The Value of Outsourcing Cardiology Specialty Billing Amidst Changes to Medicare Reimbursement Rates

Any revision in Medicare reimbursement rates will have a direct impact on physicians’ medical billing, and cardiologists are not immune to the effects of frequent changes in Medicare reimbursement rates, announced by The Centers for Medicare and Medicaid Services (CMS) from time to time. While cardiologists or their billers could anticipate the extent of earlier revisions with a fair degree of accuracy, they might not have imagined what they would be encountering in 2013 – as per CMS would have to be prepared for a 2 percent cut over and above the possible 26.5 percent cut to fix Sustainable Growth Rate (SGR) formula. In addition to these general revisions, sweeping changes in rules governing evaluation of coders for certain high percentage cardio-vascular procedures, multiple procedure payment reduction, PQRS and e-prescribing, and value-based modifiers may potentially squeeze cardiologists’ revenues or operational margins.

One of the major changes that may hit cardiologists hard is the creation of new codes and payment levels for certain complex yet frequently encountered procedures. These new evaluation codes could potentially reduce payments from 20 to 27 percent depending on procedures. While representatives are negotiating with CMS for a more rational evaluation system, cardiologists or cardiology specialty billing will continue to be affected till such time when it may be revisited.

Another major concern comes from the CMS’ scheme for implementing a multiple procedure payment reduction to cardiovascular services. This could mean a reduction as high as 25 percent on the technical component of a service relatively less expensive than services performed on the same day. While this may not apply to office visits, most of the cardiovascular diagnostic and therapeutic services that happen to administer multiple services on the same day will certainly have to forgo a major chunk of their reimbursements.

As usual there would be bonus or penalty depending on compliance or non-compliance with PQRS and e-Prescribing – CMS has already made clear that cardiologists will receive 0.5 percent bonus for successfully participation in PQRS, and also be vulnerable to 1.5 percent penalty or reduction for non-compliance PQRS and e-Prescribing standards.

And, value-based modifier that adjusts payment for quality and cost of care could either enhance or decrease the eventual payouts to cardiology practices. While this system is not yet mandatory, you never cardiologists may soon be asked to be part of it under Account Care Organization (ACO) model.

Amidst these sweeping payments changes, cardiologists could be vulnerable to revenue losses, which in turn might jeopardize their sustenance and growth plans. This concern necessitates the significance of cardiology specialty billing that is competent enough to keep cardiologists’ revenue health positive despite the inevitable Medicare cuts.

Medicalbillersandcoders.com has successfully mediated physicians’ medical billing outsourcing decisions in the past; majority of Medical Billing Practices in varied disciplines across the 50 states in the U.S. have made use of our platform to source the right and competent medical billing professionals. Given our equally commendable cardiology-specific billing experience in the past during times of critical medical billing issues, cardiologists should be able to respond instantly and amicably to these Medicare-dictated billing challenges, and keep their practices clinically and operationally efficient.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Complications in Clinical Documentation Leading to Inaccurate Billing Codes

Clinical documentation is a need that threads through the entire lifecycle of an inpatient treatment episode. The clinical documentation specialist checks the documents of a patient before or within 24 to 28 hours of admission to assess various aspects of the patient’s condition, reviews documents every two to three days, during patient stay, to check their progress, accuracy and assign proper diagnosis related group (DRG). Based on assessment, the clinical documentation specialist also sends feedback to the physician who corrects things if necessary before the documentation is used for preparing reimbursement claims.

As is evident, clinical documentation requires extensive documentation of treatment procedures together with their relationship to be used for preparing reimbursement claims. Seen from a reimbursement claim standpoint, anything that’s not documented doesn’t exist and such are coding complexities that the presence or absence of any fact in documentation affects the choice of code later, making it either accurate or inaccurate. This has become more so since the expected implementation of ICD-10-CM.

ICD-10-CM is much more nuanced than ICD-9-CDM. Whereas ICD-9-CDM included 59 codes for diabetes, ICD-10-CM has more than 200 codes for it. Additionally, for diabetes, ICD-10-CM has added a new provision called ‘poorly controlled’ to the already existing provisions under ICD-9-CDM, controlled and uncontrolled. 

Similarly, ICD-10-CM has also increased the number of categories for injuries to cover a larger set of possibilities and arrest the nuances of a wider range of physical specifications of an injury. For example, apart from various details to ascertain the character of an encounter, the ICD-10-CM requires the coder to code the size and depth of an injury. Also, ICD-10-CM contains multiple combination codes to account for relationships between various conditions. After wading through these details, it is not very pleasant to be reminded that the source of these codes is clinical documentation.

Effective clinical documentation requires a grid-like structure underneath the day-to-day healthcare activities involved in an inpatient treatment episode which will arrest medical details, record them and pass them through various phases of the treatment terminating with the discharge of the patient. This process has to be a mix of human effort (to interact with various parties involved) and technology (to record details and facilitate coordination among various specialties – healthcare and otherwise – that interact during the course of a treatment).

MBC’s Revenue Management Consulting can help you with this by performing a thorough analysis of your revenue management cycle and lubricating various points of interaction it has with other areas of operation ensuring smooth flow of data. This involves identifying gaps in your process and addressing them by replacing, if necessary, old software applications with new ones, blocking areas of revenue leakage and identifying areas of staff training.

Medicalbillerandcoders.com, the largest consortium of billers and coders in the US, has helped medical practices improve their finances by its Outsourced Billing and coding services which involve development of accurate electronic billing, intricate procedure coding, electronic filling of claims and a multi-layered application process - collectively resulting in reduced claim denials and enhanced core-business focus.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Tackling Reimbursement Challenges posed by Inpatient Coding with Professional Medical Billing and Coding!

Clinical documentation is a need that threads through the entire lifecycle of an inpatient treatment episode. The clinical documentation specialist checks the documents of a patient before or within 24 to 28 hours of admission to assess various aspects of the patient’s condition, reviews documents every two to three days, during patient stay, to check their progress, accuracy and assign proper diagnosis related group (DRG). Based on assessment, the clinical documentation specialist also sends feedback to the physician who corrects things if necessary before the documentation is used for preparing reimbursement claims.

As is evident, clinical documentation requires extensive documentation of treatment procedures together with their relationship to be used for preparing reimbursement claims. Seen from a reimbursement claim standpoint, anything that’s not documented doesn’t exist and such are coding complexities that the presence or absence of any fact in documentation affects the choice of code later, making it either accurate or inaccurate. This has become more so since the expected implementation of ICD-10-CM.

ICD-10-CM is much more nuanced than ICD-9-CDM. Whereas ICD-9-CDM included 59 codes for diabetes, ICD-10-CM has more than 200 codes for it. Additionally, for diabetes, ICD-10-CM has added a new provision called ‘poorly controlled’ to the already existing provisions under ICD-9-CDM, controlled and uncontrolled. 

Similarly, ICD-10-CM has also increased the number of categories for injuries to cover a larger set of possibilities and arrest the nuances of a wider range of physical specifications of an injury. For example, apart from various details to ascertain the character of an encounter, the ICD-10-CM requires the coder to code the size and depth of an injury. Also, ICD-10-CM contains multiple combination codes to account for relationships between various conditions. After wading through these details, it is not very pleasant to be reminded that the source of these codes is clinical documentation.

Effective clinical documentation requires a grid-like structure underneath the day-to-day healthcare activities involved in an inpatient treatment episode which will arrest medical details, record them and pass them through various phases of the treatment terminating with the discharge of the patient. This process has to be a mix of human effort (to interact with various parties involved) and technology (to record details and facilitate coordination among various specialties – healthcare and otherwise – that interact during the course of a treatment).

MBC’s Revenue Management Consulting can help you with this by performing a thorough analysis of your revenue management cycle and lubricating various points of interaction it has with other areas of operation ensuring smooth flow of data. This involves identifying gaps in your process and addressing them by replacing, if necessary, old software applications with new ones, blocking areas of revenue leakage and identifying areas of staff training.

Medicalbillerandcoders.com, the largest consortium of billers and coders in the US, has helped medical practices improve their finances by its Outsourced Billing and coding services which involve development of accurate electronic billing, intricate procedure coding, electronic filling of claims and a multi-layered application process - collectively resulting in reduced claim denials and enhanced core-business focus.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Solving the ‘Secondary Insurance’ puzzle at your medical practice

Care providers encounter patients with more than one level of health insurance coverage – a secondary insurance to complement primary insurance. While secondary insurance has considerably reduced patients’ out-of-pocket expenses and facilitated treatment plans outside primary coverage, billing for two-levels of insurance coverage has not been that easy. Even as certain secondaries to Medicare are enabled with automatic crossover to Blue Cross and Blue Shield and require no additional pursuance, majority of big and small private insurance plans continue to be unlinked with Medicare or Medicaid primary coverage. It is this isolation of secondary plans from primary that makes billing secondary insurance more difficult.

Irrespective of whether primary insurance is automatically linked to secondary insurance, it is the responsibility of care providers to arrange for co-ordination. Often, it is the insurance verification, billing, and follow up department that takes up the responsibility of coordination of benefits. Strangely, a large of proportion of relatively smaller secondary bills is never pursued or delayed till they become ineligible to be reimbursed. The collective value of such omitted secondary bills may be thousands of dollars per physicians. Therefore, with so much of hard-earned practice revenues going unrealized, physicians need to investigate and formulate corrective measures to follow up and realize secondary bills in time.

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One of the primary steps to monitor secondary bills is to have access to your patient accounts and system reports that show balances and your aging out Secondary Insurance Account Receivables (A/Rs). If you see certain bills approaching or just about to cross 90-day limit, it should be alerted immediately to your billing department for immediate follow up with secondary insurance carriers. Second, more than alerting your billing coordinating department of aging secondary bills, you should try to extract reasons for delay in reimbursements, and advice your staff for corrective measures based on the facts responsible for such delay. Third, once you have found out aging secondary bills, and advised your billing department to follow up with requisite modification or proof, it is important that they are pursued within the stipulated time limit, usually within 90-days from the date of billing. Last, it is always good to have a periodic review of your billing practices, particularly secondary insurance bills. Periodicity may range depending on the volume of secondary bills or ideally once every month. Review is an apt way to monitor the progress on secondary claims, and keep your practice’s financials healthy. In addition to challenges mentioned above, secondary insurance may have policy-specific, provider-specific, and region-specific demands. And, if you happen to be a care provider dealing with multiple insurance networks and operating across multiple clinical destinations in the U.S., you may have to be conversant with these diverse requirements. It is these multiple challenges that warrant the intervention of an external medical agency in your internal medical billing practices.

Medicalbillersandcoders.com has traditionally been care providers’ first choice in medical billing and coding; care providers of varied sizes and disciplines across the 50 states in the U.S. have found our services catalytic to their clinical and operational efficiency. And, at a time when they need their secondary billing mediated more than ever before, our resourcefulness – competent billing professionals with credentials in maximizing secondary insurance reimbursements – in secondary billing should be comforting.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Pre-empting malpractice liability risk with superior EHR systems

Electronic Health Record system (EHRs), which is the next order in clinical and operational documentation, is perhaps one of the significant technology additions to have happened to the health care industry. While care providers seem to have been convinced of its ability to elevate clinical and operational efficiency to a new level, they may still be inheriting malpractice liability risk more than ever before. Amongst many things that are intrinsic to EHR system, transition, design, implementation, application, and control issues threaten physicians’ immunity against lawsuits with respect to breach of HIPAA-mandated patient privacy and security.

As physicians begin to transit from manual to EHR-managed data centers, patient-specific data may be vulnerable to proliferation, exclusion, or faulty conversion during the process of transfer from paper to electronic medium. As a result of this inappropriate conversion, patients’ clinical management may suffer from inaccurate clinical decisions. When patients’ care gets compromised on account of such inapt transition, physicians will certainly be held accountable legally. Therefore, it is important to undertake data transition comprehensively as well as have an EHR system that can entirely accommodate such data transfer.

More than being liable for lacking in data conversion, it is the choice your EHR design, customization, and implementation process that could either make or break your case – those EHR systems that tend to deviate from HIPAA’s requirements may spell trouble for physicians who happen to own them or may be opting for such EHR platforms without knowing the eventual consequences. Therefore, it is essential that you exercise caution before deciding on an EHR platform – it is not the price or somebody else’s provocation that should drive your decision but how far you can sustain integrity in clinical documentation.

Significantly, physicians may have to contend with control and security issues – with EHR systems chances of data proliferation, hacking, and unauthorized access are going to increase. Physicians – who are generally non-inquisitive of data coming in from EHR channels – may not entirely be informed of adverse happenings at their EHR systems. Therefore, more than being happy with implementation, it is important that you monitor the functioning of your EHR platform on an on-going-basis. It is also important that you commission a support staff that can conduct and protect EHR operations as required by HIPAA mandate.

Though a bill that protects providers from malpractice and other liability (if they happen to use certified EHRs) is being contemplated on, physicians would still have to continue to safeguard integrity and the accuracy of the patient’s medical record till then.

Medicalbillersandcoders.com is essentially helping out hospital management or physicians practices that may be vulnerable to EHR-specific malpractice liability risk. The significant advantage of partnering with us is our ability to leverage our tactical knowledge in EHR implementation with technology alliances with some of the best EHR manufacturers. More than getting your EHR systems customized, it is our catalytic role in assisting transition to EHR-enabled clinical and operational documentation that is instrumental in our being a leading consortium across the 50 states in the U.S.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.