Medical Billers and Coders

  When performing outpatient procedures, many orthopedic surgeons operate in either ASCs or a hospital-based outpatient department (HOPD). Although some of the workflows and services offered may appear similar between the two, the background operations are substantially different from business and regulatory perspectives. An HOPD is owned by and typically attached to a hospital, whereas an ASC is considered a standalone facility. The goals of this study were to compare the utilization and cost of ASCs vs HOPDs. The difference between an ASC and HOPD specifically refers to the regulations that apply to the center; therefore, a “freestanding” surgery center can still be classified as an HOPD if it is within a 35-mile radius of the hospital and falls under the same financial and administrative contracts. Similarly, a facility can be operated by a hospital and still maintain ASC status if it is an independent entity financially and administratively with its own Medicare agreement. ...

  Improper use of Modifiers for Podiatry Services can be the cause of claim denials just as not using a modifier can be. When using modifiers, make sure you clearly understand what the modifier entails. Sometimes, there are related services that the physician is performing, global periods to contend with, etc. Modifiers will clarify extenuating circumstances, which should allow for payment when they otherwise may not. If the insurance company denies a claim and you rebill it by simply choosing another modifier and hoping that is the correct one, this will usually end up creating additional problems. Insurance companies may have a time limit as to how long you can file an appeal. If you continually rebill incorrectly, then by the time you send in the claims and subsequently get denied again, you may run out of the appeal window. The appeal window generally starts when you submit the initial claim.  Medicare  explanation of medical benefits (EOMBs) will indicate whether ...

  Diabetes self-management education/training (DSMET) is cost-effective and improves health outcomes as patients maintain better control of their A1C. Diabetes educators provide education/training services and enable  physicians  to provide comprehensive high-quality care for their patients with diabetes and those at high risk of developing diabetes. The primary care practitioner in DSMT  provides general medical care  and is responsible for overall care, including the coordination of medical specialists. Role of Primary Care Practitioner in DSMT Diabetes educators bring a unique skill set to the physician‘s practice and are important adjuncts to primary care. These educators: help patients with diabetes develop the skills for managing their illnesses. increase a practice‘s efficiency by assuming time-consuming patient training, counseling, and follow-up duties. serve as an extension of the physician‘s practice to enhance the quality of care delivered. ...

  Modifiers are two-digit symbols added to CPT procedure codes to signify the procedure has been altered in some way. Modifiers are accepted by Medicare and most other payers, however, using modifiers correctly can be confusing, since not all payers want modifiers used the same way. Medicare defines the ASC facility’s Global Period to be 24 hours from the time the first procedure begins – it is NOT 10 or 90 days like the physician’s Global Period might be. However, some payers other than Medicare might consider the Global Period to be 48 – 72 hours for ASC facilities. Some Modifiers are for use by physician practices only, some for use on facility claims only, and some are for use by both provider types. In this Blog, we have discussed the correct use of modifier 50 in  ASC billing . Not using Modifiers according to each payer’s specifications can cause unnecessary denials or cause claims to not pay properly. Certain Modifiers are for use because the patient had to return t...

  ASCs, bring revolution in surgical care who led to the establishment of affordable and safe outpatient surgery. Moreover, The ASC industry is ahead of the curve in identifying avenues for improving the delivery of health care. ASCs are a rare example of a successful transformation in healthcare delivery. Hence stakeholders must understand about ASCs and their benefits and growth factors of ASCs: What is ASC? ASCs are modern healthcare facilities that offer patients the convenience of having surgeries and procedures performed safely outside the hospital setting. The first ASC facility was opened in Phoenix by two physicians in 1970. These physicians saw an opportunity to establish a high-quality, cost-effective alternative to inpatient hospital care for surgical services. Benefits of ASCs Today, physicians are continually providing the impetus which helps in the development of new ASCs. Physicians have realized that they gain increased control over their surgical ...

  Medical Billing a Challenge for Struggling Primary Care Practices 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 i...

  During the Public Health Emergency (PHE), The Centers for Medicare & Medicaid Services (CMS) used a combination of emergency waivers, regulations, and sub-regulatory guidance to offer healthcare providers the flexibility needed to respond to the pandemic. In certain cases, these flexibilities suspended requirements in order to address acute and extraordinary circumstances. Now, CMS is taking steps to continue to protect nursing home residents’ health and safety by announcing guidance that restores certain minimum standards for compliance with CMS requirements. We shared a recent update on the removal of temporary emergency waivers for nursing homes, inpatient hospices, ICF/IIDs, and ESRD facilities. Emergency Waivers for Nursing Home Restoring these standards will be accomplished by phasing out some temporary emergency declaration waivers that have been in effect throughout the COVID-19 PHE. These temporary emergency waivers were designed to provide facilities with the fl...

  With patients having more financial responsibility for their healthcare, outpatient settings like ambulatory surgery centers are becoming more attractive to patients. A research report from Bain & Co. estimates that the number of procedures taking place in outpatient surgery centers will rise from 23 million in 2018 to 27 million in 2021. As per the same report, out of all outpatient surgeries done in the year 2017, half were performed by ASCs. Now as things are settling down after the corona pandemic, these numbers are again looking realistic. Before getting prepared for this growth potential, you have to streamline your current ASC billing process. In this blog, we discussed Ambulatory Surgical Center (ASC) billing challenges and ways to counter them. We are confident that these tips will help in improving your Ambulatory Surgical Center (ASC) collections.  Tips for Improving Ambulatory Surgical Center Collections Process Always Take Prior-Authorization Prior to t...

  On 7th April 2022, in response to the COVID-19 PHE and under section 1135 of the Social Security Act, CMS passed several temporary emergency declaration blanket waivers which were intended to provide healthcare providers with extra flexibilities required to respond to the COVID-19 pandemic. While the waivers of regulatory requirements have provided flexibility in how nursing homes may operate, they have also removed the minimum standards for quality that help ensure residents’ health and safety are protected.  Declaration of Blanket Waivers Recently, CMS conducted some surveys that revealed significant concerns with resident care that are unrelated to infection control (e.g., abuse, weight loss, depression, pressure ulcers, etc.). Waiver of certain regulatory requirements may have contributed to these outcomes and raised the risk of other issues. For example, by waiving requirements for training, nurse aides and paid feeding assistants may not have received the nece...

  Medicare Part A covers skilled nursing and rehabilitation care in a Skilled Nursing Facility (SNF) under certain conditions for a limited time. Coverage for care in SNFs is measured in ‘benefit periods’ or sometimes ‘spell of illness. In each benefit period, Medicare Part A covers up to 20 days in full. After that, Medicare Part A covers an additional 80 days with the beneficiary paying coinsurance for each day. After 100 days, the SNF coverage available during that benefit period is ‘exhausted,’ and the beneficiary pays for all care, except for certain Medicare Part B services. In this article, we shared Medicare SNF billing coverage for the year 2022, and also we bifurcated Medicare SNF billing coverage for Medicare part A, Medicare part B, Original Medicare, and Medicare Advantage (MA). Medicare SNF Billing Coverage Medicare Part A Coverage The SNF Prospective Payment System (PPS) pays for all SNF Part A inpatient services. Medicare Part A covers Medicare-certified SNF s...

  Challenges of Ambulatory Surgical Centre Billing Ambulatory Surgical Centre 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 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 billing could be the only solut...

  SNF Advanced Beneficiary Notice of Non-coverage Medicare requires SNFs to issue the SNF Advanced Beneficiary Notice of Non-coverage to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary; or considered custodial. The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. Form Filling Instructions for SNF Advanced Beneficiary Notice The SNFABN has 5 sections for completion i.e., header, body, option boxes, additional information, and signature & date.  Failure to use this...

As any durable medical equipment (DME) provider will confess, securing reimbursements from Medicare and private insurance carriers is one of the biggest challenges of running a DME business. It’s time-consuming and labor-intensive, and for all their effort, DME providers don’t always get full reimbursements. If not paid attention, inaccurate DME billing could lead to lower revenues and, in worst-case scenarios, cause DMEs to windup their business. Outsourcing your DME billing services to reliable medical billing companies like  MedicalBillersandCoders (MBC)  could be a smart and efficient way to get maximum reimbursements and countless other benefits. Some of the Benefits of Outsourcing DME Billing services are listed below.  Benefits of Outsourcing DME Billing to Improve Your Revenue Less Billing Errors DME billing offers a unique set of challenges. It includes coordinating with different parties and requires an understanding of the HCPCS (Healthcare Common Procedur...

Since family practices are facing a lot of factors that make it more difficult to get paid, it’s more important than ever to get proactive about billing procedures. Being proactive and preventing problems before they occur can help your family practice maximize revenue, ensuring you’re properly reimbursed so your practice can continue providing quality care to patients. Every year, medical providers in the United States leave more than $100 billion dollars of uncollected revenue on the table due to billing errors, coding mistakes, and failure to stay current on medical billing rules. Here’s a closer look at the top 5 medical billing strategies you can use proactively to begin maximizing your family practice revenue. Contact us today to speak with one of our specialists about the benefits of outsourced  Family Practice Billing  management. Top 5 Medical Billing Strategies to Maximize Family Practice Revenue 1. Review your scheduling practices You may need to fine-tune the ...

  Durable Medical Equipment 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 pati...

    Basics of ASC Billing An Ambulatory Surgical Center (ASC) is defined by CMS as a facility with the sole purpose of providing outpatient surgical services to patients. ASC is a facility that, very simply, specializes in outpatient procedures. Procedures done at an ASC are more extensive than those done at the typical provider’s office but are not so involved that they require a hospital stay. The basics of ASC billing (Ambulatory Surgery Center) are completely different than any other type of billing. For ASC services to be paid, the service must be determined to be medically necessary. Generally, there are two primary elements in the total cost of performing a surgical procedure: The cost of the  physician’s  professional services for performing the procedure The cost of services furnished by the facility where the procedure is performed (for example, surgical supplies and equipment, and nursing services). In general, the Medicare program pays ASCs 80 pe...

Physician billing, which is also termed  Ambulatory Surgical Center (ASC) billing  or professional billing is the billing of claims for services, which were offered or performed by healthcare professionals or a physician that also includes inpatient and outpatient services. In this blog, we will take a quick look at both physician and hospital billing. Majorly, these claims are billed electronically as the 837-P form. Institutional billing deals with claims for procedures or work executed by institutions like nursing facilities, inpatient and outpatient centers, and hospitals. Moreover, these claims need the 837-I electronic version or the UB-04 paper form. Institutional or hospital billing is basically more complicated and needs separate billers as well as coders. As far as physician billing is concerned, the role of billers and coders is merged many times. Nevertheless, when we emphasize medical billing and coding, one should specifically understand that physician billing se...

  Beginning January 1, 2008, the CMS publishes updates to the list of procedures for which an ASC may be paid each year. In addition, CMS publishes quarterly updates to the lists of covered surgical procedures and covered ancillary services to establish payment indicators and payment rates for newly created Level II HCPCS and Category III CPT Codes. Keep reading to learn ASC billing and coding. The complete lists of ASC-covered surgical procedures and ASC-covered ancillary services, the applicable payment indicators, payment rates for each covered surgical procedure and ancillary service before adjustments for regional wage variations, the wage-adjusted payment rates, and wage indices are accessible on the CMS Web site. To be paid under this provision, a facility must be certified as meeting the requirements for an ASC and must enter into a written agreement with CMS. ASCs must accept Medicare’s payment as payment in full for services with respect to those services defined as AS...

  Surgical Assistants Practices lose insurance reimbursement by incorrectly billing surgical assistants. In such cases, the major reason for claim denials is to use the wrong modifier/ not use the modifier. In this blog, we tried to cover every aspect of billing for surgical assistants including defining surgical assistants, billing guidelines, reimbursement policies, and accurate use of modifiers. Surgical assistance services can be provided by a Health Care Professional other than a Physician (i.e., Physician Assistants (PA), Nurse Practitioners (NP), or Clinical Nurse Specialists (CNS) in accordance with the requirements outlined in Medicare Claims Processing Manual Chapter 12. Surgical assistants include co-surgeons, assistant-at-surgery, and team surgeons. Co-Surgeons are defined as two or more surgeons, where the skills of both surgeons are necessary to perform distinct parts of a specific operative procedure. Co-surgery is always performed during the same operative sessi...

  Podiatry is one of the medical specialties, which concentrates on the diagnosis and treatment of the human feet and ankles. Podiatrists care about different conditions related to the foot such as heel spurs, toenails, fallen arches, foot/ankle injuries, and plantar fasciitis. Services offered by podiatrists should be paid for by either insurance companies or the patients or by both. Podiatry billing services are a very critical part of many practices. As far as podiatry billing services are concerned, it is able to collect money efficiently from payers that are accountable for covering the services offered by podiatrists and patients. There are some services, which are not covered by payers, especially those which are not considered medically needed for appropriate foot care as per the  Medicare Benefit Policy Manual   ( MBPM ) . Below we Mentioned the Services which are Covered by Payers: An exception to podiatry services covered There are specific foot care serv...