Common Questions about E&M Coding Answered

Lea Chatham February 11th, 2013

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By: Laurie Morgan, MBA

Do you keep a close eye on your E&M coding? Do you know if you are losing money because of under-coding? As a practice management consultant, I get a lot of questions from medical practices struggling to monitor and improve coding practices.  So, I have taken the top three and provided answers and a tool to help you evaluate your E&M coding.

Q. How do you know when your providers may need more education on E&M coding?
A.  Looking at your distribution of codes at regular intervals can help identify patterns that suggest your providers lack confidence in their coding. Skewing towards a single code – usually on the low side – is a strong indication that your providers don’t feel comfortable with the differentiation of the codes.

Some payers also provide reports that show your practice’s distribution of E&M codes versus the average of other physicians in their plan – these can be a great resource for spotting consistent under-coding or other repeated errors.

Q. How can you tell if your providers are in an E&M coding rut?
A. For most practices, E&M codes should be distributed in a pattern loosely resembling a bell-shaped curve.  When providers fall into a rut, it’s usually a habit of using one or two codes excessively – and, that’s usually the level two and three codes.  Looking at each provider’s code distribution in a bar chart can help you see if there’s an overall trend indicating that habit is driving less accurate coding.

Q. How much revenue are you losing because of over-cautious coding habits?
A. The amount of money lost due to under-coding can be staggering. If you compare, for example, 99212 and 99213 Medicare rates for the San Francisco market, the difference is more than $32 per visit ($52.01 versus $84.30). Even ten visits per week consistently under-coded at 99212 instead of 99213 would cost a practice $320 – or, more than $15,000 per year.  Worst of all, this revenue is money the practice could legitimately capture without doing any additional work.

This spreadsheet provides a jump-start for doing these calculations for your providers and your payers – fill in the bold boxes with your payer reimbursement rates and the number of visits you believe have been under-coded, and the lost revenue will be calculated in the far-right column. More payers and more codes can be added by copying and pasting.

Revenue Spreadsheet

About the Author
Laurie Morgan is a practice management and healthcare industry consultant with Capko & Company. She managed both start-ups and large-scale operations in the media industry before turning her focus to medical practice management. Her consulting focus is on driving and capturing revenue and operating more efficiently. Laurie has an MBA from Stanford University.

Lauri Morgan

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Is It Time for a New Practice Management System?

Lea Chatham February 6th, 2013

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How to Change Your Medical Billing Software

While EHR implementation may still be limping along, most established practices have purchased a practice management or billing system at some point. In fact, there are practices that have been sending electronic claims since as early as the
1990s. Unfortunately, many find that their first system isn’t the right system. As a result, you may be considering a change.

There are several reasons to look at making a transition to a new practice management system. You may have outgrown your product. Perhaps you aren’t happy with the features and functionality of the system anymore. Or the solution has been “sunsetted” or isn’t keeping up with the ongoing changes in reimbursement and claims processing.

Whatever the reason, if you are planning to make a change, don’t rush in. There are several things to think about before committing to a new practice management system, and once you make your decision, it’s just as important to plan for your transition.

Before you start your search make a list of the features that you are looking for. Also, make a list of the things that you do and don’t like about your current system and vendor. Use these lists as a guide to look for a solution that offers the same value as your old system while also fulfilling your new wish list. Ask specifically about some of the key issues you have. For example, if your current system hasn’t grown over time and rarely has new releases or updates, then ask potential vendors about their development road map and release schedule. What are their plans for continuing to enhance and grow the product.

For a list of additional questions to ask vendors and a detailed overview of how to manage your conversion, check out our new, How to Change Your Medical Billing Software: From Choosing a System to Data Conversion.

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You Can Reduce Denials, Part 2

Lea Chatham February 5th, 2013

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Last week in You Can Reduce Denials, Part 1, we reviewed strategies for reducing the number of denied claims by improving processes at your practice. Reducing errors during appointment scheduling and check-in and while coding can eliminate many denied claims. However, you will still have some claims that get denied. It could be for medical necessity or other billing issues not related to an error. When this happens, you want to be prepared to appeal. According to Elizabeth Woodcock, 75% of appeals result in denials being overturned – and paid.

In her webinar on Effective Appeals in Medical Billing: Breaking Through the Barricade to Get Paid, she reviewed how you should prepare for your claims appeals.

  1. The Patient Has the Authority: When you appeal a claim, you are appealing on behalf of the patient and not the physician or provider. As the provider or medical biller, you are not authorized to appeal an adverse benefit determination without a signed authorization from the patient. An Assignment of Benefit form is not sufficient authorization, as it only authorizes the claimant to receive payment from the payer on the patient’s behalf.
  2. Gather Evidence: When you are filing a claim appeal, you should be as prepared as a lawyer going to trial. The insurance company or payer that denied your claim should have already disclosed to you the nature of the adverse benefit determination. That communication should clearly state the reason that you were denied payment or not paid in full, including the following information:
    - Reason(s) for the denial
    - References to the plan provision on which the denial is based
    - A description of the information/documentation required to appeal the claim
    - Procedures for appealing a decision.
    You may request additional documentation, including copies of the patient’s benefit manual or any specific plan rules, rate tables, fee schedules and criteria used to ensure that the plan rules were consistently applied to your claim. The payer may also hire medical, occupational or other experts to obtain specific knowledge regarding conditions of your claim. The payer is not required to disclose the identity of these experts, but must provide that information when requested by the claimant.
  3. Prepare and File Your Appeal: By comparing the documentation provided to you by the payer with the documentation you already have regarding the patient, including chart notes, you should be able to determine where the problem lies. Draft a strong appeal letter summarizing all relevant information regarding the claim in question. Stick to the basics, avoiding any information that is not essential to the claim. File your appeal in a timely manner, and make note of the date in a file you create specifically for this claim. Follow up regularly and try to speak with the same people whenever you contact the company. With documentation and diligence, your adverse benefit determination can be overturned and the bill paid.

For more appealing denied claims, check out Elizabeth’s webinar, Effective Appeals in Medical Billing: Breaking Through the Barricade to Get Paid.

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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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