Innovations for Revolutionary Billing and Collections

Transcription

1 Innovations for Revolutionary Billing and Collections Presented by Kathy Mills Chang, MCS-P and Becky Walter, MCS-P 66 Years of Chiropractic Billing Experience Our Plan for This Breakout Session Strategy, Organization, Productivity and Time Management Coding, Billing and Compliance Collections and Follow-Up Be the Financial Liaison Records Management and Appeals Not a Lecture! Hands-on learning Learn how you can lead and guide the financial side of the practice Be the eyes and ears of the doctor It s about implementation when you return to your office Administrative Time : Time spent on prevention and implementation that is not directly related to a service. Time spent during trainings, meetings, general planning, and time OFF the floor. One of the biggest offenses to organization Doctor admin time: marketing, Day 1.5, team meetings, planning Administrative Time TEAM KMC 1

2 General Team Member Admin Time Insurance Follow-Up Posting Payments Reactive and Proactive Calls Verification Collections Calls Recalls Doctor s PRN or Monthly Duties Mail Sorting = Efficiency & Effectiveness The KMC University Systems: Mail Sorting Create organization through the mailprocessing procedure Make sure you sort the mail so that you can manage it later Create four special categories of mail Four Categories of Organization RECEIVED Mail to go to the doctor Checks and zero pays to post and process Items that need a phone call to resolve Items that need an action to resolve TEAM KMC 2

3 End of Day Balancing Petty Cash Cash Till Balancing What Are Your Time Sucks? Let s Brainstorm! TEAM KMC 3

4 Action steps for next week? Next month? This quarter? Let s discuss Take-Aways? Coding is the language used to speak to insurers CPT = what I did ICD = what is wrong Both codes must tell the story Codes must be allowed in the review policy Coding Matters Code Accurately Accurate coding is important because each service provided by the doctor is represented by a specific code (a number) That number goes on your claim form and is read by a computer Therefore, you must be sure to provide the computer with the right numbers Codes Supported By Documentation Use codes that are supported by your documentation Select appropriate codes, utilizing your coding resources Know the documentation specifics for each code Evaluation and Management Coding Overview Most commonly used codes NP E/M codes Established pt. E/M codes Key components 1995 vs guidelines Evaluation and Management Coding New Patients New patient E/M codes Key components Three out of three components must meet or exceed to code it Perhaps the most undervalued code in your arsenal TEAM KMC 4

5 History Exam INPUT E/M Visit Clinical Decision Making OUTPUT #1 Documentation of History Each type of history that we will select will contain some of all of these subcomponents: Chief complaint (CC) History of present illness (HPI) Review of systems (ROS) Past, family, and/or social history (PFSH) Selection of Type of History E/M Coding Key Component #2: Examination Examination is the quantifiable portion of the E/M service Tests and measurements will be documented Four levels of E/M must be considered Problem-focused, expanded PF, detailed, comprehensive E/M Coding Key Component #3: Clinical Decision-Making #3 Documentation of Complexity of Clinical Decision-Making Three subcomponents determine the level of CDM This is the thinking part of the E/M code Think of this as the doctoring part of the service TEAM KMC 5

6 #3 Documentation of Complexity of Clinical Decision-Making #3 Documentation of Complexity of Clinical Decision-Making Clinical Decision-Making Matrix Time: The Wild Card! Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Minimal Minimal or None Minimal Limited Limited Low Multiple Moderate Moderate Extensive Extensive High Type of Decision Making Straight- Forward Low Complexity Moderate Complexity High Complexity Counseling and coordination of care Greater than 50% of the encounter is faceto-face Document well Follow the guidelines for time in E/M Coding rules TEAM KMC 6

7 CMT Codes : the basic building blocks and best description of the DC s work Most comprehensive physician code to describe chiropractic services Basic service around which everything else is built 5 Spinal Regions Regions Regions Regions Common Ratios % % % or less Extra Spinal Manipulation Regions: Head Upper extremities (shoulder to fingers) Lower extremities (hip to toes) Anterior ribs Abdomen Supervised Modalities do not require one-on-one contact by the provider Billed only once per encounter Code Mechanical Traction Code Electrical Stimulation is not billed for Electrical Stimulation in certain cases G0283 is used instead Presently, United Health Care and Medicare are the only ones requiring this Coding Oddities TEAM KMC 7

8 97012 Mechanical Traction Mechanical Traction A recent decision by the US District Court of the District of Rhode Island may have significant implications for doctors of chiropractic (DCs) across the country who bill for mechanical traction. In 2009, Blue Cross Blue Shield Rhode Island (BCBS RI) sued two providers in state court for allegedly fraudulently billing intersegmental traction as mechanical traction, CPT code Attorneys for the providers were able to successfully move the case to federal court where the judge in the case, Senior Judge Ronald R. Lagueux, found that the fraud claims were "completely preempted" by the Employee Retirement Income Security Act (ERISA). At the conclusion of the resulting bench trial, Judge Lagueux found that the services were correctly billed by the providers as mechanical traction and rejected BCBS RI's findings of fraudulent billing, stating that the plaintiffs "did no wrong." The case was argued on behalf of the plaintiffs by D. Brian Hufford of Pomerantz, Grossman, Hufford, Dahlstrom & Gross, LLP (Pomerantz), the same firm representing ACA and other plaintiffs in class action suits against United Healthcare/Optum and Cigna and ASHN. While this lawsuit was not the result of any action by ACA, it has been ACA's policy for over a decade that roller table type traction normally meets the requirement of autotraction, the use of the body's own weight to create the force" and therefore is properly coded, as the doctors in question had and the court supported, with While doctors of chiropractic should always verify coverage to determine each payer's specific reimbursement policy, this decision may have an impact on providers who have had reimbursement for traction recouped. Constant Attendance Modalities require direct one-on-one patient contact by provider These are timed codes Code manual electrical stimulation Code ultrasound Therapeutic Procedures Coding: Active Care Therapeutic Procedures are time-based codes The patient is active in the encounter Require direct one-onone patient contact by provider of the service Therapeutic Exercises Develop one functional parameter: strength, endurance, range of motion, or flexibility Treadmill for endurance Isokinetic exercise for ROM Lumbar stabilization exercises for flexibility Stability ball to stretch or strengthen Neuromuscular Re-education Used to describe those activities that affect proprioception Balance Coordination Kinesthetic sense Posture TEAM KMC 8

9 97530 Therapeutic Activities Used when multiple parameters are trained, including balance, strength, and range of motion Must be related to a functional activity with direct functional improvement expected Use Outcomes Assessment Tools. Opportunities Average of 150 PV per week Average reimbursement for = $35/unit 40% of office visits per week participate in active care rehab = 60 OV/week What s Possible 60 OV X $35 = $ per week income 4.2 weeks per month = $ per month income 52 weeks per year = $109, per annum Group Therapy When supervising more than one individual, for a service that requires direct supervision, use code for each patient For example, if NMR is performed in a group setting, use code do not use and at the same time Billed once per session Constant Attendance - Not On-on-One S Codes Non-Medicare, temporary national codes. These S codes are used by the Health Insurance Association of America and the Blue Cross Blue Shield Association to report drugs, services, and supplies for which there are no national codes but for which codes are needed by the private sector to implement policies, programs, or claims processing. They are for meeting these particular needs of the private sector. HCPCS Low-Level Laser Therapy CPT an unlisted modality; specify type and time if in constant attendance HCPCS S application of a modality to one or more areas; low-level laser; each 15 minutes TEAM KMC 9

10 Decompression Therapy Is This or 97124? HCPCS S Vertebral Axial Decompression, per session CPT Application of a modality to one or more areas, traction, mechanical Medicare - CPT Unlisted physical medicine/rehabilitation services or procedures Which Should I Use? The service may LOOK very similar, but the difference is clarified in the documentation Treatment plan must reflect the specific service along with projected outcomes and goals Based on their definitions, the INTENT of the service is clearly different between the two codes Manual Therapy Techniques The AMA CPT 2013 edition describes as manual therapy techniques (eg. mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. It has also been described as manual trigger point therapy and myofascial release It is used to treat restricted motion of soft tissues in the extremities, neck, and trunk When to Use To effect changes in soft tissues, articular structures, and neural or vascular systems To address a loss of joint motion, strength, or mobility Must be part of an active treatment plan directed at a specific outcome Daily routine visit documentation should include progress toward those stated goals Massage Therapy The AMA CPT 2013 edition describes as therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage, and /or tapotement (stroking, compression, percussion). Massage might be used to improve muscle function, stiffness, edema, muscle spasms, or reduced joint motion TEAM KMC 10

11 When to Use Who Can Perform These Services To increase circulation and promote tissue relaxation to the muscles When treatment is prescribed for the friction-based, relaxation type massage that may be less specific than Dependent upon state law or provider contract provision Should verify each patient s plan to determine specific requirements Would be different guidelines if a cash service One-on-One means One-on-One Timed Treatment Codes One-on-one attendance is defined as maintaining visual, verbal, and/or manual contact with the patient during the provision of the service. One-on-one attendance is achieved when the provider is attending to one patient individually for each minute counted toward the required minutes in order to bill the CPT code for that particular therapy service. Timed codes are counted per 15 minutes Up to 15 minutes is not a full unit under the CPT guidelines Some carriers may have you use the Medicare standard of 8 minutes for the 1 st unit Check with each carrier and document appropriately Use of the -52 modifier could negate the service Timed Treatment Codes Modifier -25 For a single timed code being billed in a visit: 8 up to 23 min = 1 23 up to 38 min = 2 38 up to 53 min = 3 53 up to 68 min 4 And so on For multiple timed codes billed on the same visit, use this standard, but count TOTAL time spent on each timed code TEAM KMC 11

12 Modifier -26 Modifier -TC Modifier -51 Modifier -52 Modifier -59 Modifier -59 Changes in TEAM KMC 12

13 Multiple Modifiers How Follow-up Really Works Let s See What You Know! Successful Follow-Up is an A-R-T Follow this recipe for success: A = Attack Immediately R = React Proactively T = Tickle Relentlessly TEAM KMC 13

14 Doctors Accuracy of balances and A/R The beginnings of this system allow anyone to pick up the slack, any time, at a moment s notice Why it matters to Team Members Patient billing is easier when balances are accurate Front desk CAs don t have to be concerned if a balance in the computer is accurate Follow-Up and Collections The three most important calls you may not be making Proactive Follow- Up Reactive Follow- Up Tickler Follow-Up Follow-Up Calls: Proactive and Reactive This is the core of the collections process Whether those items you re reacting to or discovering Why you need both! The single biggest KILLER of a practice is lack of outgoing, follow-up, phone calls What Constitutes Reactive Calls? Denials that make no sense Payments that are incorrect Partial payments you don t understand Anything you must react to Reactive Calls Generated from your payment posting process Don t stop to do this when you re posting Planned time to complete the follow-up Systematically included in your schedule each day TEAM KMC 14

15 Sort These Daily/Work These Daily How About Another Quiz? Write on the EOB to note what needs to be done Copy this EOB so you can keep the original in your daily bundle File this in a stand up file for follow-up work Time to Grab Your Aging Reports Proactive: A/R Aging Not all money comes back in without any effort That s the reason we must work our unpaid claims list Age the accounts monthly and keep track of all unpaid bills Work it! Mark it! Work the aging according to payer class Sort by carrier if you can Sort by highest balance if you re just starting to work aging reports Mark your aging report with cryptic notes Black X when you are complete Highlight those items you feel need attention TEAM KMC 15

16 Helpful Scripting By when can I expect a check? I m unclear about the validity of this denial What other options do I have to speed up the decision-making process? Can I fax this directly to you so that you can give me an estimated date of payment? I m sorry that we re having difficulty communicating. May I please speak to your supervisor? Reconcile It! As you work through, reconcile all patient and insurance balances Apply any unapplied credit appropriately Strive to get through every aging within a month once you get caught up Develop a Tickler System Follow up on your follow-up This is the crux of a system It s not persondependent It s your brain in a box Electronic/Outlook Card file/hanging file Keep a Tickler File Electronic or paper doesn t matter! Check and review DAILY! Don t rely on your memory This is good management for a team effort If you don t get to it or your answers, move to the next business day Every Item Gets a Reminder! If you expect a payment... If you didn t get through... If you want to remember to check on something... If you need to make a call... Find a place in your software where you can keep internal notes What if you win the power ball? Internal Financial Notes TEAM KMC 16

17 What s a Reactive Action? Something happens What you do next creates a follow-up An inbound mail item clearly requires an action - like notes to send Resubmission TEAM KMC 17

18 Inner office communications slide Proactive Calls What if the Claim Is Denied? CMT Rehab Therapy Re-exam What Action Is Needed? Why Is the Claim Held? Let s Talk! How Do You Keep Track? Request For Records Rejected Claim No Reply on Claim TEAM KMC 18

19 Making Time An Example of a Submitted Bill Why Denied? Date of Service Code Billed Amount Billed Total Amount Billed 12/03/ $ /03/ $ /03/ $40.00 $ Date of Service Code Billed Amount Billed Allowed Amount Contractual Discount Patient Responsibility Amount Paid This Code Total Amount Paid Remark Code 12/03/ $50.00 $32.00 $18.00 $6.40 $ /03/ $25.00 $0.00 $25.00 $0.00 $ 0.00 C /03/ $40.00 $35.00 $5.00 $7.00 $ Total: $48.00 Total: $13.40 Total: $53.60 Play to Win Think of the A/R process as a game It is a game you want to win! Learn the rules so you can prevail She with the most information wins! Create a pile of everything there is in your mess Sort it into needs a call and needs an action Set up or enhance your tickler file Create your reactive area Create your action area Monday Mornings TEAM KMC 19

20 What Needs to be Done? Infrastructure Systems Financial Department Work Schedules Doctor/Team Member Financial Meetings Statistical Management Cash Profit Centers SOP Manual Creation Collection Processes Qualities TEAM KMC 20

21 Let s Check It Out And Finish Well Here Weekly and monthly accountability meetings with doctor/fd team member Review of productivity statistics Manage expectations Watch trends Infrastructure Musts Meetings? Here Is Your Template! Review your action steps list Prioritize them on Monday Begin with that which got the lowest score Let Team KMC University help you! We want to be on your team! Final Action Steps TEAM KMC 21

22 Managing Records Requests for Better Returns RECEIVED Everything gets stamped with the date it was received It immediately gets sorted into one of the four folders Sort by date either deadline or by date received Preparing Summary Templates Let s Rock This Template TEAM KMC 22

23 Appeal Has Worth Appeals and Reconciliation $$ = Happy Docs Success = Powerful Team Paid Claims = Satisfied Patients No Better Resolution Going the extra mile Fight the good fight Use template letters Use your best judgment Get to zero Choose your battles Live Appeals Available! Medicare Appeals Medicare Appeals Stages Let s Set Our Policy Appeal If 1. Claim was valid 2. Documentation sound 3. No Review Policy TEAM KMC 23

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