Refresh Your E-Prescribing Knowledge With This Advice

Medical Billing and Coding

Explore these incentives for adopting eRx.

In case your gastroenterologist's practice hasn't by now adopted electronic prescribing (ePrescribing or eRx) system in 2011, then you may be bound by a payment adjustment for Medicare Part B claims in 2012 and the future years. Read on this expert medical billing and coding article to know more about what these adjustments actually are and how you can circumvent them in the coming years and also take advantage from incentives CMS offers for e-prescribing.

If you have not by now implemented the e-prescribing system in 2011 (between Jan.1, 2011 and June 30, 2011) and not claimed for hardship exemptions by the prescribed deadline, then your practice will have to face a 1 percent adjustment in 2012 for all Medicare Part B claims. Your practice will evade the payment adjustments of 1 percent and will be entitled for an incentive of 1 percent of all Medicare Part B payments in case you have filed claims using the electronic prescription code G8553 (Prescription(s) generated and transmitted via a qualified eRx system or a certified EHR system) no less than ten times in the period between Jan.1, 2011 and June 30, 2011.

If you still fail to implement the electronic prescribing system in 2012, your practice might have to face additional payment adjustments of 1.5 percent in the year 2013 and 2 percent in the year 2014.

Medical Billing and Coding Update: You are also eligible for evading payment adjustments for 2013 in case you have made 25 claims using the e-prescribing code G8553 in the above-mentioned period in 2012.

Medical Billing and Coding Tip: Note These Enrollment Guidelines

The list of qualified professionals (EP) involve physicians and other recognized practitioners who fall under the purview of the Medicare Act who have prescribing authority in their scope of practice. Any EP can enroll for the eRx prescribing incentive program for their Medicare Part B claims. You are not required to pre-register to take part in the program. You are required to observe that 10 percent of your Medicare Part B covered claims should make up for codes in the denominator of the eRx measure.

Providers can report the eRx G-code with office visits, eye exams, psychotherapy or certain other services listed in the CMS e-prescribing measure conditions.

To ensure accurate medical coding and billing, you will be required to have a certified eRx system ready to enroll for the eRx prescribing incentive program. You can further check with your system vendor to make certain that the system meets all the requirements for e-prescribing. To meet the requirements for the incentive program, you will need to convey your involvement to CMS through one of the following methods:

• By submitting G8553 together with the service code on Medicare Part B claims. Keep in mind that the G code on the claim form must be charged $0.00 or if the system does not permit you to place $0.00, you must assign a very small value to it, for instance, $0.01 (this claim will not be paid out).
• On the other hand, you can submit your claims to a CMS qualified registry that is also partaking in the 2012 Physician Quality Reporting System (PQRS). Though, you must keep in mind that you must also be participating in the PQRS program to select for this system of submitting your claims.
• In case your practice has a certified electronic health record (EHR) system in place, you can submit your claims right to CMS using the system. Though, you will also have to be participating in the PQRS program to use this system for eRx prescribing.

Test Yourself: Can You Ascertain the Conditions for 'Additional Work Up' and 'Moderate' Decision Making?

Read the following scenario and determines which way you'd code.

Simply because of the fact that you code for your physician's E/M services each day doesn't imply they're always easy to resolve. Check out this real-life medical billing and coding scenario and decide how you would code it

The family physician examines an established patient for a new problem. The documentation is: Diagnosis: abdominal pain. Patient does not wish to work up today. Suspect ovarian cyst. In case pain persists tomorrow, she will call and plan pelvic u/s or CT hinging on sx at that time. Patient agrees, does not want pain pills. She will take ibuprofen."

How would you code this particular medical billing and coding encounter?

Answer: This situation signifies moderate medical decision-making. You have an undiagnosed, novel problem with an indefinite prognosis.

At first look, you might think this is just a small problem as the provider didn't push for testing and was okay with the patient going home to take over-the-counter ibuprofen. However as there was no conclusive diagnosis, and the option of testing, you must consider this a 'new' problem even without a work up.

Another problem with no diagnosis backs moderate complexity medical decision making both in terms of the diagnosis as well as management options and in terms of the danger involved. As the level of medical decision making involved depends on meeting two of the three medical decision making elements (i.e. diagnosis and management options; amount and complexity of data reviewed; and risk), this medical billing and coding documentation seems to support a moderate level, although the amount and complexity of data reviewed is minimal or none.

Code check: E/M code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) maintains "medical decision making of moderate complexity," however that should neverbe your automatic code choice. In case this instance were on your desk, you would require verifying that the physician also reached the level of "detailed" history or exam prior to you could submit 99214.

Medical Billing and Coding Tip: In case you can't support a comprehensive history or exam to go with the moderate level of decision-making, you'll be required to drop back to 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making). Based on the documentation, you can conclude at least a problem-focused history. Include diagnosis 789.0x (Abdominal pain).

Physician Billing: Stay Away from Modifier 24 Myths

If you want to ensure you get paid for services your physician carries out after a major procedure while you are still billing in the global period of the procedure, you need to be well-versed with modifier 24. Even veteran billers fall prey to modifier 24 confusions.

So it's very important that you stay away from these myths – if you are to stay away from the billing trap.

You should only add modifier 24 to a proper evaluation & management code when an evaluation & management service takes place during a postoperative global period for reasons unrelated to the original procedure. Modifier 24 tells the payer that the surgeon is seeing the patient for a just-in problem. As such, the plan shouldn't include the E/M service in the earlier procedure's global surgical package.

This modifier is only for use on E/M codes and only for use during the post-operative period.

Rule: During the global period you can't bill separately for E/M services relating to the original surgery. The global surgical package includes routine postoperative care during the global period.

What's more, modifier 24 also applies to services your physician carries out post the surgical procedure. If your physician carries out an evaluation & management service prior to a procedure on the day of that procedure, you'd need a modifier 25 or the modifier 57.

Do not assume you can't bill separate services using modifier 24

You shouldn't think that just because you cannot bill separate services using this modifier because a patient was slated to come into your office for a follow-up visit related to the surgery.

Vitiligo Treatment : Know Whether to Apply 96900 or 96910

Avoid misrepresenting phototherapy services and know what dermatology codes apply

You need to examine your dermatologist's documentation to define what type of light, wavelength, and materials he used while providing phototherapy treatment to vitiligo /dychromia patients. Read this article to know what dermatology codes you should choose in such a case and how to overcome both E/M and multiequipment correct coding initiative (CCI) challenges.

In case you are charging for an office visit on the same day as phototherapy, the reimbursement might depend on the fact whether your physician's documentation includes a different diagnosis code. Experts maintain that the payers might reimburse at times if the doctor examines the patient for a different problem, hence with a different diagnosis code.

For patients having vitiligo (709.01), your dermatologist might use narrow band UVB phototherapy. The phototherapy is administered for two to three times per week for several months until the patient attains repigmentation of the skin. For this procedure, you need to pinpoint what types of phototherapy, UVA or UVB, the physician used as well as the varying wavelengths.

In case your dermatologist used tar or or petrolatum with the light treatment, you should code 96910 (Photochemotherapy; tar and ultraviolet B [Goeckerman treatment] or petrolatum and ultraviolet B). Through this procedure, the dermatologist runs ultraviolet B light, with dosages cautiously increased as the treatment develops, resulting in longer times spent under the light source.

You should report 96900 (Actinotherapy [ultraviolet light]) in case the patient applies the treatment herself.

Note: You should always check with your payer for their rules.

In case, your dermatolist prescribed psolarens combined with ultraviolet A (UVA) light therapy, you should use 96912 (Photochemotherapy; psoralens and ultraviolet A [PUVA]). If your dermatologist doesn't use tars, petrolatum or psolarens with the light treatment, the code that remains is 96900.

The difference: UVA phototherapy is generally given with a lightsensitizing tablet named psoralen (PUVA therapy). Occasionally a light-sensitizing cream or lotion having psoralen is used in localized skin areas (for instance feet [topical PUVA]). On the other hand, UVB phototherapy uses the sunburning part of the UV spectrum.

Don't take risks: If you code either 96910 or 96912 when your dermatologist uses merely a light source in the treatment or the patient applies a topical agent, you could be accused of misrepresentation of service. It could be a fraudulent claim under the Federal False Claims Act.

Want to get more tips like these to master dermatology medical billing and coding? Click here to read the entire article and to get access to our monthly Dermatology Coding Alert: Your practical adviser for ethically optimizing dermatology medical billing and coding, payment, and efficiency for dermatology practices

Medical Coding & Billing: Tips to Improve Your Appeals Process

A particular practice after ensuring it has not made any medical coding and billing entry error automatically appeals payer denials using a standard letter. However this wasn't working in getting them their payments. The question is: How can it boost its appeals process?

Well, before starting the appeal process, one needs to check the payer's policies first. Say for instance if the payer has a policy that bundles dipstick urinalysis (81002) into any evaluation & management services carried out on the same day and will not be reimbursed separately, one should not appeal these. Writing appeals takes up a lot of time. As such you wouldn't want to waste time on appeals you cannot win since already there is a specific policy in place.

What you should do:

Next time, you should follow the payer's appeal procedure just as it is. Many a time, the address to submit appeals is different from the claims address and some payers require you to send a special form with the appeal.

Being specific is the key:

In place of sending a generic appeal letter for every denial, you can customize your letter with the proper key words for each situation. Say for instance you submitted a claim for an evaluation and management service and injection on the same date. You added modifier 25 to the evaluation & management service code, however the payer still denied it.

Here's what you can do: Instead of sending a letter saying 'the claim was submitted correctly', send a letter that addresses the specific claim and the specific reason why modifier 25 was spot on. What's more, you should quote industry guidelines (say for instance CPT and/or CMS guidelines) and if likely the insurance company's own guidelines.

Appeal letter tips: Writing an appeals letter can take up a lot of your time. However you can save time by figuring out your most frequent denials and creating fill-up-the-gap appeal letters for each of these situations.

Say for instance you may find that you get many denials for bundling issues even when you use modifier 59 correctly. Most probably the letters you put together will begin and end basically the same. By creating a base template you can focus on filling in the details for each claim instead of writing each one from scrape.

Medical Billing & Coding: Go for a Code Based on PMFSH Element Needs

Physician billing tips to save precious dollars for your practice.

Not billing higher level E/M services because your physician glosses over a patient's past medical, family, and social history (PMFSH)? Well, you could be missing out on up to $69 per E/M if you are not doing so.

In order to ensure you're recognizing every history component the patient mentions, you need to heed these three key things: Determine the level of MPFSH, select a code based on PMFSH Element Requirement and count unchanged PMFSH in current encounter.

After you determine the level of PMFSH your physician documentation contains, you can see which codes that history element supports. Let's zoom in on this aspect:

Watch out: If your physician doesn't document any PMFSH elements, you can see which codes that history element supports. This means the highest codes you will be able to report are a level-two new patient code (99202) or a level-three established patient code (99213). Reporting 99202 will fetch you $71.01, while 99213 will bring in $68.97.

Relevant past medical, family, and social history supports a detailed history level; with detailed history you can report a level-three new patient code (99203) and a level-four established patient code. You will take home $102.95 for 99203 and $102.27 for 99214.

In order to get to level-four and five new patient visits and level-five established patient visits, you need to have an all-encompassing level of history. For that, you must determine complete PMFSH in your physician's documentation. If you can get 99204 or 99205, you will take home $158.33 (4.66 RVUs) and $197.06 (5.8 RVUs), in that order. You can anticipate $137.60 (4.05 RVUs) for 99215 – as much as $69 more than if you are obliged to code 99213 as you did not have adequate PMFSH.

Remember: As established patient office visits need two of three vital components, a higher level service is still possible based on the service's examination and medical decision making (MDM) types. For an established patient, you may decide to leave history off and count only the exam and MDM and then you have the low history. As such, if you have a weak history, you may still get to the higher level evaluation & management.

Medical Billing & Coding: Don't Let Your Compassion Wreck Havoc on Your Payments

If your compassion's letting patients off the payment hook, it's time you took some action. Here's a medical billing and coding case study to help your understanding.

In a particular scenario, a physician tends to quite a few patients who were released because a local company shut shop. However, the physician wants to see those patients and also wants to ignore their copayments and deductibles.

Healthcare billing predicament: The physician wants to send the patient two bills, however he also wants them to ignore them. He wants the biller to write off the 'bad debt' after the second bill's sent out.

Here are three tips to ensure you are not setting yourself up for major troubles:

Stay away from potentially fraudulent exceptions

You should never tell patients to ignore the bills you send because you will write off the charges sooner or later. Although waiving of a fee for a professional courtesy or financial hardship may be nice, you may land yourself in a soup.

Reason: You must make a good faith effort in order to collect from your patients. Most practices send at least three statements to a patient to try to collect on an outstanding bill. It depends on your practice of how you make the good faith attempt.


What you need to do: Document your efforts – that's what you need to do.

Not only do you run the risk of hurting other patients who could not find out about the unfair policy, you could also be violating your payer contracts or even anti-kickback laws. You need to check your contracts with the insurers. Find out whether it's a violation to let go of these fees. You should not try this with federal programs. You may end up paying a heavy amount as the anti-kickback statute carries stiff fines.

In case you do waive payments, keep proof of financial hardship

You shouldn't think that you can write off a patient balance. If you have patients who cannot pay their balances owing to financial hardship, then you might want to consider writing off the balance after you've made an attempt to try to collect and you have got proof of financial hardship.

If your practice wants to write off a patient's bill owing to financial hardship, the patient needs to be able to prove he's unable to pay. For this, you should ask the patient to provide you with information like gross monthly income, assets, monthly household expenditures and number of dependants.

Your collection processes should be consistent

You also need to apply a consistent collections policy to all of your patients. If your normal process is to send a patient to collections if they do not shell out money, you have to follow the same medical coding guidelines( source "http://www.supercoder.com") with this patient.