When a chiropractor finds it necessary to adjust all 5 regions of a patients spine, he or she must be sure that the clinical documentation supports this code completely. 98942, 5 region chiropractic manipulation, is becoming a target for audits by Medicare and other payers. The reason for this is that payers have determined that many providers adjust all of the regions of the spine without documenting actual medical necessity for doing so. This makes for an easy denial and if documentation is not thorough, appeal may be impossible, and if this is frequently the case, an audit may be triggered.
When billing code 98942, be sure your documentation indicates a chief complaint by the patient stating they are experiencing pain or discomfort in, or injury to all five regions. Not only should a supporting chief complaint be documented, but clinical findings should also support the adjustment of all 5 regions, and a care planned should be outlined with subsequent clinical progress documented throughout continued care. Be sure to include diagnosis codes specific to each of the 5 regions in your documentation and on your claim. All of these factors should come together and provide support your billing, despite which code you choose to bill. Denials and audits happen, even if you are doing everything right. Don’t make yourself a target for auditing.
Protect yourself and your practice by being thorough and enjoy worry free patient care.
Keeping your Accounts Receivable, A/R, in check is absolutely key to running a successful practice. Letting outstanding balances get out of control is equal to throwing money away. Developing a system for addressing balances and making it a mandatory part of your office management routine will ensure no revenue slips through the cracks.
A/R can consist of both insurance balances, i.e. unpaid claims, as well as patient balances.
To manage your patient A/R effectively, you must understand eligibility and benefits, and you must be ready to enforce a strict collection policy and collect balances up front.
This begins with the basic knowledge that if the patient doesn’t have coverage, the claim isn’t going to get paid by the insurance company. So make verifying benefits and eligibility a priority before the patient walks through the door. This will avoid unnecessary denials and wasted time. Know which services will be covered and which won’t and discuss with the patient to be clear about their coverage. They may opt to receive a non-covered service and pay out of pocket. Also, be ready to explain to the patient what their financial responsibility will be for the services they are going to receive prior to the service being rendered. This means no surprises for the patient and less time spent chasing copays and co-insurance after the visit. Enforce a strict collection office policy and have a sign posted stating that all balances are collected at the time of service. Regular patients will become used to this policy and will arrive ready to pay. Also, have a collection plan formulated and address all patient balances in a timely manner. This includes sending statements on a regular basis and tracking outstanding balances, and even making phone calls to patients who are delinquent. It is a common practice to employ a collection agency to pursue balances that remain outstanding. And finally, know when to let a balance go. Time is money, and if you are spending more time than it is worth on an unpaid balance, it may be more cost effective to write it off and direct valuable time to balances that are more likely to be paid.
Managing insurance A/R effectively starts with understanding the billing process as a whole, and the revenue cycle of the claim.
The most important step in medical billing is ensuring accuracy. Assign CPT and ICD codes accurately and be sure medical documentation supports both. Inform yourself regarding what codes are covered by each insurance to avoid submitting non-payable services that would be written off anyway. Be sure all patient information included on the claim is accurate and complete to avoid denials for invalid or missing information. Secondly, submit your claim immediately. Once documentation is complete and the proper codes are assigned, get the claim out to the payer without delay. This will avoid dealing with timely filing issues, which could result in an unnecessary need to write off a balance that could have been paid. Thirdly, address denials in a timely manner. If you do not understand the reason for denial, call the payer to clarify. If an appeal is necessary, do not delay in submitting it as there may be a time limit. Include all documentation and any additional information that may be needed to ensure payment.
Lastly, track balances closely and run an A/R Aging report on a regular basis so nothing slips through the cracks, and balances don’t build up and become overwhelming. These reports can be filtered by patient balances or insurance balances. Address the oldest first and know when to write an unpayable balance off.
When managing your Accounts Receivable, organization is your biggest ally. Track claims and patients balances with diligence and develop policies and procedures and make them part of your office routine to ensure any issues are addressed regularly and without delay. Time is of the essence in medical billing, so stay on top of your A/R and keep that revenue flowing.
As a HIPAA Covered Entity, all providers must have a BAA, Business Associate Agreement, in place with any employee, contracted or otherwise, who may have access to patient’s PHI, or Protected Health Information. This is includes assessing the potential risks to data, and ensuring the follow through of BAA stipulations. This is especially important in todays age of technology, where patient data is stored and accessed through a number of different technological sources. Check out this article below and take the time to update and renew all of your BAAs. Don’t be caught without one!
As we all know, a partial freeze of updates to the ICD code set was implemented in the anticipation of ICD-10 in order to ease the strain of providers adjusting to the change which included an entirely new coding system with thousands of new codes added. The ICD code sets had not been fully updated and revised on an annual basis since 2011, limiting updates and revisions only to those code sets affected by new technology and diseases.
This, plus the grace period implemented by CMS allowing claims to process if a code in the same diagnosis code family was used, padded the shock and stress that providers felt towards adapting to the changes of ICD-10.
The decision has been made to proceed with annual changes and updates to the code set. As of October 1, 2016 not only will the grace period end, regular annual updates and revisions to ICD-10 will begin. This will mean providers and staff will need to stay abreast of these changes and be aware that the need to be accurate and specific with diagnosis coding is more important than ever. With every revision and update, codes are added and deleted. Be sure you are using the most current version of ICD-10 to avoid denials and rejections. Choose the most specific code available, avoid using other and unspecified codes, and as always, document, document, document!
Claim denials cost providers thousands in lost revenue each year. Many of these denial decisions can be fought and even overturned often by simply knowing the rules and being proactive.
Some of the top reasons for denials in the medical billing industry are eligibility, non-covered services, bundling, and lack of proven medical necessity.
Addressing eligibility issues is the easiest way to avoid unnecessary denials. Prior to a patient’s initial appointment, eligibility should be verified to insure that the policy is, in fact, in place and active. Obtain all pertinent information from the patient during their phone call to schedule their first visit, including full name, date of birth, and insurance ID, and be sure all information is taken down exactly as it appears on their ID card. You’ll want to contact the insurance plans provider services and verify the policy’s effective date and that the services you plan to provide are covered by their plan.
Knowing what services are covered by each patients plan is one way to stay ahead of the denial game. With so many plans out there today, it’s difficult to keep track of the benefits covered by each plan. Be sure you are using the most accurate and correct CPT codes when entering information on the claim form and that your attached diagnosis supports the procedure to be billed. If you discover that a plan does not provide benefits for the diagnosis used, take another look at the medical notes that were documented for the visit. You may substitute another diagnosis if the condition was present and documented for that visit and submit a corrected claim with the updated information. If the plan does not cover the service at all, discuss this with your patient. He or she may decide to receive the service anyway and agree to pay out of pocket. Just remember to have them sign a non-covered services waiver, or an ABN form, attesting to their agreement to be financially responsible for payment.
Bundling services means billing for additional services that are considered included in the primary procedure billed. You can check to find out whether you are bundling services by referring to NCCI, or National Correct Coding Initiative, edits. This table can be found on the CMS website and will clearly tell you whether the codes to be billed are not allowed to be billed together or require a modifier in order to be billed during the same visit. Be familiar with your modifiers, you may need to add a 25 or a 59 to your primary procedure, or one of the Medicare X- modifiers. If you check your NCCI edits, and there are no stipulations regarding billing the two codes together, appeal a denial with supporting documentation. Always fill out the correct appeal form for each payer completely and accurately and attach all supporting documentation as well as a HCFA claim form and the original denial. Be aware that payers will only accept appeals within certain time limits from the denial determination.
And finally, services lacking medical necessity can be the most difficult to dispute. The original documentation must support the service billed, and any procedure deemed cosmetic or maintenance care may be denied without recourse. Also, know the policy limitations of the services billed, it’s possible that the procedure will only be paid a certain number of times per year or a certain benefit limitation may apply, such as maximum dollar amount paid. Be thorough in your initial documentation, and never alter documentation after the claim has been billed. Be sure your diagnosis supports the procedure code billed and that it is accurate to the patients condition. It is never okay to use an inaccurate diagnosis specifically in order to receive payment. If a claim is denied for medical necessity but the you feel that it was necessary, don’t hesitate to initiate a clinical appeal, with a letter written by the provider explaining why the service was needed and include all supporting documentation.
Tackling denials can be a daunting task, especially if you are new to the game and a lot of money can be left on the table when you are unsure of how to proceed. Always call the insurance company and verify the denial reason, it may reveal some otherwise unknown aspect of the denial and facilitate reconciliation. And yes, sometimes insurance companies make mistakes and a simple phone call to reprocess the claim is all it may take. Always be one step ahead by staying educated, being organized and prepared, and knowing the rules. Be confident and don’t hesitate in seeking the help and the tools you need to get the job done.
Now go get ’em!
HIPAA is the Health Insurance Portability and Accountability Act, put into place in 1996. Title II specifically deals with privacy and is something to be taken very seriously in today’s age of electronic workplace management.
Title II of HIPAA has enforced the establishment of a set of standards regarding electronic transactions of health care related information, this includes requiring national identifiers being assigned to all providers, health plans, and employers.
HIPAA is designed to protect the privacy of individually identifiable health information, or PHI, which is often transmitted electronically to health care plans and used to process claims and issue payment by a “covered entity”, i.e. health care provider, clearinghouse, and health plan. PHI is any information that identifies a patient, such as demographic information, or any information relating to a patient’s condition or care. It is the responsibility of covered entity to follow all rules and regulations to ensure confidentiality and integrity of this information. Covered entities must also have in place procedures to maintain compliance at all times, such as identifying risks, creating a compliance plan, assigning a security officer to oversee compliance and to perform internal audits, and having a business associate agreement with any outside contracted employees.
Simply put, as a health care provider, you must be familiar with all requirements and stay active in keeping your staff trained and aware of HIPAA compliance. Have technical and physical security measures in place to protect PHI. Limit communications of PHI to secure areas such as EHRs, and Practice Management software which are password protected. Never email or text any patient information or identifiers, and make patient privacy a top priority in your practice. Your patients will love you for it!
Refer to HHS.gov for information on how you can stay compliant.