How Important Is EHR and Billing System Integration for Medical Practices?

Lea Chatham May 29th, 2014

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Kareo Ranked #1 Integrated EHR, PM, RCMThe healthcare IT market is maturing, and providers are gaining a greater understanding of what their practices need from new technologies. Applications that were once seen as innovative now label themselves as “1.0,” signaling the limited nature of the first generation of products to hit the market.

For example, “patient portal 1.0.” The first iteration of patient portals had limited functionality, beyond their core purposes. Now, providers—not to mention Meaningful Use standards—expect and require more.

The desire for integration is perhaps the most prominent expectation among current healthcare IT buyers. Tweet this Kareo story
This makes sense: as practices begin building a technology infrastructure that contains electronic health records, practice management, and billing functions, it’s only logical for these systems to integrate.

To return to the example of patient portals, new reports find that best of breed, or EMR-agnostic, solutions are losing market share to their integrated competitors. And that’s despite best of breed portals often offering greater options for interfacing with other systems.

The latest Black Books Rankings, an annual survey of the EHR market, supports these trends. For example, 90 percent of managers in independent practices believe integrating practice management, electronic medical records, and revenue cycle management into a single system will ensure long term gains in both productivity and profitability.

The same overwhelming percentage of physicians plan to source all three platforms from a single vendor by the beginning of 2016. All indicators point to tremendous demand for integrated healthcare software. Lets examine some of the main benefits to such a system.

The Benefits of Integration
You don’t have to dig too deep to understand why combining electronic health records with practice management makes sense for providers. Some key benefits include:

  1. Consolidation: Housing the patient data used by your EHR and practice management system in one database makes both clinical and administrative workflow smoother. Office staff won’t have to stop working on one program and open another to find specific data, and they also won’t have to enter data twice into two programs since the PM software can pull information from the EHR, and vice versa.
    In addition to increasing efficiency, this software model can also increase revenue. Since the data all live in one warehouse, it’s easier for practice management software to pull claims to submit to payers and CMS. Along the same lines, it will be easier for the practice management system to identify and correct improperly coded procedures, which could increase reimbursement for providers. Finally, consolidating patient data increases the accuracy of the reports generated, resulting in greater insight.
  2. Interoperability: While healthcare professionals may immediately read this word and think about communication between external systems, in this context it refers to communication between internal systems. Creating a seamless transition of data between your PM and EHR system increases the accuracy of healthcare data on all fronts.
    While integrated tools such as computerized physician order entry do reduce the risk of prescribing errors, the possibility of human error will always exist. A system that integrates different programs (i.e., EHR, practice management, and even billing), reduces the number of data entry points, and therefore minimizes the situations that require redundant data entry. Ultimately, this reduces the opportunity for human error.
    Furthermore, internal interoperability helps prevent privacy breaches. Though external threats are not unheard of, nearly all privacy breaches stem from human error, which again, is influenced by the number of data entry points through which office staff must navigate.
    A concerted push for integration is good for providers and patients alike, and signals a growing maturity in the technology both parties rely on. For providers, integration simply makes too much sense, from both a cost and quality perspective.

Moving forward, the best EHR systems will feature integrated practice management capabilities that handle the administrative workload, while the EHR attends to the clinical responsibilities. The data already prove it’s what providers want.

Is your practice moving toward a single, integrated platform? Share your experience in the comments.

About the Author
Zac WatsonZach Watson is a content writer at TechnologyAdvice. He covers healthcare IT news, business intelligence, and more. Connect with him on Google+.




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Boost Revenue through Correct Incident-to Billing but Use Caution

Lea Chatham May 27th, 2014

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By Lisa A. Eramo

imagesWhen reported correctly, incident-to services can definitely boost a practice’s revenue. The bad news is that when reported incorrectly, these services can raise a red flag to auditors, Jean Acevedo, LHRM, CPC, CHC, CENTC, told coders at AAPC’s 22nd annual HEALTHCON conference in Nashville, TN last month.

During a presentation on maintaining compliance with incident-to billing, Acevedo called attention to a 2009 OIG report titled Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services. The report states that in the first three months of 2007, Medicare allowed $12.6 million for approximately 210,000 services performed by unqualified physicians—i.e., those lacking the necessary licenses, certifications, credentials, or training to perform the service. She said this report—as well as the subsequent inclusion of incident-to services in the 2012 OIG Work Plan—is proof that compliance concerns with incident-to services remain high.

What exactly are incident-to services?
To be as covered incident-to the services of a physician, services and supplies must meet all of the following criteria:

  • Be an integral, although incidental, part of the physician’s professional service
  • Commonly rendered without charge or included in the physician’s bill
  • Of a type that are commonly furnished in physicians’ offices or clinics
  • Furnished under the physician’s direct personal supervision
  • Furnished by an individual who qualifies as an employee of the physician

When practices bill services as incident-to, they receive 100% of the Medicare physician fee schedule (MPFS) amount. When services billed under the non-physician practitioner’s NPI, practices receive 85% of the physician fee schedule amount.

Who can perform services incident-to a physician?

  • Registered nurse (RN)
  • Licensed practical nurse (LPN)
  • Medical assistant (MA)
  • Technician
  • Physician assistant (PA)
  • Nurse practitioner (NP)
  • Physical therapist (PA)
  • Occupational therapist (OT)
  • Clinical psychologist (CP)
  • Licensed clinical social worker (LCSW)

Note that PAs, NPs, PTs, OTs, CPs, and LICSWs can also bill Medicare directly as opposed to billing incident-to a physician.

Acevedo urged coders to review the incident-to guidelines as well as the provider’s state-specific scope of practice and organization bylaws before billing incident-to services.

Consider medical assistants. “The overwhelming majority of states don’t allow a medical assistant to do something without direct physician supervision,” Acevedo said.

What if the scope of practice doesn’t align with requirements?
In some cases, a provider’s scope of practice won’t align with CMS benefit requirements. When this occurs, Acevedo said that the more stringent of the two requirements would apply.

For example, the Medicare Benefit Manual, Section states that Medicare doesn’t require, for coverage purposes, that a doctor of medicine or osteopathy order the vaccine for pneumococcal pneumonia, influenza virus, or hepatitis B. The Benefit Manual further states that beneficiaries may receive these vaccines upon request without a physician’s order or supervision.

However, in some states, the scope of practice doesn’t allow medical assistants to perform this task at all or unless they operate under direct supervision of a physician. When this occurs, the state scope of practice trumps the Medicare requirement because it is the most stringent.

Per the Florida Department of Health, medical assistants cannot even take vital signs unless they operate under direct supervision of a licensed physician, Acevedo pointed out. Although this requirement may seem surprising, it couldn’t be clearer, and practices must abide by this, she said.

Coders should always be on the lookout for potential changes to incident-to billing and/or scope of practice published in the annual MPFS. For example, in calendar year 2014, Medicare revised its benefit for fecal occult blood testing to include coverage when the test is ordered by nurse practitioners, physician assistants, and clinical nurse specialists acing with their scope of practice and who are the patient’s attending nonphysician practitioner. Prior to January 1, 2014, this particular Medicare benefit only occurred when a physician ordered the test.

Practices should closely examine all documentation related to incident-to billing, Acevedo advised. Documentation should specify the following:

  • Specific individual who rendered the service
  • Whether and how supervision requirements were met
  • Physician initiation and continued involvement in treatment
  • Medical necessity for services rendered
  • Whether services are included in the nonphysician practitioner’s scope of practice

Acevedo said proving that supervision requirements were met could include something as simple as printing the physician’s schedule for certain dates of service to show that he or she was in the office.

She reminded coders that they cannot bill incident-to services for new patients, consultations, or established patients presenting with a new problem. Tweet this Kareo story

Incident-to services are also not appropriate for the inpatient setting or services provided at the patient’s home. Coders should not assume that a third-party payer recognizes a nonphysician practitioner’s services as incident-to. Always verify whether the payer includes nonphysician practitioners as covered providers, she said.

About the Author

Lisa A. EramoLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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Meaningful Use 2011 Edition Extension-What Does It Mean for You?

Lea Chatham May 23rd, 2014

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The CMS and the ONC announced a proposed rule this week that gives eligible professionals (EPs) the option to attest for Stage 1 of Meaningful Use for 2014 using 2011 Edition certified EHRs. The rule also formalizes past changes extending Stage 2 to 2016 and beginning Stage 3 in 2017.

So, what does this actually mean for healthcare providers who are currently attesting or plan to attest this year? It’s a little complicated, but here is an overview of your options:

  • Any EP attesting for Stage 1 in 2014 can use a 2011 Edition, 2014 Edition, or a combination of the two. Reporting periods stay the same: 90 continuous days for Year 1 and a 3-month period on the calendar quarter for subsequent years. See the chart below for which objectives and measures to use.
  • EPs who started Stage 1 in 2011 or 2012 who were required to start Stage 2 in 2014 have a reprieve. They can attest again for Stage 1 using a 2011 Edition, 2014 Edition, or a combination of the two on a 3-month calendar quarter. See the chart below for which objectives and measures to use.
  • EPs who were required to start Stage 2 in 2014 who have a 2014 Edition certified EHR have the option to start Stage 2 and attest on the 3-month calendar quarter as previously planned using the 2014 meaningful use criteria.
  • Medicaid EPs seeking a first incentive must adopt, implement, or upgrade to 2014 Edition certified EHR only. Incentives will not be given for adopting 2011 Edition systems that will be out of date for 2015.
  • In 2015, things go back to the way the way they were. So, those EPs who were required to attest to Stage 2 in 2014 must attest to Stage 2 in 2015 whether they opted to do one more year of Stage 1 in 2014 or go ahead with Stage 2.

MU Extension Overview

According to the proposed rule, all of the Meaningful Use timelines stay the same. So, providers choosing to attest for the first time in 2014 still need to get started by July 1, 2014 and report by October 1, 2014. This extension is only for 2014 and doesn’t change the reporting periods. Everything goes back to the previous schedule in 2015. According to the CMS, “We will maintain the existing policy that all providers must use 2014 Edition CEHRT for the EHR reporting periods in CY 2015, FY 2015, and in subsequent years or until new certification requirements are adopted in subsequent rulemaking.”

If adopting an EHR for the first time, it would only make sense to choose a solution that is already 2014 Edition certified. Tweet this Kareo story
As the CMS stated for the Medicaid EPs, it just doesn’t make sense to adopt Meaningful Use technology today that will be outdated for attesting in 2015.

The extension is really intended to help those practices that are currently using a system that is in the backlog of EHRs trying to get certified for the 2014 Edition or for EPs who are struggling to get their 2014 Edition EHR implemented.

For more information, read the full proposal which provides updated attestation charts and examples for providers based on current stage and year.

For help getting started with Meaningful Use, visit the Meaningful Use Resource Center.

Note: This Meaningful Use information is subject to change. For the latest updates, visit

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3 Reasons to Upgrade Your Medical Practice Technology Now

Lea Chatham May 21st, 2014

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2014 Black Book Survey

With increasing challenges each year, many small medical practices are struggling to stay independent. Today, over 80% of physician practices anticipate declining-to-negative profitability in 2015 due to diminishing reimbursements and underutilized or inefficient billing and records technology.

To combat this problem, practices are planning to upgrade and add technology. Over 45% of practices are looking to upgrade their revenue cycle management (RCM), practice management (PM), and EHR collectively and 90% of physicians replacing their EHRs are seeking a seamless single source vendor.Tweet this Kareo story

The reasons for the change are simple. Technology improvements can help practices recruit and retain patients, meet challenges like ICD-10 more effectively, and increase revenue. These improvements could make the difference between staying independent and being forced to sell.

Recruit & Retain Patients
The way patients perceive healthcare is changing. They want a more service-oriented experience. This includes care using an EHR and access to medical records through a patient portal. Two-thirds of patients would consider switching to a physician who offers secure access to medical records online, and 73% of patients are more loyal to their physician when there is an EHR. If a practice doesn’t have an EHR or has outdated technology, it will be a struggle to appeal to today’s patients and stay competitive.

Adapt to Industry Changes
The same goes for meeting industry changes like the Affordable Care Act (ACA) and ICD-10. More than 90% of practices are concerned about changes to clinical documentation, coding staff productivity, and changes to clinical productivity with ICD-10. A successful transition to ICD-10 requires technology that will provide top codes reporting, ICD9 to ICD-10 crosswalks, training, and coding support. No provider wants to work with a 10-page paper superbill. An integrated EHR and practice management system that is ready for ICD-10 can make the process of changing so much easier to manage.

Streamline Tasks & Increase Revenue
Another big benefit of upgrading to integrated practice management and EHR is the reduction or elimination of many tedious office tasks and an overall improvement in billing. The result according to a UBM white paper is an average increase in revenue of $33,000 per FTE provider per year! The added bonus is the ability to access incentives like meaningful use and avoid the coming penalties, which could be as much as 11% in five years.

There are many other positives to upgrading to a single source vendor for new technology. With only one vendor to work with, training, support and upgrades are easier. Vendors like Kareo offer a seamlessly integrated RCM, PM, and EHR solution for one low monthly cost, helping the practice keep expenses in check. And a single solution has a short learning curve for staff, getting the practice up and running on new technology quickly.

Recent extensions for ICD-10 and meaningful use have given practices time to choose and implement new solutions effectively. Take advantage of this time to upgrade technology.

Learn more about the coming trends in upgrades, outsourcing, and integration for small practices in the 2014 Black Book Survey.

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3 Surprising Ways Technology Can Help Build a Patient-Centered Practice

Lea Chatham May 20th, 2014

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KareoPatient engagement and patient-centered care are hot topics in healthcare. Some of the changes happening in reimbursement are even tied to patient care, satisfaction, and outcomes.


It is likely that all practices will have at least some of their revenue tied to value-based reimbursement at some point.Tweet this Kareo story

While there are plenty of no-brainer tips and tools for improving patient satisfaction and creating a more patient-centered practice, there are also some unexpected features in your practice management and electronic health records systems that can help.

Eligibility Verification
Many practices know that verifying eligibility can help ensure you get paid, but most don’t think about how it impacts the patient experience. Studies have shown that medical billing is a common frustration for patients. They don’t understand their insurance coverage and/or their statement from the practice. The practice is a in a unique position to provide an explanation of coverage and expected patient due amounts at the time of service. Along with a clear policy about patient payment—that can also be reviewed at that time—this can help eliminate surprises for the patient. When patients know what to expect and what they owe, they are less likely to call the practice with questions and more likely to pay their outstanding balance.

Phone Visits
Many patients want phone visits, but most practices don’t think they can get paid for them. Many providers either choose not to consult on the phone or they do it and eat the cost, losing as much as $25,000 a year in uncompensated care. New technology from companies like Ringadoc addresses this problem by providing a solution that enables practices to charge patients for a phone visit up front. This allows the practice to offer a premium, concierge service at a reasonable cost without adding a burden to practice to manage it.

Preventive Care Recommendations
Preventive care recommendations are an often overlooked feature of your EHR, but the benefits can’t be overstated. Based on demographic data, your EHR should provide a list of recommendations like vaccinations, tests (i.e., mammogram, colonoscopy, etc.), and screenings like blood pressure, obesity, or depression. This is valuable not only because it helps ensure that patients get necessary preventive care—much of which is now covered by insurance—but also because it can help generate revenue for you practice through follow up visits or testing services.

Transitioning your practice a patient-centered model has many benefits for you and your patients. Tweet this Kareo story
It can improve patient outcomes and satisfaction while also potentially increasing revenue and making it easier for you to take advantage of value-based reimbursement down the road. For more on how to become a patient-centered practice, download this simple checklist.

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Get Patient Engagement Tips & MU News in Kareo Newsletter

Lea Chatham May 15th, 2014

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The May edition of the Kareo Getting Paid Newsletter is packed with Meaningful Use updates, compliance tips, and patient engagement tools. The newsletter also provides a chance to discover upcoming events, news, and resources from Kareo and links to connect with Kareo on social media. Plus, you’ll learn about how to register for our upcoming free educational webinar, Your Medical Office Software: Coding Pitfalls & Promises, presented by Betsy Nicoletti. Read all this and more now!

May Kareo Getting Paid newsletter

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It’s Crunch Time: Make Your Meaningful Use Decision by July 1

Lea Chatham May 14th, 2014

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Meaningful Use ResourcesJuly 1, 2014 is an important deadline for Meaningful Use (MU) if you haven’t taken any action yet. Tweet this Kareo story
It is your last chance to attest for stage 1, year 1 to avoid the penalty that kicks in starting January 1, 2015. It is also the deadline to submit your hardship extension request if that is the way you want to go.

Of course you can also choose to do nothing, but consider this… When you add up the adjustments for MU and other programs like PQRS and eRx, the total penalty on your Medicare Part B claims will be more than 10% in five years.Tweet this Kareo story

So, it is worth considering your options if you haven’t started MU yet. Here is what you need to know about your two choices:

  • Attest for Meaningful Use: To avoid the penalty in 2015, you need to attest by October 1, 2014. This means you have to start by July 1 (at the absolute latest) and complete your reporting by October 1. Before you can start, you need to have a 2014 Edition Certified EHR in place and you need to register as an eligible professional with CMS. Then, you attest for stage 1 for 90 consecutive days and submit your reporting by October 1, 2014.
  • Apply for a Hardship Exception: To qualify for a hardship exception you need to meet specific criteria that show you are unable to participate due to factors that are beyond your control:
    • Your area lacks the necessary infrastructure (i.e., no broadband)
    • You’re a new provider
    • Natural disaster or other unforeseen barrier
    • Lack of face-to-face interaction with patients
    • Practice in multiple locations
    • EHR vendor issues (i.e., your current vendor was unable to certify for 2014 Edition)

If you’d like to attest for MU, but need more time AND you meet one or more of these criteria, then you should consider this option. The CMS tipsheet provides more detail. Applications and supporting documentation are due by July 1, and if approved, the extension lasts for one year.

If you are still on the fence about MU, then look at the numbers. If you don’t serve any, or many, Medicare or Medicaid patients, maybe it doesn’t make sense. But if you do, then the long term impact of the penalties could really affect your bottom line.

If you are a solo doc and you generate an average of $30,000 a month and about 30% of your patients have Medicare, that’s $10,000 a month. A 10% cut adds up to $12,000 a year. To make that up, you would have to conduct about 100-120 more patient visits a year (if your average visit reimbursement is around $100-150). Plus, if you start this year, you’ll get $24,000 in incentive payments over three years.

If you need more information on Meaningful Use, check out the Meaningful Use Resource Center.

Note: This Meaningful Use information is subject to change. For the latest updates, visit

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2 Things to Remember about Using Your EHR Compliantly

Lea Chatham May 14th, 2014

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By Betsy Nicoletti

Learn about OIG EHR recommendationsPhysicians and other healthcare providers can be excused if they feel a sense of irony about the messages they get about their Electronic Health Records (EHRs). First, we ask them to switch their method of record keeping from paper to computerized and then caution them, “But please don’t use them conveniently, by copying from one note to another.” There are constant warnings about cloning. Even the popular press reported on recent Office of Inspector General (OIG) reports about the topic, finding “errors in digitizing” medical records. This leaves clinicians, coders, and managers with questions about how to use their EHRs effectively and compliantly. Two of the many issues highlighted in the recent OIG reports were authorship and copying and pasting from a previous note.

Sign & Date Entries
All entries into the medical record should be dated and signed and the authorship should be crystal clear. “Written by Anonymous” is good for the author of a Victorian novel, but not in the EHR. Medical assistants should sign their portion of the note when entering the reason for the visit. It shouldn’t be confusing to a reader what part of the history was entered by the MA or nurse and what part was entered by the billing provider. If a record is shared between two providers, such as a Physician Assistant and physician each professional should enter and sign their own portion of the note.

Although we all want to be part of the healthcare team, there is no “we” in medical record documentation.Tweet this Kareo story

Use Caution When Copying Notes
Clinicians do want to carry forward history from note to note. Often the medical assistant will enter or review this data, but if a clinician signs off on the note, it is assumed that the clinician also reviewed the data. That is, the billing provider is responsible for what is in note that day. Past medical, family, and social history recorded at a previous visit can be reviewed and updated and incorporated into a current encounter. Diagnostic data is also often summarized and carried forward, making data retrieval easier for the clinician. Coders and clinicians often have differences of opinion about the history of the present illness. Coders tell clinicians not to copy anything into the HPI section of the note from a previous visit and clinicians tell coders it is clinically relevant and a time saver to do so.

I distinguish between a clinical summary that is carried forward from the HPI documented at the current visit. An example of a clinical summary is, “this is 78 year old woman with COPD, lung nodules by CT scan and asthma. She is a past smoker, who quit at age 55 after a bout of pneumonia.” Then, the provider would add the HPI. “Since I saw her six months ago, she reports a worsening of her symptoms and an increase in shortness of breath.” The clinician is happy because the clinical summary is available at each visit, and the coder is happy because the HPI is documented after the statement, “Since I saw her six months ago.”

Medical practices should heed the OIG warnings and recommendations regarding EHRs. Many of the recommendations are easy to implement. Some require only this: remembering that although we use the documentation for billing and coding, the primary purpose of the medical record is healthcare communication.

Adopting the OIG recommendations will protect the integrity of the medical record.Tweet this Kareo story

To learn more about the latest OIG recommendations, join me at my upcoming webinar, Your Medical Billing Software: Coding Pitfalls and Promises.

About the Author
Expert Betsy_Nicoletti_advises how to improve your patient collectionsBetsy Nicoletti is the author of The Field Guide to Physician Coding and the 2007 Physician Auditing Workbook, as well as founder of She developed The Accurate Coding System to help doctors get paid for the work they do. She simplifies complex coding rules for practitioners and engages physicians in a positive and respectful way, which encourages attention and accuracy in their coding. Besides doing auditing and compliance work, she is a speaker, writer and consultant in coding education, billing and accounts receivable.

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Free Webinar: Coding to Maximize Revenue and Stay Compliant

Lea Chatham May 12th, 2014

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Register Now



Your Medical Office Software: Coding Pitfalls & Promises
Wednesday, May 21, 2014
10:00 AM PT, 1:00 PM ET


You want to use your EHR and practice management (PM) software in a way that ensures capturing fee-for-service revenue and doesn’t conflict with Office of Inspector General (OIG) warnings about cloning and over-documentation.

The OIG has released two reports recently warning healthcare providers about copy/paste, over documentation, and audit functions in their EHRs. You need to balance these warnings with the desire to use software tools and techniques to make coding easier.

In this webinar, coding expert Betsy Nicoletti will describe the OIG recommendations and suggest policies and procedures that will allow you to use your EHR in a way that saves them time and promotes good patient care, but doesn’t conflict with those OIG recommendations.

At the end of the session you’ll:

  • Have three techniques to help use the coding functions in their software to improve accuracy and efficiency
  • Know three key audit functions that a practice should use in their EHR programs
  • Understand the pros and cons of using an E/M calculator and how to assess its accuracy

Who should attend? Anyone in the practice who has a role in coding the visit from physicians to billers.

Register now to learn how to maximize coding and stay compliant

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Transitional Care Management: Know the Requirements before You Bill

Lea Chatham May 7th, 2014

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KareoBy Lisa Eramo

Knowing your carrier’s policy is the key to billing transitional care management (TCM), Jill Young, CPC, CEDC, CIMC, of Young Medical Consulting, LLC, told coders and other healthcare compliance professionals at AAPC’s 22nd annual HEALTHCON conference last month.

However, regardless of payer requirements, understanding the general concept of TCM is important. TCM occurs when providers render or oversee the management and coordination of services, including care for medical conditions, psychosocial needs, and activities of daily living.

“TCM is for certain patients. It’s not for every patient,” Young said during her presentation. “Just because you have sick patients doesn’t mean it’s TCM.”Tweet this Kareo story

TCM codes include the following:

  • 99495—TCM services with the following required elements:
    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge
    • Medical decision-making of at least moderate complexity during the service period
    • Face-to-face visit within 14 calendar days of discharge
  • 99496—TCM with the following required elements:
    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge
    • Medical decision-making of at least high complexity during the service period
    • Face-to-face visit within seven calendar days of discharge

Assuming all other requirements are met, providers may bill TCM when discharging patients from one of the following settings/statuses to the patient’s community setting (e.g., home, rest home, or assisted living):

  • Inpatient hospital (i.e., acute care facility, rehabilitation hospital, or long-term acute care hospital)
  • Skilled nursing facility(SNF)
  • Nursing facility
  • Observation status
  • Partial hospitalization

TCM does not apply when patients are discharged to a SNF.

Young reminded attendees that TCM is not restricted to certain specialties. However, she acknowledged that there is no clear definition of what technically initiates or triggers TCM. A phone call from the hospital to confirm a follow-up appointment, for example, is not appropriate. One audience member suggested that the discharge physician include the verbiage ‘initiate TCM’ in his or her discharge summary or specifically order TCM.

Young said an order is not technically required. The only requirement is that the provider initiating the TCM communicate with the community physician. Documentation is critical. This documentation should include any communication, coordination of care, and services that the patient requires.

Providers rendering services with either a 010 or 090 global period cannot bill TCM. “A lot of the TCM components are considered to be part of global care,” Young said.

Young also made it clear that any E/M services that the discharge physician provides on the date of discharge (i.e., 99217, 99234-99236, 99238-99239, or 99315-99316) do not qualify as the ‘face-to-face’ visit requirement for TCM.

“Why? Because it has the components of a discharge,” Young said. “If you are not billing these codes, then you could see the patient on the day of discharge and have that count as your 7- or 14- day face-to-face visit. Doctors that do provide the discharge service can subsequently provide TCM services, but the face-to-face visit must be on another day.”

The first face-to-face visit is considered part of the TCM service and not separately reportable. Additional reasonable and necessary E/M services required for managing the beneficiary’s clinical problems may be reported separately, she said.

Keep in mind that the 7- and 14-day requirement is mandatory, Young said. Providers must schedule a follow-up appointment within this timeframe in order to bill TCM. Providers cannot use a busy schedule as an excuse as to why they could not accommodate the patient within the timeframe, she added.

The face-to-face visit is typically provided in the physician’s office; however, it may also occur in the patient’s home or other location where the patient resides, Young said.

Young also clarified the business day requirement for communication. “If you cannot get a hold of people within that timeframe, and you provided the remainder of the services for TCM, consideration for payment would be made,” she said. “Exceptions can be made, but everything must be documented.” Business days are Monday through Friday, she added.

Medical decision-making is another important consideration. “It must be during the service period—not just in that first visit,” Young said.

Young provided the following other documentation suggestions:

  • Document the date, time, and content of the initial communication with the patient and/or caregiver. Identify who provides the care.
  • Summarize the inpatient course based on the discharge summary and conversations with the patient, caregiver, or others involved in the care.
  • Thoroughly document the face-to-face visit. Ensure that this documentation includes medication reconciliation and supports the medical necessity and complexity of the TCM services.
  • Document all communication with other individuals and agencies involved in the patient’s care.
  • Ask clinical staff to document the date, time, duration, and content of any communications involving the patient.

Young advised coders to check with their carrier to clarify these and other TCM requirements.

For more on transitional care management, check out Betsy Nicoletti’s webinar.

About the Author

Lisa A. EramoLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.


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Practice Management

Simplify the daily essential tasks of your medical office from patient records, to scheduling and more.

Electronic Medical Records

Improve patient care with electronic charting, electronic prescribing and medical labs interfaces.

Medical Billing & Collections

Streamline your entire medical billing and collections process from charge entry to reporting.

Clearinghouse Services

Integrated electronic claims, electronic remittance advice and insurance eligibility services.

Analytics & Data

Store and access data with insightful reports, document management and faxing, and an integration