Evaluation & Management: the History Component

MedPro Services strives to maintain current knowledge of the ever-changing medical billing and coding industry.  In one of our many continuing education efforts, a group from the MedPro Services’ team recently attended the Karen Zupko & Associates conference on General Surgery coding in Chicago, IL.  With the recent changes in the healthcare industry, medical billers/coders and providers alike must be especially vigilant in maintaining appropriate and accurate practices.  Insurance companies are cracking down on coding and billing errors and ensuring that provider reimbursement reflects services rendered.  With insurance auditing on the rise, providers must make sure that documentation and coding meets the Centers for Medicare and Medicaid Services (CMS) guidelines.  Over the next few weeks, I will be writing a series of posts highlighting some of the most integral aspects of what we learned at the conference and what we feel providers should know to keep their practices operating as efficiently and successfully as possible.

Today’s post focuses on something almost everyone in the medical billing industry is highly aware of, are continuously learning about, and is one of the most commonly miscoded and over-billed services: the evaluation and management (E/M).  This was a hot topic at the conference and something that all medical billing companies should be acutely aware of and knowledgeable on.  From personal experience, I can tell you that E/M codes are notoriously difficult to code simply because the CMS language is not as clear as it is for other areas of coding.  The most important thing to consider when coding E/M services is documentation.  Regardless of what happened in the exam room, documentation MUST meet CMS guidelines to bill varying levels of services.  Without appropriate and accurate documentation to support the level of service billed, providers are really opening themselves up for major issues with payors and very possibly the law.  As was mentioned in a previous post, today’s electronic health records (EHR) systems are highly intuitive and useful in hitting all of the necessary documentation markers.  Do NOT fall pray to templates and cloning.  Always document the unique aspects of each examination.

The speakers at the conference spoke extensively on correct E/M coding.  To code E/M’s properly, providers must be aware of three main components: history, exam, and medical decision making.  The level at which each of these are completed is what determines the level of service billed.  I must emphasize that wordy or over-documentation does NOT equate a higher level of E/M.  Because each component requires a great deal of consideration, I am only focusing on the history component in this post.

What does the history component in an E/M entail?  There are some important areas that should be hit to ensure that a history component is accurately and appropriately performed and documented. First, what is the chief complaint?  Document this in a clear and efficient statement, basically explaining why the patient is presenting for the visit.  Second, the history of present illness (HPI) should be performed and documented.  An HPI includes such things as when and where the injury or illness began to occur/appear, symptoms of the illness, when the injury/illness seems to worsen or get better, how often is it experienced and in what environments, etc.  Detail clearly the history behind the patient’s condition.  Third, past, family, social history (PFSH) should be addressed.  PFSH is pretty self explanatory, but includes such details as any family diseases, social history, such as smoking and alcohol use, etc.  Finally, a review of systems (ROS) is needed in the history component of the visit.  An ROS is as it sounds, a review of different bodily systems and part, such as the eyes, the heart, respiration, etc.  PFSH and ROS may be documented on a patient-completed form, but the provider must review this with the patient to ensure accuracy and to ask any questions that may arise.

Clearly coding E/M services is lengthy and requires special attention to detail, but doing so will result in not only more accurate and appropriate payor reimbursement, but will also help to maintain practice integrity and better patient care.  MedPro Services is continually educating and informing our providers on appropriate and accurate E/M documenting and coding.  We strive to ensure that documentation meets CMS standards and is reflective of actual services rendered.  In the following weeks, I hope to address further aspects of E/M coding and how MedPro Services can help providers address any areas of issue or concern with the topic.  If you have questions on E/M coding or are concerned your current billing company is not performing up-to-par, feel free to send us a message detailing your questions and concerns.

Are You Avoiding EHR Perils?

Electronic Health Record (EHR) systems are an integral part of today’s healthcare.  Not only do they provide quicker, easier, and more accessible means for storing patient health information, most EHRs offer critical features that help providers to properly document and report meaningful use.  Per Clements (2017), EHRs can be beneficial in a variety of ways, such as:

  • Allowing for more efficient, complete, and legible documentation
  • Providing easier and immediate access to medical records and patient information
  • Coordinating care among providers

EHRs are designed to assist and help providers by offering a more technologically advanced means for storing and accessing patient health information. Even with the numerous benefits that EHRs provide, they are not without potential pitfalls and limitations.  Clements (2017) points out areas in which EHR features may be used inappropriately or inadequately:

  • Many EHRs offer a “cloning” or copy and paste feature, which allows physicians to transfer information from prior visits that may be relevant for a current visit in a fast and efficient way.  However, auto-populating or copy and paste/cloning features can potentially lead to fraudulent or inaccurate documentation.  Documentation may be carried over that is no longer relevant to the patient or is not relevant to the current visit.
  • Building off the cloning point, over-documentation can also be a problem.  Copying and pasting, auto-population, or simply over-documentation to justify the billing of a higher evaluation and management (E/M) code is fraudulent and unethical.  Each visit should be documented based on what occurred during that particular visit.  It is best to not use the auto-population templates or cloning features to avoid these issues entirely.   I cannot stress enough that over-documentation does not equate medical necessity for billing higher-level E/M codes. E/M codes should meet all of the specified CMS guidelines for medical necessity.
  • Some EHRs offer the provider the ability to generate diagnosis and procedure codes based on descriptors in the documentation.  While this is clearly an efficient means for documenting patient conditions and procedures performed during a given visit, it is NOT to be solely relied upon.  Providers or other clinical employees should ensure that all diagnoses and procedures are coded and generated appropriately.  With the onset of ICD-10, diagnosis codes should be monitored for the highest accuracy and specificity possible and unspecified codes, which from my experience are the most commonly auto-generated in EHRs, should be avoided.

More and more often in the medical billing industry we are seeing insurance companies control for appropriate and accurate billing (e.g. medical records requests, CMS initiatives) through companies such as Optum.  Insurance companies are only ensuring that providers are maintaining authentic patient medical information and are billing only what is accurate and necessary. Poor or inappropriate documentation due to the above mentioned EHR issues can lead to insurance denials and fraudulent billing, both of which providers and medical billers certainly want to avoid.  At MedPro Services, we strive to find EHRs that fit our providers’ needs and consult on ways in which the EHR can be used more effectively and appropriately where applicable.  We are familiar with numerous EHRs and are always willing to provide recommendations.  Please contact us for more information.

Clements, A. (2017, October). Conquer E/M challenges of EHRs. Healthcare Business Monthly, 46-49.


Are Payor Non-payment Issues Affecting your Practice?

It is our responsibility as a third-party, medical billing company to monitor all insurance payment trends and activity to ensure that our clients are receiving the highest and most accurate reimbursement possible.  Often we see insurance payors from all over the nation across all of our clients using incorrect denial codes or applying improper fee schedules.  As a medical billing company, we must be vigilant in identifying issues of integrity with insurance payors.  Some of the most common issues we see involve:

  • Global denials/issues.  These types of denials are marked by multiple non-payments, low-payments, or incorrectly applied denial codes.  Your billing company should be prepared to monitor denial reasoning codes, know what they mean, and recognize when an error has occurred.  Global denials/issues tend to happen across almost all patient claims from a particular insurance company and are fairly easy to identify.  If these types of denials occur, then your medical billing company should immediately contact the insurance payor, preferably the appointed provider representative, and work to correct the error right away.
  • Improperly applied denials.  Insurance payors are incredibly notorious for issuing unfounded claims denials (e.g. no authorization when one was not needed, CPT bundling).  Your billing team must be aware when a denial code is incorrectly applied and how to fix these denials at the onset.  It is possible that insurance payors experience system glitches, which could lead to these types of denials, or it could be a way for insurance payors to avoid making appropriate payment on a claim line.  As a medical billing company, it is almost impossible for us to truly know the reasoning behind improperly applied denials.  Regardless, we must identify when errors like this occur and rectify the issues in a timely fashion as not to disrupt the revenue stream.
  • Fee schedule errors.  I am continually astonished to find that legally-binding contracts are breached on a regular basis on the part of the insurance payor.  More and more we are seeing fee schedules improperly applied, thus leading to lower than required reimbursement.  Your medical billing company should absolutely be monitoring each insurance payor’s fee schedules per your agreed upon contract.  While these are not difficult to apply by hand with the appropriate tools and technology, most practice management (PM) systems have the capability of applying fee schedules at the time of payment posting, allowing for quick identification of incorrect payment.  Our PM system, Healthpac, is readily equipped with this feature and we continuously monitor fee schedule errors and have been very successful in correcting issues with the insurance payor almost as soon as errors are identified.
  • Payor specific “rules.”  As remarkable as it may seem, not all insurance companies are bound by law to follow a specific set of guidelines for billing and reimbursement.  While more and more companies are adopting CMS-guidelines, some actually have payor-specific guidelines, which really are not easily identifiable until a denial or reduction in payment occurs.  Your medical billing team should have the knowledge of how to access payor specific “guidelines” and should contact the payor with further questions should these types of denials and issues arise.

As a medical billing company, we continuously identify payor issues when we are posting payments.  MedPro Services staff are highly skilled in quick claims follow-up and correcting any payor non-payment issues almost immediately upon receiving them.  At some point in time, we have run into each of the above mentioned non-payment issues and have found the best means for addressing each of these issues, so that our providers experience minimal delay in receiving the correct reimbursement.  Are you questioning your medical billing team’s skill in rectifying and monitoring non-payment issues?  Please feel free to contact us for more information on how we can improve your practice’s revenue stream.

Taking Full Advantage of Electronic Payor Systems

Electronic payor systems are growing in popularity as the medical billing industry adapts to an increasingly paperless world.  Today’s major payors, such as UnitedHealthcare and Aetna, offer completely electronic solutions for submitting and managing claims, reimbursement, and provider/administrative solutions.  Some of the most well-known of these online systems are OptumNavinetAvaility, and many more.

There are numerous benefits to taking advantage of these systems.  These include, but certainly aren’t limited to:

  • Claim Status:  A number of these electronic solutions, such as Optum and Navinet, allow for identifying claim status (e.g. pending, adjudicated, paid, or denied).  This cuts down on calling time and allows for instant verification of claims receipt and where the claim stands with the payor.  This feature significantly cuts down on time wasted waiting to speak with insurance representatives and provides more substantial evidence of claims receipt and status.
  • Appeals & Claims Corrections:  Gone are the days of paper appeals and claims corrections.  Numerous payors allow for online appeal submission and claims corrections.  Submitting appeals and claims corrections electronically/online allows for better tracking of these submissions and faster processing time.  As a medical billing company, we utilize these functions on a daily basis.  Online access to appeals and claims corrections allows us to see in real-time what the status of these submissions are and if further work is needed.  It also decreases the amount of time spent calling insurance companies and waiting to speak to a representative, who may or may not have the information we need.  It also decreases the potential for “lost mail” or appeals that have been received, but are never even reviewed.
  • Electronic Remittance Advice (ERA):  In today’s world, we no longer have to wait for payments and explanation of benefits to be mailed.  Not only can we receive remittance advice through our online clearinghouse, but we can also obtain the original ERA from the payor’s electronic system.  This is especially useful for finding payments from payors, who may not submit ERAs through your chosen clearinghouse.  Even if ERAs are received through an online clearinghouse, the exact remit information may differ from what the actual payor ERA states.  It is important for medical billers to know where and how to access the original payor remits for purposes of follow-up and appeals.
  • Authorizations: Authorizations can be easily obtained and retrieved from numerous electronic payor systems.  Some systems even allow authorization verification for certain procedure codes.  Various insurance companies require that authorizations be obtained online.  This feature is especially useful for office staff and those responsible for obtaining authorizations.
  • Administrative Functions:  A number of these electronic systems will allow for a certain amount of administrative functions to occur online.  Some offer the ability to update provider information, which must be updated on a regular basis to avoid any delays in processing and payments for a particular provider.  It also allows for important letters and messages to be received that may otherwise take longer when received through mail.  Payor-provider communication is also possible on a number of these systems.  Utilizing this feature allows for more accurate record of communications, less time on the telephone, and quicker turn-around time.

Because most of these services are readily available and relatively easy to use, there really is no excuse for a medical billing team to not use them.  However, we still continue to encounter office staff, providers, and medical billing teams that do not utilize these systems to their fullest potential or at all.  This is true for large practices and small practices alike.  Avoidance of electronic payor systems not only wastes valuable time and resources (e.g. reimbursement), but it also increases the risk for not addressing follow-up in a timely fashion.

At MedPro Services, our staff is highly-aware of numerous electronic payor systems and will use them to the highest potential possible.  We have had incredible success with addressing appeals, finding claim status, correcting claims information, retrieving authorizations, communicating with payors, and updating provider information while utilizing these systems.  You can find out more about our relationship with a number of electronic payor systems here.

Is Your Data Entry Team Working for You?

The very first step in successful medical billing is having a reliable, educated data entry team.  Data entry is the first point at which the claims process begins for medical practices and is, arguably, one of the most important aspects of medical billing.  A medical billing team must have proven accuracy and extensive knowledge of the data entry process because without these things the practice runs of the risk of lost revenue and the potential for failure.

A poorly motivated, under or improperly educated, and inadequately trained data entry team is destined to make costly errors, resulting in huge initial revenue losses for the practice.  While most of these errors can be fixed during follow-up, it is best to avoid data entry errors in the first place because additional work does equal additional costs.  From my experience in medical billing, there are two main types of data entry errors:

  • Demographic errors.  Incorrectly entered data, such as names, insurance numbers, and dates of birth, can result in insurance denials, which can delay payment and result in additional work and resources.  To avoid such errors, have patient demographics prepared electronically, as handwriting is often difficult to read.  Require that the data entry team check all demographic information at least once before charges are entered.  Provide clear copies of patient identification and insurance cards (both the front and the back).  Having an intuitive clearinghouse, such as the Zirmed, may help to stop any of these errors from even reaching payors.
  • Coding errors.  Far too often, data entry errors occur at the time of charge entry.  This is most likely the result of having poorly trained and inadequately educated data entry clerks.  I want to emphasize that medical billing and coding certification does NOT equate expertise in medical billing.  Just because an employee has the credentials does not mean that he or she is a skilled medical billing expert.  Data entry in medical billing is not an easy trade and is a position that requires a strong skill set in the task at hand.  Because of the complicated nature of medical billing, charge entry goes beyond entering whatever information is presented on the superbill.  Providers make mistakes and even though most providers have extensive knowledge in medical billing, superbill errors still occur.  Ultimately, it is the responsibility of the medical billing team to ensure that all claims are being billed correctly and that charges are not simply copied from the superbill.  This skill takes training, education, and thought.  Some common coding errors are: missed or incorrectly used modifiers, inappropriate procedure codes, incorrectly coded diagnoses, place of service errors, and bundling errors.  Data entry clerks must be knowledgeable on claims coding guidelines.  This also includes billing appropriately, even when reimbursement will not be likely.  Coding charges incorrectly just to obtain reimbursement is illegal and could result in auditing.  As a general rule of thumb, provide the medical billing team with the medical reports, so that greater specificity and accuracy can be made when billing out charges.

MedPro Services’ data entry team is comprised of knowledgeable, highly educated staff with extensive expertise in the field.  We take the time to properly train our team on claims coding guidelines and ensure that all checks and balances are in place prior to claims submission.  As a team, we strive for continued education and obtaining current knowledge of claims coding guidelines.  Our staff is highly motivated in obtaining top revenue for our clients because if our providers are losing money, then so are we.  For more information on our data entry services, please visit the data entry section of our website.

MedPro Services also offers consulting.  Our consultation services can help you determine if you are getting the best possible outcomes from your current medical billing department or company and can offer insights into potential areas of improvement, particularly in areas of data entry.  For more information on our consulting services, please visit our dedicated Consultation page.