My daughter recently had out-of-network medical services, so I requested a copy of the superbill. Without so much as glancing at it, I submitted it to my health insurance company for processing towards our deductible. A few weeks later, I received a letter denying the services. Confused, I looked through the paperwork and quickly realized that the CPT codes were incorrect on the superbill. I connected with the practice’s biller, noting the mistake. She apologized, not for the mistake, but for the failure to understand the codes. I educated her about the codes that should have been recorded – and thought about the challenge – and importance - of maintaining currency in the ever-evolving field of coding and reimbursement.
A recent article in the popular peer-reviewed journal, Annals of Internal Medicine, pointed out that primary care physicians were leaving more than $200,000 on the table in unbilled services each year – to be exact, “$124,435 (interquartile range [IQR], $30,654 to $226,813) for prevention services and $86,082 (IQR, $18,011 to $154,152) for coordination services.” Most, if not all, physicians, would agree that this revenue boost would be a welcome addition to their practice’s bottom line. Coding opportunities are particularly appealing because there are rarely any costs associated with the revenue bump – the space, staff, computer systems, etc., have already been paid. Therefore, financial earnings because of improvements in coding fall directly to the bottom line as profits.
Before we unpack the opportunities, let’s determine the reason behind the problem. Just like the biller with whom I interacted, medical practices typically rely on one or two people as subject matter experts. That person is normally overworked and underappreciated. Unless prompted, seeking information about coding opportunities is typically not a priority due to their workload, and they don’t make an incremental dime for correcting a past mistake or discovering a new coding opportunity. Coding conferences for billers ceased during the pandemic and are just now resuming. And, perhaps most importantly, coding is not easy. There are thousands of CPT® codes. Understanding how they are matched or paired with other codes is a massive undertaking, let alone the reimbursement rules that govern getting paid. Did I mention that the typical practice participates with dozens of health plans, if not hundreds? Each one has different rules for getting paid. Frankly, it’s a hot mess.
It's not possible to escape the chaos of the reimbursement landscape in healthcare. However, there are opportunities to effectively navigate the challenges. Invest in good people – and have them attend formal training at least once a year. Ask them to prepare a presentation upon their return, with a minimum of three recommendations. Make sure they connect with at least one other practice of your specialty to exchange ideas once or twice a year. Engage with an online coding advice service to maintain currency; CodingIntel is a good resource. Consider adding an automated code scrubber package to your electronic health record system.
To determine the opportunities, take a multi-pronged approach. First, ask the person who codes and bills for you to shadow you for a half-day. Without showing the coder/biller what you do, the employee may never know the “real” opportunity. The employee can experience what you do firsthand, thereby identifying potential gaps in documentation. Take, for example, the moderate “risk” column in the medical-decision making (MDM) table. It includes: “Diagnosis or treatment significantly limited by social determinants of health (SDOHs).” Moderate risk is one of two components (in addition to data and problems) needed to code an office or hospital encounter as a level 4, yet many physicians don’t realize that patients’ inadequate housing, unemployment, divorce, low income, or other SDOHs can lead to a higher level of code. Therefore, it is not documented. Shadowing the physician allows the employee to identify the opportunities firsthand – thereby encouraging documentation that can lead to improved coding opportunities.
Next, know the basics yourself. Physicians and practice executives should spend at least one hour per month perusing the coding section of their specialty society website. Whether you’re a pediatrician – or an interventional radiologist – there is a coding resource section for your association. Read it.
Finally, contemplate the situation. What services did you perform today – or last week? How did you code them? Perhaps you’re confident in the codes you submitted; however, are you sure the auxiliary services you ordered in your practice – or performed yourself – were coded and billed appropriately? Prior to computers, these were all captured on forms; since the visibility is gone, make sure your practice has replicated the workflow in your computer. One way to do this is to take a single clinic day from last fall and ask an employee to pull all the codes submitted and payments received. Are there any surprises? Without going overboard, gather evidence about the coding and billing protocols for your practice so that you can make changes for the better.
Coding opportunities take some effort, but the payoff is certainly worth your time.
For primary care physicians – as well as specialists engaged in preventive care – query the government’s “Medicare Preventive Services” reference chart to ensure you’re billing appropriately for services rendered. https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-1.html
In addition to being a value-add to patients’ care, many services can be provided at no cost to Medicare beneficiaries, thus eliminating the administrative burden of collecting from the patient.
Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.
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