Home Health Agencies: Here's Why PDGM Payments Keep Falling Short

-
Image
Home health agencies can provide the right care, submit claims on time, and still see Medicare reimbursement come in lower than expected. The reason is often not simply a billing error. Under the Patient-Driven Groupings Model (PDGM), reimbursement depends on several factors, including the patient's clinical characteristics, functional needs, comorbidities, timing of the period, and whether the period meets the requirements for a full 30-day payment. For 2026, CMS also finalized changes to PDGM case-mix weights, functional impairment levels, comorbidity adjustment subgroups, and Low-Utilization Payment Adjustment (LUPA) thresholds. CMS also finalized permanent and temporary payment adjustments for home health. That means a reimbursement drop deserves more than a quick review of the claim amount. The real question is: What changed between the care provided and the payment received? How PDGM Determines Home Health Payment PDGM uses a 30-day period of care rather than the older 60-day...
Post a Comment

Avoid These Common Coding Mistakes in Your Family Practice with a Medical Billing Partner

-

 

familypracticemedicalbillingservices.jpg

Operating costs were listed as the top concern for medical practices in 2013; however, billing and payment hurdles also kept physicians on their toes. Family practitioners also raced to keep up with changes in CPT codes which proved extremely challenging, especially for providers with weak profit margins. The majority of revenue for a typical family practice comes from the submission of ICD-9 and CPT codes to third-party payers. Therefore, it becomes essential to code accurately for every single service to receive timely payments during family practice billing.

Coders while carrying out family practice billing need to have a firm grasp on standard primary care coding because, unlike other specialties, family practices keep facing a variety of patient problems.

Time is required to study the CPT manual and documentation guidelines for accurate coding for error-free practice billing. An updated CPT manual will have to be ordered every year to make providers and coders aware of new, revised, and deleted codes.

Common Coding Mistakes That Can Cost Your Family Practice:

Here are a few medical coding and billing procedures that coders should not avoid at any cost to ensure accuracy in claim submission during practice billing:

  • Encounter forms should be up-to-date or else your practice can lose various opportunities to obtain revenue. This task is time-consuming but extremely vital for error-free coding
  • The medical necessity of services being offered by your practice should be substantiated as payers are becoming increasingly concerned about the same
  • Physicians need to get involved with billers and coders in a selection of ICD-9 codes, codes valid for a visit, or services linking the codes to associated CPT codes
  • Appropriate levels of E/M services should be selected and documented to ensure error-free coding
  • Coders will have to learn the rules of using modifiers because they can be the difference between denials, full reimbursement, or reduced payments
  • Charges should be captured for every offered service

How can you Achieve Error-Free Coding?

Family practice physicians can improve the revenue cycle management of their practice with correct CPT coding. Staying up-to-date with the coding changes related to family practice billing is a tedious task but it cannot be avoided if you want to prevent revenue loss and fraud and abuse concerns.

To learn more about Avoid These Common Coding Mistakes in Your Family Practice with a Medical Billing Partner, click here: https://bit.ly/3NCEE9F  Contact us at info@medicalbillersandcoders.com/ 888-357-3226.

Location: United States

Comments

Post a Comment

Popular posts from this blog

Is Your Neurology Billing Outsourcing Helping or Hurting You at Year-End?

-
Image
  As year-end approaches, neurology practices face a crucial decision: Is your billing outsourcing truly improving your financial performance, or silently affecting your revenue? Neurology billing is complex due to time-based coding, modifier usage, high documentation requirements, frequent audits, and prior authorization challenges. If your billing partner lacks neurology-specific expertise, it may lead to claim denials, revenue loss, and compliance risks. Signs Your Neurology Billing Outsourcing Is Helping If your billing partner is performing well, you will see: • Reduced denial rates for neurology codes (EEG, EMG, Botox, Nerve Conduction Studies) • Faster reimbursements and fewer delays from payers • Active recovery of old AR beyond 60, 90, or 120+ days • Accurate CPT, ICD-10, and modifier usage for neurology procedures • Clear billing reports, denial analysis, and revenue insights • Compliance with Medicare, commercial payers, and documentation standards Warning ...
Read more

How Hidden OB-GYN Billing Errors Are Quietly Costing You Millions Each Year

-
Image
  The Silent Revenue Leak in OB-GYN Practices Most OB-GYN practices don’t realize they’re bleeding money. Not in dramatic, headline-grabbing ways, but quietly, steadily, month after month. The phones are ringing, appointment slots are full, deliveries are happening, and yet the numbers never seem to match the effort. Sound familiar? This is often the first sign of hidden OB-GYN billing errors working behind the scenes. These errors don’t announce themselves. They don’t crash your systems or send angry alerts. Instead, they slip through claims, hide in coding nuances, and quietly shave thousands—or millions—off your annual revenue. OB-GYN billing is uniquely complex compared to other specialties. Between global maternity packages, split billing scenarios, high-risk pregnancy coding, and ever-changing payer rules, the margin for error is enormous. A single missed modifier or incorrectly bundled service might seem insignificant on its own. But when repeated across hundreds or thousand...
Read more

The #1 Reason ASCs Lose Revenue from Medicare Claims (And How to Fix It)

-
Image
Ambulatory Surgical Centers don’t lose Medicare revenue because of low case volume. They lose it because of one recurring, preventable failure: Incorrect coding and documentation for Medicare’s ASC-specific payment rules. This single issue triggers denials, underpayments, delayed reimbursement, and permanent write-offs — especially at year-end. If your ASC’s Medicare revenue feels unpredictable, this is why. The #1 Revenue Killer: Not Billing Medicare the “ASC Way” Medicare does not treat ASCs like hospitals or physician offices. Yet many ASCs still: Use hospital-style assumptions Miss ASC-only payment rules Underestimate Medicare’s bundling logic The result? Claims get paid less than expected — or not at all. Where Medicare ASC Claims Go Wrong 1. Incorrect CPT eligibility for ASC payment Not every CPT code is payable in an ASC setting under Medicare. Common mistakes: Billing procedures not on Medicare’s ASC approved list Assuming “covered in hospital” = “covered in ASC” Missing annual...
Read more