A Look Back At 2017

2017 was a big year for the MedPro Services’ blog.  Not only did we cover some of the most important topics of today’s medical billing industry and practice management, but we also hit record numbers of views and visits.  Thank you for making 2017 such a great year!

Throughout the year, we covered numerous topics, all of which were designed with the provider in mind.  Here at MedPro Services, we strive to educate and help our providers in whatever capacity that we can.  Our blog just happens to be one of those informational avenues, which really allows us to reach a vast, global audience.

We began the year introducing our new website.  MedProServices.net is a project we are really proud of.  The MedPro tech-team put a great deal of time and energy into planning and redesigning the MedPro website.  The new site introduces who we are, what we do, and how we can help providers from all over the United States.  Visitors to the site are able to meet the staff and put names to faces, something we feel really gives us that personal touch.  We also provide information on pricing and practice solutions.

Later, we discussed topics related to medical billing best practices.  Some of our favorite topics covered were:

  • Appeals Best Practices: This post discussed the most efficient and appropriate means for addressing appeals in a timely and successful fashion.  This post is a favorite because we pride ourselves in quick, accurate, and successful follow-up.  At MedPro Services, each dollar is valuable and we continuously strive to follow-up on all claims, no matter the dollar amount.  Appeals Best Practices perfectly illustrates how we operate as a company in one aspect of the follow-up process.
  • Is Your Data Entry Team Working for You?: This is another favorite and one that has been visited numerous times by viewers globally.  The MedPro Services’ data entry team is competent, educated, and hard-working.  Since data entry is the first point in the claims process, we believe it is also one of the most important.  Clean claims can make all the difference in provider revenue.
  • Electronic Health Record (EHR) Systems: This year, we wrote two posts (EHRs are the Solutions: Making a Successful Transition; Are You Avoiding EHR Perils?) on EHRs and how these can make or break a modern practice.  With current and upcoming Medicare initiatives, EHRs are becoming increasingly important and knowing how to use them correctly is one of the best tools for success in today’s medical billing and healthcare industry.  These posts were some of our favorite to write and really highlight how EHRs can be used to the fullest potential possible, as well as some of the downfalls of relying on the electronic features.
  • Evaluation and Management (E/M) Series: Finally, we ended the year with a 3-part (Part 1, Part 2, & Part 3) series on E/Ms. E/Ms are notoriously difficult to code.  By writing these 3 posts, we hoped to emphasize some of the important components of the E/M and how they can be correctly coded by providers.  This was not only an interesting post to research and write, but we believe it was also informative to our audience too.

We hope that 2018 will also be a landmark year for MedPro blogging.  Our team has numerous projects in the works, including upcoming seminars and conferences.  It is our goal to share those experiences and what we learn with our audience and clients.

For more information on some of the services we provide and how we can help your provider practice, please feel free to send us a message.  We would love to hear from you!

Evaluation & Management Part 3: Medical Decision Making

Now it is time to wrap up the evaluation and management (E/M) series with the third and final part: the medical decision-making component.  This too was a topic covered at the Karen Zupko & Associates conference on General Surgery coding in Chicago, IL, and has been identified as one of the more difficult components to code because of its complexity.  The Centers for Medicare and Medicaid Services (CMS), does, however, provide detailed guidelines for documenting and determining the appropriate level of medical decision making.  Per CMS (2017), “medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option” (p. 13).  Additionally, per CMS (2017), the medical decision-making component is determined by three major factors:

  1. The number of potential diagnoses and/or various management options
  2. The amount and complexity of data, such as diagnostics and medical records, that are reviewed or must be obtained
  3. The level of risk associated with the patient’s condition.

What makes coding medical decision making so difficult is determining exactly which level of complexity the E/M represents.  Per CMS (2017), there are four levels of medical decision-making complexity.  These are ordered from level of least complexity to level of highest complexity:

  • Straightforward:  Minimal or no amount and complexity of data reviewed, minimal diagnoses or management options, and a minimal level of risk
  • Low Complexity:  Limited amount of complexity of data reviewed, limited diagnoses and management options, and a low level of risk
  • Moderate Complexity:  Moderate amount and complexity of data reviewed, multiple number of diagnoses or management options, and moderate level of risk
  • High Complexity:  Extensive amount and complexity of data reviewed, extensive number of diagnoses or management options, and a high level of risk.

Even with these definitions and guidelines put forth by CMS, there still remains some confusion as to how to accurately represent this component of the E/M.  The language may seem clear, but as was discussed at the conference and from my personal experience in coding, there is still a gray area in determining just how complex a provider’s medical decision-making component really is.  CMS does provide a useful table, which indicates the various levels of E/M medical decision-making complexity and examples to illustrate what each might look like in actual practice.  As was mentioned in parts 1 and 2, documentation is key and must reflect all medical decision-making aspects performed during the E/M.  This will help medical billers, coders, and providers alike in determining which level of complexity is most appropriate, and ultimately will lead to more accurate and appropriate E/M coding.

MedPro Services continuously seeks out educational opportunities, such as the Karen Zupko & Associates conference that was featured prominently in this three-part series.  Our team is informed and knowledgeable on current and future CMS guidelines and initiatives.  For more information on how we can help your practice, please send us a message and we will be more than happy to assist.

References

Centers for Medicare & Medicaid Services. (August, 2017). Evaluation and management services.  Medicare Learning Network. 

Evaluation & Management Part 2: The Exam

In continuation of the evaluation and management (E/M) series, this post will be on the exam, a part of the E/M that can vary greatly in extent and specificity.  At the recent Karen Zupko & Associates conference on General Surgery coding in Chicago, IL, a great deal of emphasis was placed on the importance of accurately documenting and coding the E/M.  The examination is one of the main components of the E/M, which was discussed at some length during the conference.  Depending on the patient’s presenting condition, the provider may determine at what level an exam is required.  An examination may be performed on numerous body systems, or it may be performed on the problem of focus and body part for which the patient is presenting.  Per CPT guidelines, a problem focused visit is usually just that, focused on the problem at hand, and a problem focused examination will be limited and directed at the impacted body part or system.  This varies greatly from a comprehensive examination, in which a provider will perform a more general evaluation of numerous patient systems (e.g. cardiovascular, respiratory, musculoskeletal) and organs.  It really all depends on how familiar the provider is with the patient’s specific condition and how much time and consideration is needed to determine the level of medical decision making.

As was mentioned in part 1, documentation is key.  Today’s electronic health records systems (EHRs) are especially useful in documenting the level of examination and on which body parts and systems and examination is performed.  Documentation may include such things as notating appearance, vital signs, or any assessment tools utilized during the exam.  These should all be documented and should be unique per the visit.  I have seen EHRs be very useful, but cloning can really affect the quality of documentation.  Providers must ensure that what is recorded is accurate for the specific visit.  For example, vitals from a visit two months ago should NEVER be included in a follow-up visit.  If these are going to be documented, then they must have been performed in that specific E/M.  Correctly documenting the examination portion of the E/M is critical because it plays a key role in determining which level of service to code (e.g. 99202, 99213).

I find that overall, providers do tend to code the examination portion of the E/M better than other portions.  That being said, as a medical biller and coder, I cannot emphasize enough how critical it is to correctly and accurately document.  MedPro Services strives to maintain coding and billing accuracy, but we cannot control a provider’s documentation.  We are, however, always willing and endeavoring to assist our providers in more accurate documentation, superbill coding, and other aspects of medical billing.  Please contact us with any and all inquiries, including consultation, coding,and billing.

Evaluation & Management Part 1: 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.

EHRs are the Solution: Making a Successful Transition

Considering some of the pitfalls and drawbacks of using an electronic health record (EHR) system as were mentioned in my previous post, one might be reluctant to use EHRs to their full potential.  However, most EHRs today are highly intuitive and have features that are more likely to benefit a practice than damage it. The MedPro team has worked with numerous providers on the transition from a paper-based health records system to an electronic one and the experience has varied from provider-to-provider.  Hayes (2017) also offers some suggestions on making the transition as smooth as possible and ensuring the success of providers with their chosen EHR:

  • Maintain open-communication with the provider. As a medical biller, it is critical to be open with the provider and allow them to discuss any misgivings they may have with the transition.  Offer practical solutions to any of their questions and concerns and present any you may have yourself.  Most often, providers are not experts in coding, which is why we as medical billers must be aware of areas for potential improvement and provider suggestions for things such as better documentation and coding.
  • Identify areas in which problems have occurred in the past when a paper-based system was used. I can attest that providers are not always aware of the type of documentation needed to ensure proper coding and billing.  Accurate and necessary documentation is a skill that sometimes needs guidance and as professional medical billers, this is something that we can provide support on.
  • The provider is not the only individual in the office maintaining and using the EHR. Ensure that all office staff and billing staff are aware of the functions of the system and provide roles for each person who will be using it.  Training is absolutely essential for everyone who will be using the EHR.  Providers, especially, should be trained on how to appropriately use templates, which can be highly efficient and time saving when used appropriately, to avoid the drawbacks of “cloning”.   Providers should be focusing on patient care and any help they get with documentation can be essential for ensuring that patient care remains their top priority.
  • One of the goals of most EHRs is to allow for proper documentation and reporting of all upcoming CMS initiatives. As a medical billing company, we try to discuss with providers and staff on how EHRs can be used to meet these goals, how this feature will be maintained, and areas that may need improvement to ensure all initiative markers are met.

Each practice and provider differs in terms of what they are seeking from their chosen EHR and what the demands of that practice/provider require.   In my experience, some providers find transitioning to be a daunting task and are at first reluctant to change.  However, it is partially the responsibility of the medical billing team to help with this transition and to offer counseling and solutions along the way.  In today’s healthcare, electronically-based records systems are really the best way for any practice to store patient medical information and should never be avoided.  In my personal experience, I have worked with providers who were at first adverse to change, but once we provided the necessary consultation and information, we were able to put their concerns at ease and transition them smoothly to a new and more compliant system.  EHRs provide for a much cleaner, efficient means for storing medical records.  The MedPro Services team is well-versed in various EHRs and is willing and capable of learning and adapting to new ones too.  For more information on our experience with EHRs, please visit the PM and EHR Solutions section of our website.

Hayes, J. (2017, September). EHR transition is an open opportunity to improve documentation. Healthcare Business Monthly, 48-49.

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.