

For additional resources, please click the following link: Medical Reimbursement, Inc. Resources

How to Streamline Cardiac Care for Heart Attack Patients

A solution created at Memorial Regional Hospital was called "Code Heart" streamlining the cardiac care for heart attack patients in the Emergency Department who required PCI. Some takeaways from the article were the following:

• The purpose of this solution was to: "Eliminate redundancy in treating heart attack patients so patients receive care as quickly and efficiently as possible."
• "Code Heart" eliminated the redundancy in treating heart attack patients with ST-elevation myocardial infarction (STEMI) and the patients now receive care as quickly and efficiently as possible.
• The goal of Code Heart was to ensure that door-to-balloon time in 90 minutes or less.
• With the most current and available data, Memorial met the 90-minute door-to-balloon goal an average of 85 percent of the time.

To view the full article along with the changes that were implemented in the Emergency Department, please visit the following link: Code Heart

*We are not affiliated nor endorsed by Memorial Regional Hospital. The Urgent Matters article is used with permission on our website*

How to Simplify Your Claims and Appeals Process

The American Medical Association (AMA) published a helpful guide titled: "Appeal that Claim - Be informed. Be approved. " on how to simplify your claims and appeals process by assuring proper payment to streamline your claims revenue cycle and streamlining your claims audit and appeals procedures

The guide was divided into the following sections:

• Step 1: Determine who will be responsible for auditing health insurer payments
• Step 2: Collect recommended health insurer auditing resources
• Step 3: Run monthly collection reports
• Step 4: Review the health insurer basis for the denied, delayed, or partially paid claim
• Step 5: Gather supporting documentation to corroborate reversal of the health insurer's determination through the claims appeals process
• Step 6: Develop a claim appeal letter and resubmit the claims to the health insurer
• Step 7: Maintain a health insurer follow-up log
• Step 8: Hold claims processing and review meetings
• Step 9: Continue to appeal partially denied, delayed or partially paid claims

Also contained in the guide are checklists and sample documents to assist you in the claims appeals process.

To download and view the guide, please go to the following link: Appeal that Claim - Be informed. Be approved. 

How to Improve Emergency Department Patient Flow

Looking for a solution on how to improve patient flow?

A case study done at William Beaumont Hospital in Royal Oak, Michigan discusses their new strategy that improves patient flow by decreasing the amount of time they spend in the waiting room.

Their strategy is called a "straight back triage policy", under this system the patient is sent to one of three different treatment areas:

1. Adult and Pediatric Emergent Care
2. Adult and Pediatric Urgent Care
3. Adult and Pediatric Non-Urgent or Prompt Care

Implementing this solution resulting in the following in the Emergency Department:

• Prioritized patient care needs according to severity of illness.
• Assured a prompt initial primary survey of all patients by a health care professional.
• Promoted patient safety.
• Facilitated expeditious care.
• Improved public relations and promote effective communication with patients/significant others.

To view the full solution as well as other solutions to help your Emergency Department, please go to the following link: Improving Emergency Department Patient Flow

*We are not affiliated nor endorsed by William Beaumont Hospital. The Urgent Matters article is used with permission on our website.  

How to Reduce Patient No-Shows

The Medical Group Management Association's (MGMA) In Practice Blog developed a helpful post on how to reduce patient no-shows consisting of 30 tips - some of these tips were common and some were not so common.

A sampling of the tips included:

• Develop a call list of patients who are able to come in for short-notice appointments
• Track the reasons each patient gives for a no-show
• Provide the option to send your patients an e-mail appointment reminder
• Hold a gift card drawing for all patients who show up on time in a given month
• Develop strong relationships with patients to increase their commitment to your practice. Suggestions include sending birthday or holiday cards and assigning nurses to specific patients to work and follow up with.

To view the full blog post with all 30 tips, please click here: 30 Ways to Reduce Patient No-Shows

Practices for Better Health Care

The Agency for Healthcare Research and Quality (AHRQ) published a fact sheet on "30 Safe Practices for Better Health Care" to assist in preventing medical errors which cause harm to patients.

These 30 safe practices that have been endorsed by the National Quality Forum.

According to the article, this National Quality Forum consists of 215 representatives from a variety of the United States' health care providers, purchasers, and consumer organizations.

Some notable organizations in the National Quality Forum include: The American Medical Association, The American Hospital Association, and the General Motors to name a few.

The article is broken down by the following categories:

• Creating a Culture of Safety
• Matching Health Care Needs with Service Delivery Capability
• Facilitating Information Transfer and Clear Communication
• In Specific Settings or Processes of Care
• Increasing Safe Medication Use

Each of these categories has at least one "safe practice" under it.  For the full PDF and all of the safe practices, please go to the following link: 30 Safe Practices for Better Health Care (PDF)

Items and Services That Are Not Covered Under the Medicare Program

The Department of Health and Human Services - Centers for Medicare and Medicaid published a guide on Items and Services not covered under the Medicare program

The guide is broken down into the following 4 sections:

• Services and supplies that are not medically reasonable and necessary
• Excluded items and services:
• Items and Services Furnished Outside the U.S. (with exceptions)
• Custodial Care (with exceptions)
• Cosmetic Surgery (with exceptions)
• Dental Services
• Certain Foot Care Services and Supportive Devices for the Feet (with exceptions)
• Services Related to and Required as a Result of Services That Are Not Covered (with exceptions)
• Examples of services and supplies that have been denied as bundled or included in the basic allowance of another service include:
• Physician standby services
• Prolonged care
• Examples of items and services reimbursable by other organizations or furnished without charge:
• Items and Services Authorized or Paid For by a Government Entity
• Defective Equipment or Medical Devices Covered Under Warranty

To download the full guide with more examples, please click the following link: Items and Services That Are Not Covered Under the Medicare Program

Changes in Pain Management Coding for 2012

Published by the AAPC's Coding Edge, the article Complete, Current Pain Management discusses the changes to pain management coding that were made in CPT® 2012.

Implant Pump Refill and Reprogramming

• According to the article, the codes for pump refill and analysis/reprogramming are often reported together, as often as 75% of the time
• The revised codes are:
• Pump Analysis Only
• Pump Analysis and Reprogramming Only
• Pump Refill and Reprogramming
• Pump Refill and Reprogramming by a Physician

Determination of Simple vs. Complex Neurostimulator Programming Changes

• Revised instructions for application of the neurostimulator codes
• The revised codes are:
• Neurostimulator Analysis Only
• Simple Neurostimulator Programming
• Spinal Cord or Peripheral Complex Neurostimulator Programming
• Cranial Nerve Complex Neurostimulator Programming

The article also has instructions on how to apply these pain management coding changes as well as guidelines.

Interested in downloading the full article? Please go to the following link: Complete, Current Pain Management to receive the CPT® 2012 Pain Management coding changes. 

AMA 2011 National Health Insurer Report Card

Published by the AMA (The American Medical Association), the 2011 National Health Insurer Report Card is provided as a source for health insurance claims processing timeliness, accuracy, and transparency.

The report card  is broken down for the following health insurance companies (Aetna, Anthem, CIGNA, HCSC, Humana, Regence, UHC, and Medicare) in these categories:

• Payment Timeliness
• Payer claim received date, first Remittance response time
• Cash Flow
• Cash flow analysis, % of claim lines paid $0, EFT adoption rate, EFTs still receiving checks
• Accuracy
• Allowed amount, Contracted fee schedule match rate - major CPT code categories - match rate by state, First ERA accuracy
• Prior Authorization
• Prior authorization frequency
• Claim Edit Sources and Frequency
• Source of payer, Total number of claim edits
• % of total claim lines reduced to 0 (disclosed claim edits, undisclosed claim edits, disclosed and undisclosed claim edits)
• % of edited claim lines reduced to 0 (undisclosed claim edits)
  
• Denials
• % denied, Reason codes, Remark codes, % of reason codes reported with remark code
• Improvement of Claims Cycle Workflow
• CORE certification, Prior authorization, Claim acknowledgement.

To view and download the 2011 National Health Insurer Report Card, please click this link: 2011 National Health Insurer Report Card

Choosing Emergency Room Care vs. Urgent Care Centers

Do you know all the facts when it comes to choosing whether to go to the Emergency Room or an Urgent Care Center?

An article published on fairhealthconsumer.org highlighted important information that you should know.

The article discussed the following:
Emergency Room Care

• You many encounter: ER co-payments, co-insurance or deductibles
• You many encounter: Additional ER out-of-network charges
• Deals with potentially life-threatening emergencies & is open 24 hours a day
• Many plans cover a portion of emergency care
• Most health plans will not pay for ER visits if the visit is not considered an emergency
• To determine this they follow the “Prudent Layperson Standard” under PPACA to determine what is a true emergency.

Urgent Care Centers:

• Most health plans include urgent care centers in their networks
• Have extended hours (primarily when your primary care doctor is not available)
• Provides treatment for less serious emergencies
• Not equipped to deal with major medical traumas or emergencies

The article also went into the cost of the Urgent Care vs. the cost of the Emergency Room.

To view the full article, please go to the following link: Emergency Room Care vs. Urgent Care

Rules for Refunding Duplicate or Overpayments to Medicare

Our whitepaper, "Rules for Refunding Duplicate or Overpayments to Medicare", highlights:

• What to do if the primary payment exceeds the deductible and coinsurance amounts
• How to refund a primary payment from both Medicare and a primary plan
• The MSP Regulation at 42 CFR 489.20
• What form to use to report credit balances resulting from MSP payments
• If an MSP credit balance occurs late in a reporting quarter

Check out our resources page for the following document: Rules for Refunding Duplicate or Overpayments to Medicare as well as for common billing and coding questions and facts. 

How to Prepare for ICD-10

Although the implementation of ICD-10 is now October 1, 2014 instead of October 1, 2013, your practice must still be preparing. 
AAPC's Coding Edge published an article titled: “ICD-10 Spotlight: Continue Practice Preparation” highlighting the importance of continuing preparation for ICD-10.

The article highlighted the following topics:

• ICD-9-CM Fracture Codes vs. ICD-10-CM Fracture Codes
• The new ICD-10 codes will be more specific than the current ICD-9 codes. There will also be more codes with ICD-10 as the article states with the fracture codes example.
• Importance of External Cause vs. Condition Codes
• Procedure Code Benefits
• Physicians and facilities will be able to more accurately represent the work they are performing.

To download and view the full document, please go to the following link:  ICD-10 Spotlight: Continue Practice Preparation.

More Coding Resources are also located on our website at http://medicalreimbursementinc.com/utility-pages/resources/

Tips on Modifier 33

Modifier 33 was added in November 2011. Are you aware of the appropriate times to append Modifier 33?

To help, the AAPC's Coding Edge Magazine published an article titled: "8 Tips to Give You Straight Facts on Modifier 33"

The following are the tips that the article discussed in further detail:

1. Do You Know Where to Find Information on Modifier 33?
2. Do You Know Which Services are Covered?
3. Apply Modifier 33 for Private Payers Only
4. Turn to Modifier 33 for Screening Turned Diagnostic
5. Selected Services Covered In-network Only
6. Apply Modifier 33 to All Eligible Services
7. Cost Sharing Doesn’t Apply for Separate, Same-day Services
8. Designated Preventive Services Don’t Require Modifier 33

To download and view the full article in detail, please go to the following link: 8 Tips to Give You Straight Facts on Modifier 33 (PDF)

Bundling Rules for Radiology

AAPC's Coding Edge Magazine published an article on bundling rules for Radiology.

The article highlighted bundling the following procedures and discussed CPT codes:

• Abdomen CT and Pelvis CT
• Abdomen CTA and Pelvis CTA
• Endovascular Revascularization Studies
• Renal Angiography
• CPT Codes addressed:  Renal Angiography selective: 36251-36252, Renal Angiography superselective 36253-36254, insertion 37191, repositioning 37192, and retrieval 37193.
• AV Shunts for Dialysis

To download and view the full article, please go to the following link: Bundling Rules You Can Take to the Radiologist

Ensure You Are Billing the Proper Place of Service (POS) Codes

The AAPC's Coding Edge Magazine published "Keep Out of Hot Water with Proper POS", an informative article regarding proper Place of Service (POS) coding.

It's important to note that the Office of Inspector General (OIG) has been conducting audits and the proper POS codes are becoming more frequent in the errors they are reviewing.

The article is broken down into the following topics:

• How POS Affects Payment
• Frequent Errors Raise OIG's Ire
• How to Avoid POS Problems
• Clear Guidance on POS Definitions

This article also has an informative list of settings where physician's services are paid at the facility rate.

To download and view the full article, please go to the following link: Keep Out of Hot Water with Proper POS (PDF)

Join Our iPad 2 Giveaway Contest!

Medical Reimbursement, Inc is giving away an Apple iPad 2!  To be eligible for the contest, you must "Follow Us" on one of the three following social media sites where we provide billing and coding advice daily:

• Follow us on Twitter
• Follow us on LinkedIn
• Like us on Facebook

Upon engaging with us on any of the three social media sites listed above, you must also fill out this form to ensure you wish to be entered in our contest.  Full contest details are also available on the form page.

Medical Reimbursement is a physician-founded coding, billing, collections and revenue cycle management company. We currently code and bill for approximately 1,000,000 patient encounters each year. The majority of our clients are large physician groups. We have built long lasting relationships with our clients who represent some of the largest hospitals and academic medical practices in the country. 

10 Tips for Improving A/R

Radiology Today wrote an article titled: "10 Tips for Improving A/R" to help your practice.

The overview of the tips were as follows:

1. Ensure that there are no surprises.
2. Do your homework
3. Gather all the evidence
4. Collect from the patient
5. Document well
6. Understand coverage controversies
7. Use professional billers and coders
8. Befriend the payers
9. Know the law
10. Set collections targets

To view the full article in detail, as well as more Radiology resources & resources listed by specialty, please go to the following link: Medical Reimbursement, Inc. - Radiology Resources

CMS ASC Manual Chapter 14: 50-70

Medicare Claims Processing Manual for Ambulatory Surgical Centers Chapter 14: 5-70 produced by the CMS Covers the following topics:

• ASC Procedures for Completing the Form CMS-1500

• Medicare Summary Notices (MSN), Claim Adjustment Reason Codes, Remittance Advice Remark Codes (RAs)

• Applicable Messages for ASC 2008 Payment Changes Effective January 1, 2008

• Applicable ASC Messages for Certain Payment Indicators Effective for Services Performed on or after January 1, 2009

• Ambulatory Surgical Center (ASC) HCPCS Additions, Deletions, and Master Listing

To view and download the full manual of Chapter 14: 50-70, please go to the following link: ASC Manual Chapter 14: 50-70 (PDF)

Need Assistance With Your Ambulatory Surgical Center?

Medicare Claims Processing Manual for Ambulatory Surgical Centers Chapter 14: 30 & 40 produced by the CMS Covers the following topics:

• Rate Setting Policies
• Where to Obtain Current Rates and Lists of Covered Services
• Payment for Ambulatory Surgery
• Payment to Ambulatory Surgical Centers for Non-ASC Services
• Wage Adjustment of Base Payment Rates
• Payment for Intraocular Lens (IOL)
• Payment for Terminated & Multiple Procedures
• Payment for Extracorporeal Shock Wave Lithotripsy (ESWL)
• Offset for Payment for Pass-Through Devices Beginning January 1, 2008
• Payment When a Device is Furnished With No Cost or With Full or Partial Credit Beginning January 1, 2008
• Payment and Coding for Presbyopia Correcting IOLs (P-C IOLs) and Astigmatism Correcting IOLs (A-C IOLs)

To download and view the full CMS ASC Claims Manual on Rate-Setting Policies & Payment for Ambulatory Surgery click the following link: http://ww2.medicalreimbursementinc.com/l/3732/2012-06-08/2746tl (PDF)

Ambulatory Surgical Center Payment Updates to be Implemented in July 2012

Changes to the ASC Payment System and billing instructions for various payment policies to be implemented in the July 2012. An ASC update guide produced by the CMS highlights the following:

• Changes in Manual Instructions
• Funding
• For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers
• For Medicare Administrative Contractors (MACs)
• New Category III CPT Codes that are Separately Payable Under the ASC Payment System Effective July 1, 2012
• Instructions for Device Pass-Through Category C1840
• Billing for Drugs, Biologicals, and Radiopharmaceuticals
• Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective July 1, 2012
• New HCPCS Codes for Drugs and Biologicals Separately Payable under the ASC Payment System Effective July 1, 2012
• New HCPCS Codes Effective July 1, 2012 for Separately Payable Drugs and Biologicals
• Adjustment to the Payment Indicator for Certain HCPCS Codes Effective April 1, 2012
• Coverage and Business Requirements
• Provider Education

To download and view the full guide, please click the following link: Ambulatory Surgical Center Payment Updates to be Implemented in July 2012

Managing Underpayments in Medical Billing

An article, "Managing Underpayments in Medical Billing: Getting Every Penny You Deserve" published by Kareo, recommends the following tips on how to manage your underpayments

1. Know what you should get paid
2. Seek other sources
3. Deploy alternate strategies
4. Establish a process to ensure payments are correct
5. Examine remittances
6. Evaluate staff motivation
7. Recognize that underpayments may not come from the insurance company

To view the full article and the tips in further detail, please go to our resources page located here: Medical Reimbursement, Inc - Current News Articles

How to Use the Medicare Coverage Database

Do you know what to use to determine Medicare coverage?

A fact sheet was produced by the Centers for Medicare and Medicaid Services highlighting how to use the Medicare Coverage Database.

The document addresses the following topics:

• What is the Medicare Coverage Database (MCD) ? 
• Why would a Health Care Professional, Supplier, or Provider Use the Coverage Database?
• Background: Medicare Coverage and Coverage Determinations
• How Up-to-Date is the MCD?
• How to locate, navigate, and search the MCD 
• Using the Indexes & Reports Feature - National & Local Coverage
• Tips and how to use MCD Downloads
• Additional Resources on the MCD
  
  To download and view the document on the MCD, please go to the following link: How to Use the Medicare Coverage Database (PDF)

The National Provider Identifier (NPI) What You Need to Know

According to the Centers for Medicare and Medicaid Services, The National  Provider Identifier (NPI). The Administrative Simplification provisions of the Health  Insurance Portability and Accountability Act  of 1996 (HIPAA) mandated the adoption of  a standard, unique health identifier for each  health care provider.

To further explain the process, a short fact sheet highlighting the topics below was created by the Centers for Medicare and Medicaid Services:

• What is an NPI?
• Benefits
• Eligibility
• Who Must Obtain the NPI?
• What the NPI does and does not do
• Who Cannot Receive an NPI?
• National Plan and Provider Enumeration System (NPPES) 
• NPI Registry
• NPPES Downloadable File
• Healthcare Provider Categories
• How to apply for an NPI
• Additional Website Resources

To view and download the full fact sheet, please go to the following link: National Provider Identifiers (NPI): What You Need to Know

Global Surgery Fact Sheet

Are you billing the necessary services before, during, and after a surgical procedure?

The Centers for Medicare and Medicaid Services produced a Global Surgery billing guide with guidance on how to properly bill the global surgery package, the fact sheet highlighted the following:

• Definition of a Global Surgical Package
• FAQs
• Is the global surgery payment restricted to hospital inpatient settings?
• How is Global Surgery classified?
• Where can I find the post-operative periods for covered surgical procedures?
• What services are included in the global surgery payment?
• What services are not included in the global surgery payment?
• How are minor procedures and endoscopies handled?
• Global Surgery Coding and Billing Guidelines
• Pre-operative Period Billing
• Day of Procedure Billing
• Post-Operative Period Billing
• Special Billing Situations
• Resources Pages with links to additional resources

To download and view the guide, please go to the following link: Global Surgery Fact Sheet

How to Use The National Correct Coding Initiative (NCCI) Tools

Are you familiar with the NCCI (National Correct Coding Initiative) and how to tell if your coding is up to par?

The guide, "How to Use The National Correct Coding Initiative (NCCI) Tools" Produced by the Centers for Medicare and Medicaid Services highlights the following topics:

• What is the National Correct Coding Initiative (NCCI)
• Who should use the NCCI Web Page, Tables, and Manual
• How Up-to-Date are the NCCI Tables
• Background: NCCI Edits
• Using The NCCI Tools 
• Looking Up 2 Types of Code Pair Edits  
• How to Use the Code Pair Tables 
• Looking up the 3 Provider-Types of Medically Unlikely Edits (MUEs)
• Using the NCCI Policy Manual For Medicare Services
• Resources page with additional websites
• How to Filter NCCI data tables

To download and view the full guide, please go to the following link: NCCI Tools

Basics of Internet-based PECOS for Physicians and Non-Physician Practitioners

Do you know how to use Internet-based PECOS to enroll in the Medicare Program?

A fact sheet produced by the Centers for Medicare and Medicaid Services (CMS) provides this information for physicians and non-physician practitioners

The fact sheet highlights the following:

• Submission Options on the Medicare Enrollment Application
• How to get started on the Internet-based PECOS
• Completing an Enrollment Action Using Internet-based PECOS
• Limitations of Internet-based PECOS
• How to use Internet-based PECOS (listed by group description)
• Medicare Enrollment Processing Time Frames
• Role of the Medicare Enrollment Contractor
• Who to contact if you run into problems
• Additional resources for the enrollment process

To download and view the fact sheet, please click the following link: Guide on PECOS

CMS-1500 Claim Form Instructions

Need help with your CMS-1500 Claim Forms?

Check out CMS-1500 Claim Form Instruction guide produced by NHIC highlighting the following:

• Instructions for Filling Out the Health Insurance Claim CMS Form-1500 
• Appendix A – Sample Wording For Authorization  & Appendix B - Place of Service Codes with Definitions 
• National Correct Coding Initiative (NCCI)
• Medically Unlikely Edits (MUEs)
• Limitation of Liability (Advance Beneficiary Notice)
• Local Coverage Determination (LCD) & National Coverage Determination (NCD) 
• Medicare Fraud and Abuse
• Recovery Audit Contractor (RACs)
• Comprehensive Error Rate Testing (CERT)
• Provider Enrollment Help Line/Provider Enrollment Status Inquiry Tool
• Mailing Address Directory
• Provider Services Portal (PSP)
• Durable Medical Equipment (DME)
• Reconsideration (Second Level of Appeal)
• Additional Resources to fill out your claim forms

To download and view the instruction guide, please click here: CMS-1500 Claim Form Billing Instructions

Correctly Using Modifier 33 and Modifier PT

Do you know the difference on when to use CPT® Modifier 33 and Modifier PT?

Modifier 33

• Developed by the American Medical Association (AMA)
• Modifier 33 is for services with US Preventive Services Task Force (USPSTF) A or B rating

Modifier PT

• Developed by the Centers for Medicare and Medicaid Services (CMS)
• Modifier PT is more specialized

An article published by Kareo, explains Modifier 33 & Modifier PT, as well as, addresses the following questions:

• What services have an A or B rating?
• What to do if you forget the modifier
• Should you use both Modifier PT and Modifier 33?

To go to the full article, please go to the following the link: Modifier 33 and Modifier PT

Coding Assistance with Quick Reference Coding Cards

Are you struggling to keep up-to-date with changing rules and requirements for coding?

To help, we created a handy pocket-sized "Quick Reference Coding Card" for Emergency Medicine, Internists, and Hospitalists:

An overview of the cards are listed by their specialty

Emergency Medicine:

• Explains Observation Guidelines/Key Procedures with appropriate codes
• Amount of Observation time required by Medicare and Medicaid
• Critical & Fracture Care Coding Guidelines with the appropriate codes
  

Office Visit Coding Card:

• Describes how to distinguish between new and established patients
• Explains time based codes, E/M levels and MDM (Medical Decision Making) criteria

Hospitalist Coding Card:

• Explains the difference between the Initial and Subsequent visits and the related codes used.
  

To download and view the quick reference card of your choice, please click the following link: Quick Reference Coding Cards