A new case study is now available for download in our Library. The case study details the experience of the urology practice of Dr. Cataldo Cacace in Union City, N.J. More than a decade ago, Dr. Cacace outsourced his practice's urology medical billing to PGM Billing to help overcome many challenges, including money lost to non-payments, delayed payments, a high rate of denials and insufficient claims follow-up.
Hear from Practice Manager Dolores Cacace as she explains why the practice is "very happy with PGM as our medical billing outsourcing partner."
To view the case study, click here (pdf).
Nearly 25 percent of the American Medical Association's changes to the CPT code set affect gastroenterology, according to an AMA news release.
AMA indicated that these substantial changes were a result of efforts to "revise gastroenterology codes to capture significant advances in endoscopic technology, devices and techniques."
In total, there are 335 code changes in new CPT edition. The revised code set should be used for claims filed as of Jan 1, 2014.
To assist in the transition to the revised gastroenterology codes, AMA developed a table, which can be viewed by clicking here (pdf), to illustrate the conversion to the updated codes.
If your facility performs gastroenterology billing, it is critical that you take these substantial coding changes into account. Failure to properly perform medical coding and billing can result in your leaving significant money on the table.
Facilities cannot afford to spend a significant amount of time ensuring it is collecting the proper — and maximum — reimbursement for the services provided to patients, which is why more and more practices and ambulatory surgery centers are outsourcing their gastroenterology medical billing. An experienced medical billing company will help increase a practice's and ASC's revenue by improving collection rates while reducing payment denials and delays.
Roey Hine is Senior Vice President, Client Services & Operations, for Physicians Group Management.
Q: What is claims scrubbing?
Roey Hine: Claims scrubbing is a review of billing data and claims prior to submission to clearinghouses and insurance companies. That review is performed to ensure the claim is accurate, complete and compliant upon first submission so that the insurance company perceives it as a clean claim and has no excuse not to pay it upon its initial submission.
Q: Why is claims scrubbing important?
RH: There are two reasons in particular: 1) so the practice gets paid promptly from the insurance company; and 2) so the practice doesn't incur additional expenses in personnel time, claims clearing costs and delay of payment associated with handling a denial on the back end and needing to clean the claim up and resubmit it. We want to get paid on the initial claim and reduce expenses that are created by appeals, denials and resubmissions.
Q: How do you ensure a submitted claim is accurate?
RH: The rules we follow are the National Correct Coding Initiative (NCCI) Edits, developed by CMS. Scrubbing makes sure the data is complete, and the next step would be to determine whether the data passes certain tests: Are codes bundled or unbundled? Does the code require any modifiers? Does the diagnosis support the service being provided? In summary, does the claim meet the CCI edits?
Q: What approach does PGM take to scrubbing?
RH: At PGM, there are three levels of claims scrubbing designed to ensure claims submitted are as accurate, complete and compliant as possible. The first test takes place when billing data is imported or entered into our system manually. The system is designed to flag any mandated fields that are incomplete or missing.
The second level here at PGM involved our skilled account representatives. Every PGM account has a designated account representative who has knowledge of the practice and the practice specialty(s). This rep performs a visual review of all of the transactions to identify any transactions that may need refinement or correcting based on the representative's knowledge. For example, let's say a primary care practice submits an office visit and a procedure code done on a same day with separate diagnosis, and the office visit code should have a modifier -25 appended to it. If that's missing, the account rep, with knowledge of primary care coding rules, would add the modifier -25 prior to submitting the claim. The inclusion of modifier -25 would tell the insurance company that the office visit was separate from the procedure and should be payable separately.
After claims are processed at PGM, the third level of scrubbing occurs when the claims are run through a software edit through our clearinghouse. This checks to make sure the diagnosis supports the service and make sure the codes are not unbundled based on the CCI edits. That's done instantly after claims are run, and we are provided an opportunity, if necessary, to correct the claim before it's submitted to the insurance company.
The U.S. Department of Health and Human Services (HHS) is more closely scrutinizing services billed at physician reimbursement levels but performed by nonphysicians, according to a Medical Economics report.
HHS indicated its intention to take a closer look at these "incident-to" services, which are often performed by nurse practitioners and physician assistants, in its Office of Inspector General's 2013 Work Plan.
According to the Work Plan, the HHS "... will review physician billing for 'incident-to' services to determine whether payment for such services had a higher error rate than that for non-incident-to services. We will also assess Medicare's ability to monitor services billed as 'incident-to.' Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident to a physician office visit. A 2009 OIG review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician. We also found that unqualified nonphysicians performed 21 percent of the services that physicians did not personally perform. Incident-to services are a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose beneficiaries to care that does not meet professional standards of quality."
Billing for "incident to" services are permissible under Medicare Part B as long as practices follow Medicare's criteria as identified by the American Academy of Physician Assistants in this report (which also provides answers to frequently asked questions about "incident to").
The five criteria are as follows:
The Office of the National Coordinator for Health Information Technology has released a free, downloadable guide designed to assist providers who plan to acquire electronic health record (EHR) systems.
The guide, titled "EHR Contracts: Key Contract Terms for Users to Understand," is intended to help buyers better understand critical EHR contract terms. As the report notes, "Understanding these terms may help you select an appropriate EHR system and protect your practice or organization from business and patient safety risks that may arise when you rely upon EHRs for critical aspects of your operations. It should help you make sure that your EHR system does what you expect and that you have ways to manage issues as they arise. If you misunderstand these terms you may not be able to rely on your contract to help prevent disruptions to your practice."
The contract terms discussed in the 25-page guide are as follows:
Each section explains what its term(s) mean and what EHR buyers and users need to know about how the term(s) may affect a contract.
To download the free guide, click here (pdf).
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