The Ten Biggest Coding Mistakes in Medical Billing and How to Avoid Them

Betsy Nicoletti, M.S., CPC May 9th, 2011

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Avoid the ten biggest coding mistakes in medical billing with these tips from Betsy NicolettiA good way to insure you’re avoiding denials and getting your claims paid the first time is to make sure you’re not making one of the ten biggest coding mistakes. Check this list to be sure you’re using best practices:

1. Hoarding old coding books

While it is okay to keep your old coding books as reference material, no one should ever use an old coding book.  Each year, purchase new CPT, HCPCS and ICD-9 books.  Even if a practice has electronic versions of these codes built into their software, the editorial and instructional materials in the CPT and ICD-9 books are not generally easily available electronically.  Buy a new set of books, and read the editorial content at the start of each section for the services the practice offers.

2. Ignoring the editorial comments in the CPT book

The answers to many vexing coding questions are at the fingertips of all coders, billers and physicians.  The answers are hiding in plain sight–in the editorial comments at the start of each section.  Can you bill for an initial hospital service when admitting a mom-to-be in labor?  Look no farther than the introductory comments to the Maternity section in your CPT book.  If a physician bills for a preventive service and a problem-oriented visit on the same day, is the modifier appended to the preventive service or the problem-oriented visit?  Find the answer in the editorial comments at the start of preventive medicine.

3. Clinging to long-held beliefs

Codes change.  Rules are revised.  Memory fails.  Consult source documents frequently.  Two useful source documents for physician practices are the CPT book and the CPT Assistant.  For Medicare rules, download Chapter 12 of the Medicare Claims Processing Manual (100-04), which can be found at

4. Failing to link CPT and ICD-9 codes

Physician services are paid based on the fee levels associated with CPT codes.  But payers deny claims based on diagnosis codes if the diagnosis does not support the medical necessity of the service or is not a covered indication for that service.  Clinicians need to match the diagnosis code to the correct CPT code. This is particularly important for diagnostic tests and some Medicare preventive medicine services.

5. Neglecting to bill both an administration code and a medication code for an injection

When a patient receives a therapeutic injection or immunization or allergy shot, bill for the medication if the practice purchased it.  If the state provided the serum or the patient brought it with them, bill only for the administration.  Double-check these claims.  If an administration code is charged, look for the medication.  Many groups post the vaccines provided by the state without a charge.

6. Forgetting modifier 25

Modifier 25 is used to indicate that a separate, significantly identifiable E/M service was performed on the same day as a procedure.  Failing to add the modifier to the E/M service or mistakenly adding it to the surgical procedure will result in a denied claim.

7. Abusing modifier 25

Beware the person who knows how to get a claim paid.  “Just add modifier 25 to all of the E/M services.  We don’t have time to look at the notes.” Appending modifier 25 will result in both the E/M service and the procedure being paid, so be sure that the person who selects the modifier knows the rules.

Medicare and some other payers restrict the use of an office visit with minor skin procedures.  The National Correct Coding Initiative (NCCI) says:

 “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.  However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25.”  (Chapter 11, Letter R.)

8. Confusing modifiers 51 and 59

Modifier 51 is used to indicate that the physician did two procedures on one day, and the second is not a component code of the first.  Most Medicare payers do not require modifier 51 on claims.  Modifier 59 is used to indicate that the physician performed a second procedure, which is bundled into the first and meets the requirements of a separate, distinct service.  Access to the NCCI edits is critical.

9. Sloppy diagnosis coding

Non-specific diagnosis codes are the result of relying too heavily on pre-printed encounter forms or lists of favorites.  There are two unfortunate results:  The first is denied claims. The second is a more subtle and long term effect: When payers calculate the acuity of the practice for risk based contracting, they base that formulation on the diagnosis codes submitted on claims.  Non-specific diagnosis coding results in decreased reimbursement.

10. Basing code selection on abbreviated descriptions

Whether it’s a paper encounter form or electronic charging in an Electronic Health Record, abbreviated descriptions are an invitation to incorrect code selection, particularly for minor surgical procedures and medications.

Betsy Nicoletti is a medical coding expert, author of several coding books and founder of Nicoletti is the founder of, a source of free coding advice for physician practices and is a nationally known consultant and speaker. She can be reached at Watch a complimentary recorded webinar featuring Betsy speaking on Medical Billing Compliance – How to Keep CMS Out of Your Business now.

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Focus on Adjustments in Medical Billing – Where is the Money Really Going?

Deborah Holzmark, RN, MBA, CPHQ, MCS-P, CMPE May 9th, 2011

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Focus on adjustments in medical billing to find out where your money is goingOften practices spend time focusing on the steps leading up to getting the money in the door, and with good reason; however, sometimes we overlook what happens after the money is received. Missing out on further examination of the rest of the collection process can result in leaving a significant amount of money on the table.

Once payment has been received in the practice and the amounts posted, how do you determine, monitor and follow-up on adjustments? In consulting, it is not unusual to find practices with a listing of adjustment codes that numbers in the 100’s, making a detailed analysis of adjustment activities difficult; or perhaps they are at the other end of the spectrum and provide only 2-3 categories. When set up and used properly, adjustment categories can provide valuable, timely information on trends, patterns and issues in the practice collection activities.

Defining your policy

To really understand your collection activities, we recommend printing off a report showing the adjustments by category for the most recent year or quarter. Then meet with the accounts receivable (AR) team and clearly define all the adjustment categories.

Make sure everyone is on the same page when reviewing and defining such categories as “other adjustments” or “not collectible,” categories we find often and usually with wide variations in application. It may be the time to retire use of some of the categories so you can monitor issues more closely. You may have to work with your vendor to define how you can make categories so they can no longer be used or how to remove from the adjustment listing.

Once you have defined the categories, you can now write a clear policy with your AR  team, outlining when to use each adjustment category. You can even develop a “cheat sheet” that everyone can use until they are completely comfortable with the definitions.

Along with defining when to use each category, you can further define at what point some adjustments may need further approval. Often practices set parameters that require that someone other than the payment poster to approve adjustments other than contractual or other pre-approved reductions. This is a strong check and balance that allows an opportunity to sometimes reverse or prevent unintended adjustments. It can also be a point to reduce the risk of potential embezzlement. A common scheme is to pocket funds intended for the practice and writing off the amount received to a particular adjustment category.

Making a difference

Now that you have defined the appropriate way to use the adjustment categories and who can make particular adjustments, you now have the opportunity to start tracking where the money is going. It is not uncommon for consultants and administrators to find balances for unpaid portions of claims that are written off without sufficient follow-up and possible appeals. This is the opportune time to now expand your activities into education and training on the appropriate method for follow-up on unpaid portions and to further expand your AR policy development. Some categories we see that can lead to further policies include such categories as:

1) Timely filing – how and when is this happening? Are there issues with providers turning in charges in a timely fashion? Is there a problem in the time from date of service to posting? Are coding issues causing a problem?

2) Provider not credentialed – Unfortunately, provider credentialing can take months to complete and we are finding fewer and fewer payors willing to back date effective dates to allow for claim filing. This often leads to some serious discussions and policy development about when providers can start seeing patients and how much potential revenue can be lost if sufficient time is not given for the credentialing process.

3) Professional courtesy – Now is a great time to start tracking the amount of professional courtesy and to also further examine the policies that define how professional courtesy can be provided. It is not uncommon for this to be a very ill-defined and sometimes non-compliant policy in the practice. Once you define the policy, we recommend having the policy reviewed by healthcare legal counsel.

4) Small balance write-offs – Does everybody follow the same policy? Does the amount written off make sense for the practice? Policies usually allow for small balance write-offs when pursuing the amount owed will cost more than the actual amount to be collected. Writing off balances above this amount probably does not make sense.

5) No authorizations – Has this become an increasing number in your practice? Is everyone clear when an authorization is required and is the AR staff providing feedback on denials? Lack of clear responsibility on how and when authorizations are performed can represent a significant, reversible amount of money loss for the practice.

Ongoing monitoring

Once you have addressed the top adjustment issues, you can now track compliance and variations on a month to month basis and provide meaningful, timely feedback to your staff on their role in managing the categories. Often you will find improved communications, more frequent appeals, and lower adjustment values that represent an increase in collecting every available dollar! You will have comfort in knowing that the AR staff is making the efforts that will truly improve the bottom line in your practice.

Deborah Holzmark, RN, MBA, CPHQ, MCS-P, CMPE, is a Senior Manager at Dixon Hughes Goodman LLP, one of the largest firms in the nation offering accounting, tax and advisory services for healthcare providers. She can be reached at

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Best Practices: Smart-Sourcing Can Get You the Expertise You Need in Medical Billing

Judy Capko May 9th, 2011

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“Smart-sourcing” is the latest coined phrase for being smart about outsourcing some of the services you need and knowing when it makes sense. It is my belief that if you have the potential to get a higher level of expertise and pay less than the current cost for having those services in-house, outsourcing is worth pursuing.

So when should you consider outsourcing? Start by keeping a pulse on your needs and identifying when you seem to be at capacity with use of existing resources.  For example, if the practice is bursting at the seams – either not enough space or not enough staff – smart-sourcing just might be the right solution. 

Perhaps billing functions could be managed off-site with a billing service invested in providing you with the highest level of expertise at a time when you are challenged to staff your own billing department.  With instant access to information that is managed off-site, this can be a seamless process and can open up space to improve the function of the  practice, such as adding another provider to resolve pent-up demand that has resulted in poor access, or you may want to add ultrasound or other ancillary services.

Outsourcing can resolve another fairly common problem in the medical office setting:  The temptation for physicians to pile more work on managers, even when he or she is already on overload.  If we fail to look for opportunities to offload work by smart-sourcing, it may result in sabotaging the practice’s efficiency and ability to grow and become more profitable.

Just the same, before you begin to explore the opportunity to outsource, it is important to decide what gains you expect to achieve.  The common goals medical practices typically hope to achieve when seeking outside help are:

  1. Improved performance
  2. Reduced costs
  3. Increased satisfaction
  4. Improved accountability

These are worthy and reasonable goals, but each practice must determine its own objectives, based on the current situation they are experiencing.  This will set the stage to begin searching for the best source to meet the practice’s needs.

 When looking for a professional source to provide needed support, turn to people you know and trust.  Talk to your colleagues and professionals you rely on for other practice needs and such as the management consultant or accountant.   What sources do they know about that could meet your needs and who might they recommend?

Gather additional information from your local medical society or specialty association. The Internet is a great resource to collect all sorts of information about a myriad of vendors serving the medical community and you can gain detailed information on vendor websites to learn more about their history and what services they have to offer.  

Narrow your search to vendors of interest, limiting the preliminary selection to between five and seven possible contenders. Conduct an initial telephone screening and schedule interviews with those that seem to meet your needs. This provides the opportunity to obtain detailed information about the companies. Explore each vendor’s background, philosophy, structure, size, how long they have been in business, their performance history and fee structure.   Before the interview is completed, ask for a list of medical practices that use their services.

The next step is to conduct detailed reference checks with at least three of their clients, preferably practices that are likely to have similar needs. Here are some potential questions you might ask, depending on the type of business support service you are exploring:

  1. How long have they been with the company?
  2. Has the company been responsive to their needs?
  3. How quickly does the company respond to problems?
  4. Do they hear any complaints from staff or patients?
  5. Have performance expectations been met?
  6. Rate the overall performance of the company on a scale of 1 to 10.

Armed with the information obtained in the preliminary research, you will be in a position to conduct a comparative analysis and make the final decision.  You may want to conduct a second interview with the two top contenders.  Such meetings are a time to dig deeper and get a clear understanding of exactly what to expect and what you will get for your money.  Be sure all questions have been answered to your satisfaction when making the final selection.

The success of smartsourcing depends on building strong relationships from the ground up.  Clearly communicate expectations and discuss how such expectations will be measured and met.  Identify who will be the contact in your office and who will be the point person at their end. 

Conducting comprehensive research and having confidence in the company’s performance is critical to a successful business relationship and optimal performance. The wrong decision can cause emotional and/or financial problems and has the potential to compromise patient service.  The right decision can eliminate headaches, save you time and money, and result in better performance.

Judy Capko, an expert on practice management, explores when "smart-sourcing" makes sense in medical billingJudy Capko is a healthcare consultant with more than 25 years experience.    Her focus is practice operations and finance, marketing and strategic planning. She is the author of the popular books “Secrets of the Best-Run Practice” 1st and 2nd edition and “Take Back Time – Bringing Time Management to Medicine.”  Judy is a national lecturer for executive management and physician specialty conferences.  She is based in Thousand Oaks, CA; contact her at  or e mail: Hear her speak in a recent Kareo webinar on What You Need to Know for 2011 – Maximizing Medical Billing and Revenue Management

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ICD-10 Training Camp: What are the Differences Between ICD-9 and ICD-10 for Medical Billing?

Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT May 9th, 2011

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“Knowledge is information that changes something or somebody — either by becoming grounds for actions, or by making an individual (or an institution) capable of different or more effective action.” - Peter F. Drucker in “The New Realities” 

Learn the differences between ICD-9 and ICD-10 and what it means for your medical billingICD-10-CM coding classification is a diagnosis and procedural alphanumerical structure that will impact medical claims processing and data gathering to a significant degree.  This implementation will be complex but should not be feared nor cause unnecessary anxiety.  A proactive approach and advance planning are prerequisites to successful compliance.

The adoption of ICD-10 will bring the United States into conformity with the rest of the world and allow us all to speak the same language when describing diseases, morbidity and mortality. This means that medical offices, hospitals and other entities must learn a new language to keep everyone on the same page when submitting claims and statistical data.

ICD-9 diagnosis codes presently consist of 3-5 numeric digits representing illnesses and conditions. ICD-9 also contains two supplementary sections containing alpha-numeric E codes, describing external causes of injuries, poisonings, and adverse effects; and V codes to describe factors influencing health status and contact with health services. This system is running out of space to expand and is over 30 years old. There are 17 chapters and approximately 14,000 codes in ICD-9-CM. 

ICD-10-CM alphanumeric diagnosis codes number 68,000

In comparison, ICD-10-CM alphanumeric diagnosis codes number 68,000 in 21 chapters.  The external causes of injury codes are listed in chapter 20 of ICD-10 and include letters “V”, “W”, “X” and “Y”; many require a 7th character code assignment (A, D or S).  The “V” codes presently in ICD-9 are located in chapter 21 of ICD-10, beginning with the alpha “Z”.  ICD-10 codes may require three to seven alpha-numeric characters, requiring billing software program changes to accommodate the additional digits, as well as extensive coder and clinician training. 

The ICD-10 diagnosis codes have an alpha first character; the second through seventh characters will be alpha or numeric.  Seven characters will be required on many codes in the obstetrics, musculoskeletal, injury and external causes of injury chapters.  Except for fracture diagnosis, the most frequent 7th character requirement will be an “A”, “D” or “S”.  “A” designates the initial encounter; “D”,  subsequent encounter and “S” is sequela encounter (late effect).  Fracture codes will have different 7th character options because they describe the status of the healing process as well as the type of encounter and depth of injury in open fractures.

The changes from ICD-9 to ICD-10 are considerable, and include revision of categories and chapter titles, re-groupings of diseases, and modification of coding rules.  Some chapters have been re-sequenced in a logical related order.  For example: chapter 14 (Diseases of the Genitourinary System (N00-N99); chapter 15 (Pregnancy, Childbirth, and the Puerperium (O00-O9A); chapter 16 (Certain Conditions Originating in the Perinatal Period (P00-P96); and, chapter 17 (Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99). 

Chapter 14 of ICD-9-CM describes Congenital Anomalies (740-759) and is an example of title revision in ICD-10 by the addition of “Malformations, Deformations and Chromosomal” terms. 

Another example is Chapter 1 of ICD-9-CM with a title of “Infectious and Parasitic Diseases” (codes 001-139), in ICD-10 classification Chapter 1 describes “Certain Infectious and Parasitic Diseases” (A00-B99)).  The word “Certain” stresses the fact that localized infections will be located in the pertinent body system (e.g., urinary tract infection will be classified to chapter 14).

ICD-10-CM codes will provide depth and detail about the patient’s condition

ICD-10-CM codes will provide depth and detail about the patient’s condition that can be more easily captured in an electronic medical record. Physician (HCFA 1500) and hospital (UB-04) billing forms have been updated to accommodate the changes. The upgrade to transaction set 5010 will enable submission of the alphanumeric ICD-10 codes.  The final compliance date for 5010 is January 1, 2012.  The compliance date for submission of the ICD-10 codes is October 1, 2013.  This lead time will allow anyone or anything that touches the diagnosis codes to familiarize themselves with the new codes and their structure and differences.  Remember, “Knowledge is information that changes something or somebody”… and ICD-10 implementation will be grounds for action and change.

In addition to the alphanumeric structure, ICD-10-CM defines other differences in code formatting. An “x” is used as a placeholder to save space for future expansion. So, for example, there may be a six-character code for which there is no fifth character subclassification at the present time. In this case, an “x” is used in the fifth character position. An example is code T36.4x4A, Poisoning by tetracycline, undetermined, initial encounter (“A”).  If the encounter was subsequent to the initial treatment, the 7th character would be “D”.  If the encounter was documented as sequela (late effect), the 7th character would be “S”.  Extensions (7th digit) provide additional information in certain circumstances and will be found in chapters 13, 15, 18 and 19. ICD-10 also describes laterality (side of the body affected), right, left or unspecified side.

The “S” codes in chapter 19 describe injuries grouped by anatomical site rather than type of injury grouping found in ICD-9.  The new classification codes reflect modern medicine and updated medical terminology, which may require additional training and advanced anatomy and physiology coding education.

A welcome new feature in ICD-10 will be “combination” codes

A welcome new feature in ICD-10 will be “combination” codes, where two or more conditions/symptoms or etiology/manifestations are assigned to one code instead of the multiple codes required in ICD-9-CM classification. For example, Diabetes Mellitus is presently assigned to category 250.xx and requires 5 digits to complete the code.  ICD-10 classifies Diabetes Mellitus to five categories:

  • E08.- Diabetes Mellitus due to underlying condition;
  • E09.- Drug or chemical induced diabetes mellitus;
  • E10.- Type 1 diabetes mellitus; E11.- Type 2 diabetes mellitus;
  • E13.- Other specified diabetes mellitus 

The (.-)   after a category code, in the index, means additional characters are required to complete the full code.  The terms “controlled” vs. “uncontrolled” status required in ICD-9 are not mentioned in ICD-10 diabetes coding.  For example, code E10.321 describes Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema. In ICD-9 the same conditions required three codes.

Hypertension is no longer classified by type (i.e., benign 401.1, malignant 401.0, unspecified 401.9); there is no hypertension table as we now have in ICD-9.  The ICD-10 code for essential hypertension is I10; this is a full code because it does not break down into additional digits.

Codes for postoperative complications have been expanded and moved to the appropriate procedure-specific body system chapter, and a new concept of “postprocedural disorders” has been added.  These code descriptors are placed at the end of the individual body system codes: Code K94.22 describes a Gastrostomy infection.  Chapter 11 of ICD-10 tabular list contains codes for Diseases of the Digestive System (K00-K94).  Code D78.12 describes an intraoperative complication: “Accidental puncture and laceration of spleen during another procedure” and is listed in Chapter 3 describing diseases of the blood and blood-forming organs.

ICD-10-CM has many similarities to ICD-9-CM

ICD-10-CM has many similarities to ICD-9-CM. For example, it has the same hierarchical structure and many of the same conventions, instructional notes, and guidelines.  The “Excludes” note is the exception.  In ICD-10-CM “Excludes” notes were expanded to provide guidance on the hierarchy of chapters and clarify priority of code assignments. Also, two types of Excludes notes are clearly distinguished to eliminate confusion as to the meaning of the exclusion. An “excludes 1” is a pure excludes note and designates condition codes that can never be used together. An “excludes 2” note is used to clarify that the excluded condition is not a part of or included in the referenced code but can be an additional code assignment, when documented.

It is important to put this change into proper perspective. We each choose how we look at everything in work and life. Choice is the ability to select one course of action from a set of alternatives to achieve a goal. Compliance to the HIPAA mandated transition to ICD-10 implementation is the goal. You make choices every day, and your life becomes more convenient or frustrating because of them. Set priorities and focus on the important issues at hand. Each task you accomplish, each step you take, can lead to a smooth transition – the choice is yours.

To learn more about how to prepare for the transition, view a recorded webinar on ICD-10/5010 featuring Nancy Maguire now.

Nancy Maguire, an expert on coding and ICD-10, teaches you how to prepare your medical billing staff for the changeNancy Maguire, ACS, PCS, FCS, HCS-D, CRT, author of The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide, is a nationally-renowned procedural and diagnostic coding instructor, bootcamp trainer, and workshop leader. She has spent more than 30 years as a hands-on coder and has authored countless coding articles and presentations. In her expansive career, she has transitioned from nursing, to coding, to practice management, auditing and consulting. Nancy served as Director of Coding and Reimbursement at UTMB in Galveston Texas for four years. She served the first two terms as president of AAPC in the early 1990s.

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Medical Billing Tip of the Month – May

admin May 9th, 2011

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How to Easily Do a Mass Rebill on Claims for Patients

When you need to do a mass rebill on claims for patients in Kareo medical billing software, you can go into your “Encounter” drop down menu and click on “Track Claim Status.” Then type in the patient last name and it will open all the claims that were pending or closed for this patient. If you need to rebill a bunch of dates, instead of going into each one, highlight a group of them by using your control button and you can click on “Action” and “Rebill” and it will rebill all that are highlighted.

This has come in handy for me when I have several claims for a specific patient that I need to send back out to the insurance company. Instead of having to go into each encounter one by one or clicking on each one and then the “Action”/”Rebill” on each line, I prefer to highlight a bunch when needed. You can also do this for settling claims on a patient’s account too, by highlighting a bunch of their encounters/line items. I hope this helps. I know it has helped me several times.

Melissa England
Billing Dept. Manager

Thank you to all who entered; please be sure to submit your Medical Billing Tip of the Month to by Friday, May 27 for inclusion in the next round of judging. You could win a $250 American Express gift card if your tip is chosen. Good luck!

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Medical Billing Software Update: News and Ideas from Industry for May 6, 2011

Kathy McCoy, MBA May 6th, 2011

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We want to help you make the most of your medical billing software and improve your practice profitability. That’s whyyou’ll find a section of news and ideas from the medical billing industry in each issue of our monthly newsletter. Since these news items are often extremely popular with our readers, we are now bringing them to you on a more frequent basis so that you can stay up to date on the latest in medical billing and medical billing software. We hope you find these items useful. Subscribe now to receive our monthly newsletter filled with tips on improving your medical billing results.

ICD-10 Costs for Practices Estimated

David Stone, Government Health IT, May 02, 2011

The Medical Group Management Association reported from a recent Nachimson Advisors Study that the average cost of moving to ICD-10 based on practice sizes were $83,000 for small practices, $285,000 for medium practices, and $2.7M for large practices. Practices need to consider these significant issues and potential concerns outlined in the article, along with ways to alleviate several operational and budgetary issues… Read More

Electronic Medical Records: What Your Data Can Tell You

Pamela Lewis Dolan, Amednews, May 2, 201

One of the perceived advantages of electronic medical records is that physicians will have a wealth of information that can help them gain greater insight about patients. Data analysis will help your practice achieve meaningful use, qualify as part of an accountable care organization, and identify at-risk patients or inefficient business practices. But even a practice that isn’t participating in these programs can use analytics to get a solid, fact-based snapshot of how it is performing… Read More

AHRQ Study: Many Physicians Find eRx Systems Cumbersome

HIMSS News, May 6, 2011

New research funded by the Agency for Healthcare Research and Quality (AHRQ) finds that “e-prescribing systems can provide physicians access to important patient information, such as drugs prescribed by physicians in other practices and formulary information that can help reduce insured patients’ drug costs, but many physicians are reluctant to use these features… Read More

Embracing Health IT Increases Doctor-Patient Face Time

Pamela Lewis Dolan, Amednews, May 2, 2011

Physicians probably have felt pressure from patients to offer more options for electronic communication by email, text messaging, social media or chat rooms. What doctors may not know is what patients hope to get from that communication or what technology patients prefer… Read More

Medicare Criticized For $4 Million Drug Overpayment

Charles Fiegl, Amednews, May 5, 2011

The Centers for Medicare & Medicaid Services overpaid for dozens of drugs in 2009 by an estimated $4.4 million, the Dept. of Health and Human Services Office of Inspector General said in an April report… Read More

AMA Releases New Edition of E-Prescribing Guide

 Pamela Lewis Dolan, Amednews, May 5, 2011

The American Medical Association and four partner organizations in late April issued an updated version of “A Clinician’s Guide to Electronic Prescribing.” The organizations said the guide reflects changes in the health care environment… Read More

10 Proven Ways for Surgery Centers to Improve Workflow Processes

Leigh Page, Becker’s ASC Review, April 27, 2011

“The definition of insanity is doing the same thing over and over again and expecting different results.” That well known saying applies well to workflow processes at ambulatory surgery centers, says Jeff Blankinship, CEO of Surgical Notes in Dallas. Rather than clinging to old practices, Mr. Blankinship says ASCs need to find new ways of doing things more efficiently and effectively. Here he cites 10 proven ways for ASCs to improve workflow processes… Read More

50 Things to Know About the Proposed ACO Regulations

Scott Becker, JD, CPA, R. Brent Rawlings, JD, Barton Walker, JD, and Lindsey Dunn, Becker’s ASC Review, April 04, 2011

This article briefly outlines 50 things to know about the Medicare Shared Savings Program proposed rule — which established Medicare accountable care organizations — released by the U.S. Department of Health and Human Services on March 31… Read More

Subscribe now to our monthly e-newsletter to receive additional articles and news on improving the profitability of your medical billing.

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How to Maximize Your Medical Billing Software: Train Your Staff to Improve Patient Collections

Kathy McCoy, MBA May 2nd, 2011

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Improve your patient collections with these tips on how to maximize your medical billing softwareIf your practice is like most medical offices, the payment picture has changed markedly over the last three years. With the exponential rise in health care costs, employers are choosing plans where workers are footing a bigger portion of the bill for their care. Higher deductibles, bigger co-payments, and reductions in covered services all mean that getting paid for medical services has become less about medical billing and payor reimbursement, and more about patient collections. In fact, revenue cycle management experts estimate that patients’ direct payments now account for 20 to 30 percent of a practice’s total charges. Couple that reality with the fact that so many workers no longer have jobs, and it becomes clear that collecting money from patients for services rendered has become one of the biggest challenges facing practices today.

Unfortunately, there is no medical billing software in the world that will ever replace a face-to-face interaction when it comes to communicating patients’ financial responsibilities for their care. For that, medical practices must rely on their office personnel who are on the front lines in dealing with patients. There is no question that handling the delicate subject of payment at a time when patients are most vulnerable is not an easy task. That is why having a clear payment policy in place is so essential. If your office staff is unclear on what the patient’s fiscal liability is, how can they ever convey that to patients? But having defined financial policies in place is only half the battle. Your employees need to know how to walk that delicate line between facilitating the delivery of services and ensuring you are paid for that care.

Here are some tips to help prepare your staff for those delicate discussions.

1) Convey the “Big Picture” – Employees need to know how important it is to collect what is due from patients—-and the fact that it pays their salaries. Healthy cash flow equates to job security and continued financial viability for everyone. In this environment, there really is no place for an employee who is reluctant to ask upfront for payment. After all, could your employees defer paying for a meal or manicure at the time those services are rendered?

2) Give them the words – Many practices find that scripting how to approach patients about their financial obligations has many benefits. It takes pressure off the employee to find the right words to say, in a way that providers feel is personable yet professional. It ensures consistency among employees on how your financial policies are presented to patients and what is asked of them in payment. For instance, reminding patients that co-pays are due when they arrive for their visit, or asking patients to pay larger balances, are easier discussions when they are scripted.  There is a big difference —and higher payoff—when staff ask patients how they’d like to pay their balance, rather than whether they’d like to pay their balance today.

3) Give them the tools – Provide your staff with print-outs that document your financial policies. It provides additional documentation that employees can refer to when talking to patients in a format that makes your policies more “official.” Having a printed Explanation of Benefits (EOB) handy is extremely useful when dealing with patients who express reluctance about paying an outstanding balance. The EOB allows employees to explain that the insurance company has already taken care of a portion of their bill, and how the patient’s financial obligation has been determined by their insurance company. EOBs set the framework for collecting balances on the spot while empowering staff to re-direct patients back to their insurance plan if there are questions on the payment due. This positions your practices as more of a patient advocate than enforcer of what some patients may view as inadequate coverage.

4) Role-play with the stars – Every successful practice has a “star” collector who outperforms the rest when it comes to bringing in cash. Allow your star performers to show other employees the tips and techniques that have made them successful. Even if you have no clear winner, allowing employees to role-play with each other on a periodic basis raises their comfort zone in initiating financial discussions. By identifying best practices in collecting from patients, you’ll be taking a more uniform and effective approach to getting paid for your services.

The bottom line is: your front line and back end staff are key to maximizing your reimbursement and cash flow. They are just as important as having the right medical billing system in place. Give them the tools they need and train them well, and you will reap the financial rewards for years to come.

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Welcome to Getting Paid, a weblog by Kareo offering ideas, news and opinions about medical billing and practice management with the goal of making medical billing easier and yes, getting you paid. Visit the Product Blog for more information on our products.

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