Medical Billers and Coders

Medical billing on its own can be a complex process, requiring specific expertise. However, substance abuse billing comes with unique challenges even for certified billing and coding experts. Substance abuse billing is one of the major areas with which drug and alcohol addiction treatment centers struggle resulting in lost revenue and delayed payments. Many drug rehabilitation centers and behavioral health organizations are closing their doors due to rapidly changing industry laws, regulations, and payer reimbursement policies. Substance abuse services are provided by: Physicians (medical doctors or doctors of osteopathy); Clinical psychologists; Clinical social workers; Nurse practitioners; Clinical nurse specialists; Physician assistants; and, Certified nurse-midwives. These substance abuse treatment providers are finding it increasingly difficult to get reimbursements from payers. To get more information about Substance Abuse Billing and its challenges click here: https://bit.ly/3Wh

  Challenges of Ambulatory Surgical Centre (ASC) Billing Ambulatory Surgical Centre (ASC) billing and coding are completely different from the rest of medical specialties or the usual physician billing or even facility billing as they majorly are a combination of hospital and physician medical billing. Plus Ambulatory Surgical Centre (ASC) billing involves specialties like  orthopedics ,  pain management , bariatric surgery,  podiatry,   ophthalmology , obstetrics, gynecology, endoscopy, and dental. CMS and Medicare allow only certain surgical procedures can be done in ASC, which makes the billing and reimbursement from Insurance difficult with restrictions on out-of-network coverage. Frequent release of upgrades in coding guidelines and billing regulations can add up to the complexities involved in billing and coding for ASC. Sourcing and retaining highly experienced ASC billers and coders can be a pain point and outsourcing  Ambulatory Surgical Centre  (ASC) billing could be the only

Increased administrative hassles and reduced potential for income are two main reasons behind the shortage of PCP in the US. Primary Care Billing and revenue-related challenges have been causing great dissatisfaction among primary care doctors. This has also led to a steady decline in the number of medical students willing to pursue a career in primary care. Around 52,000 more PCPS will be required in the United States by 2025 The total number of office visits to primary care doctors will increase to 565 million in 2025 By 2025, the population in the USA will increase by an estimated 15.2%. There will be a 60% increase in the older-than-65 age group Challenges Faced by Primary Care Doctors PCPs are paid less than surgeons and other specialists. Care provided by them is not appropriately recognized by payment policies and this affects their compensation Due to low income, physicians have no option but to keep the costs down They are forced to attend to a large number of patients on a da

It has been observed that for emergency room and urgent care providers, the collection of payment is becoming more complex owing to the increasing number of payers. As a result which scope of the capacity of payable charges appears to be diminishing.   Emergency medicine   is widely different from other specialties of healthcare, specifically when there are factors like reimbursement, payer mix, and others that are responsible to strengthen the business model. Emergency Room (ER) services are blessings for medical conditions, which need quick action like sudden illness or injury. Treating patients is a primary objective of Emergency Departments (ED), however, many of them fail to understand the challenges in emergency room   medical billing . Let us understand Emergency room medical billing and its challenges: What is Emergency Room Medical Billing? Emergency room medical billing is considered one of the critical challenges for healthcare organizations and physicians. It encompasses th

On 4 th  April 2022, CMS published a rule on “suspension of prior authorization requirements for orthoses prescribed and furnished urgently or under special circumstances”. Prior authorization helps Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers ensure that applicable Medicare coverage, payment, and coding rules are met before DMEPOS items are delivered. The prior authorization program helps to protect the Medicare Trust Fund from improper payments while ensuring that beneficiaries can receive the DMEPOS items they need in a timely manner. CMS maintains a master list of DMEPOS items that requires either a face-to-face encounter and written order or prior authorization requirements. You will find the updated list  here . Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the two-day expedited review would delay care and risk the health or life of the beneficiary, CMS suspended pri

  Exponential Growth of Pathology Services during COVID-19  COVID-19 is caused by severe acute respiratory syndrome corona virus-2 (SARS CoV-2), a highly contagious single-stranded RNA virus genetically related to SARS CoV. The lungs are the main organs affected leading to pneumonia and respiratory failure in severe cases that may need mechanical ventilation. Pathologically, the lungs show either mild congestion and alveolar exudation or acute respiratory distress syndrome (ARDS) with hyaline membrane or histopathology of acute fibrinous organizing pneumonia (AFOP) that parallels disease severity. The treatment for COVID-19 was principally symptomatic and prevention by proper use of personal protective equipment and other measures is crucial to limit the spread. Digital pathology was also introduced and the COVID-19 pandemic accelerated its adoption as there is the need to deal with higher (as much as 250 percent increase) case volume. During the COVID-19 pandemic, pathology billing wi

The beginning of the   Patient Protection and Affordable Care Act  resulted in millions of Americans becoming insured on plans with out-of-network benefits. Also, this act has narrowed insurance networks which left many providers completely out-of-network. Therefore, the out-of-network strategy for   ASC   is only revenue enhancing strategy for some ASCs. There are some key opportunities available with out-of-network offerings and you will get the details of opportunities in the following briefs: The rise in overall reimbursement The changing and sometimes volatile world of insurance can be stressful for practitioners who desire a more predictable income stream. Fortunately, there are some ways that exist to improve your reimbursements and it starts with developing a good out-of-network strategy combined with the right expertise. You can avail the best pay-off by creating a hybrid strategy that includes an out-of-network and in-network strategy. Moreover, you can enhance revenues by ma

Need for Consolidated Billing for SNFs Prior to the Balanced Budget Act of 1997 (BBA), a Skilled Nursing Facility (SNF) could elect to furnish services to a resident in a covered Part A stay, either, directly using its own resources; through the SNF's transfer agreement hospital; or under arrangements with an independent therapist (for physical, occupational, and speech therapy services). In each of these circumstances, the SNF billed Medicare Part A for the services. However, the SNF also had the further option of ‘unbundling’ a service altogether; that is, the SNF could permit an outside supplier to furnish the service directly to the resident, and the outside supplier would submit a bill to Medicare Part B, without any involvement of the SNF itself. This practice created several problems, including the following: Potential for duplicate (Parts A/B) billing if both the SNF and outside supplier billed; An increased out-of-pocket liability incurred by the beneficiary for the Part B

General surgery medical billing  involves a variety of procedures. Procedures under the general surgery category must be performed by a  physician  who is fully credentialed and qualified to perform these surgeries. Medical billing for general surgery practices requires a certain level of expertise and skill. One of the biggest challenges general surgery practitioners are facing is concerned with patient care; instead, many of today’s care providers are concerned with the business side of health care, especially concerning medical billing and coding. General Surgery Medical Billing Challenges with Billing Coverage Billing Errors It is estimated that up to 78% of medical bills contain errors. Insurance companies are very strict on correct medical billing and  coding  practices, and even the smallest mistake can cause an insurance company to reject a medical billing claim. This starts a long process requiring general surgery practitioners to fix the error, submit the claim a second time,

In   DME medical billing , your DME coders require correct HCPCS codes along with correct modifiers that are used for providing more details about the equipment. If your medical coders are unable to use modifiers or not using them in the correct manner, then the claims may get denied by the insurance company. Some common DME modifiers include RR- rental, UE- purchase of used equipment, and NU- purchase of new equipment. When a laboratory demand, request for DME is being filled, medical coders will be needed for  ICD-10  codes for a patient’s diagnosis. To use an appropriate HCPCS code for the DME item, many  HCPCS  codes need a modifier. Modifiers are used to provide more details about the DME item. e.g. The modifier might indicate to HMSA that an item is new, rented on a capped basis, or rented. For capped rentals, modifiers differentiate which month’s rental is being billed. If your billers use these modifiers incorrectly then the claim will be rejected. To speed up this process of y

  What is Collaborative Care Management (CoCM)?  Psychiatric Collaborative Care Management (CoCM) typically is provided by a primary care team consisting of a primary care physician and a care manager who work in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations with the primary care team to review the clinical status and care of patients and to make recommendations. Billing Codes for Psychiatric Collaborative Care Management CPT Code 99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the fo

Durable Medical Equipment (DME) Billing   is different from the other   medical billing   and   coding   for the specialties. Unlike the other coders and billers who work on DME need specialized training to deal with different medical situations and equipment that require different types of modifiers as requested.  DME billers need specialized in-depth, specialized knowledge of different types of HCPCS Level 2 codes. Let’s understand the procedures of coding that can be implemented to make the billing process more effective: ICD-9 codes are 3-5 digits in length and speak to the patient’s conclusion CPT restorative charging codes are in fact HCPCS Level I codes. They are 5 digits in length and speak to the methodology performed at the patient’s visit HCPCS codes are in fact HCPCS Level II codes. They incorporate the two numbers and letters and are likewise 5 digits in length. These codes speak to the majority of the provisions or gear utilized in the patient’s consideration. All Durable

CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a   skilled nursing facility  (SNF 3- Day Rule Waiver )   stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who need to be transferred as a result of the effect of a disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period. Second, CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission. Background Under the Shared Savings Program, the Centers for Medicare & Medicaid Services (CMS) enters into a participation agreement with each participating Accountable Care Organization (ACO). CMS will reward eligible ACOs when they lower growth in Medicare Parts A and B fee-for-service (FFS) costs (re

  Medical billing is a complex process and it’s always been a reason for the struggle of   primary care   physicians. In addition, their practice is often overwhelmed with constantly changing information, including protocols and billing codes which makes the situation more challenging. When the covid-19 pandemic strains the U.S. healthcare system, primary care physicians were working to educate their patients, employ safety protocols, and handle large volumes of calls. This large volume of calls is creating administrative hurdles and operational challenges. Hence in response, many primary care practices are making changes to their  medical billing processes  to accommodate new patient needs. The recent release of the Medicare physician fee schedule final rule from the Centers for Medicare & Medicaid Services (CMS) contains new hope for struggling primary care physicians and you will get to know about it in the following brief. The recent release of the Medicare physician fee schedu

  There are not a lot of us who believe that family practice physicians are adequately paid for the kind of valued care they deliver to patients and to the health care system. As an established  medical billing  and  coding organization , we regularly observe how desperately clinicians need primary care payment reform. Agreed that there is a better future for the healthcare industry on the horizon, but as of now, we have to make the best of what the dysfunctional healthcare system offers. For many doctors whose reimbursement depends in part on our productivity, increasing gross revenue is one vital element to your success. Family practitioners can protect their  revenue  stream by being equipped to provide as many procedural services as possible and also by making sure that you are billing and coding for the minor procedures that you already perform, but might not know that you can be paid for. Strategies to increase your family practice revenue Review the scheduling practices The sing