Email not displaying correctly? View it in your browser. Issue #1 — July 30, 2010
AAPC ICD-10 Newsletter

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F E A T U R E D   A R T I C L E

Tips to Eliminate the Cracks in your Reimbursement Cycle

Just like a balanced diet, exercise and other factors keep you healthy, there is a balance of things you should do to keep your practice healthy. Eclipsed by outside pressures, internal issues often go unnoticed and can leave practices feeling financially out-of-sorts. Here are a few tips that will help your practice remain healthy and eliminate the cracks in your revenue cycle:

Adhere to a security triangle. The same person should not open the mail, handle cash and deposits, and post money and perform write-offs.  In addition to the protection against theft or embezzlement, one person can become stressed in the chaos of a modern-day medical practice, and items become lost or hidden.  This results in a disorganized office and a staff member who is handling all of the stress associated with managing these important tasks.  In smaller practices this is sometimes harder to maintain due to fewer staff members, but it can be addressed with attention to details utilizing a couple of staff. 

Simplify your systems and perform an audit of billing and coding. Regular audits can assess your organizations coding and billing practices and ensure they are sound, as well as evaluating the full office.  Compliance audits (are all policies and procedures being followed?) can reduce risks and improve the efficiency of an office.  You can identify any compliance risks that are found and quickly fix them.  The size of your practice and the issues discovered in the initial audit should help you in determining how often an audit should be performed; this could be annually, bi-annually, or quarterly.  Regular audits can become part of an office’s normal procedure.  Outside, independent auditors can do this and are typically not very expensive.

Review billing and coding accounts receivable (AR) reports regularly. The medical billing process should be standardized regardless of the insurance company being private or government-owned. Providers need to review and understand their AR report to help decrease denials, get quicker payments and reduce outstanding receipts.  A practice typically deals with a large number of insurance companies and plans, so doctors must be familiar with each carrier and their contracts.  Going over this with staff is an easy way to ensure everyone is on board with office policies and properly implementing them.   In staff meetings, the billing analyst or the practice manager for small practices should present a summary of the AR report, explain the contents to physicians or other administrators and note all problems so proper decisions can be made.  Documentation and/or coding issues can be resolved during these meetings.

Set up policy and procedures for billing staff.  A written policy and procedures manual gives guidelines and a chain of command of how a particular situation should be handled by staff.  Policy and procedures should include information on all payer contracts for staff to have access to in order to resolve billing and collection problems quickly.  Although most billers are not in involved in the contracting process, it is important for the biller to understand the information contained in the established contracts. Make sure both your billing staff and those with whom you contract perform the duties as assigned.  The policy manual should also have write-off policies.

Write-offs can occur for many reasons; the provider deciding to accept what the insurance pays and not bill the patient; an improperly coded service that is not discovered until it is too late to request payment from a payer, or even not collecting the co-pay at time of service and patient not paying from the invoice.  The policy should have set amounts for write-offs to be approved by various staff—for large write-offs, it is the physician or manager; for smaller write-offs, it could be the biller.  It is important to keep track of write-offs to ensure too many are not occurring.  Maintain separate categories for items or services needing adjustment, with an explanation as to why will also help reduce write-offs. Monitoring the write-offs is like monitoring a budget; it tells you where the money is going and why, which will help your practice prepare for future needs, identify major issues and revise services if necessary.

Make the most of your practice management system by checking to ensure payments posted match the allowable contract amount. This benefits the practice by alerting you to any missed revenue in a timely manner, which will allow you to contact the payer to establish the reason for the low reimbursement and to do any additional follow-up that is required. Your patients will appreciate this as well, as it will reduce the amount for which they are then responsible for.  Most systems allow you to set up alerts that notify you when the payment being posted don’t match what are received; once set up, this is easy to maintain and watch.


I N   T H E   N E W S

The New PECOS System for Medicare—What Does This Mean for Billing?

The Provider Enrollment, Chain and Ownership System (PECOS) is a national filing system implemented by Medicare to maintain a listing of those physicians and non-physician practitioners who are eligible to order or refer patients under Medicare . All providers who were being paid by Medicare were to enroll in PECOS by July 6, 2010 in order to continue being paid. Keep in mind even if your providers were already enrolled in Medicare and were being paid previously, they will need to enroll in the PECOS system to continue being paid. The problem that some billers and providers are having is that most were not aware that the PECOS system exists mostly because enrollment was considered voluntary until now. The following resources will provide you with additional information:


F R O M  T H E   F I E L D

Modifier 25 and 59

Often it is very tempting for billing personnel to append a Modifier 25 or 59 to override or bypass the CCI edit process this is a common misuse of the 25 and 59 modifiers as this is not always the appropriate solution. It is important for billing personnel to understand that a modifier is used to modify a procedure or service but is not intended to change the definition of the CPT code.

Appending a Modifier 25 or 59 to bypass edits can be risky business potentially causing an audit for noncompliance. Because of this, it is imperative to understand both your federal and local guidelines when appending modifiers to claims based on your individual state and payer guidelines. With proper guidance and education in applying correct modifiers will allow your claims to make it through the edit process, allow for correct payment and ensure billing compliance. Keep in mind, payers consider modifier 59 the modifier of "Last Resort."

Please refer to the CMS website to access Chapter 1 of the NCII Policy Manual and the Modifier 59 article.

FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies or just anecdotes please submit them to us for future edtions.

In This Issue
Reimbursement Cycle Tips
New PECOS System
Modifier 25 & 59

Don't underestimate the importance of policies and procedures in the billing world. A good set can help the practice set up parameters and keep the practice running in the direction of good financial health.



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