Medical Billers and Coders

  In the Final Medicare Physician Fee Schedule (MPFS) for 2022 issued on November 2, 2021, the Centers for Medicare and Medicaid Services (CMS) added five new CPT codes in the categories of Chronic Care Management (CCM) and Principal Care Management (PCM) and increased reimbursement for already existing codes in the same categories. These codes are like chronic care management services in that the work involves the establishment, implementation, revision, and monitoring of a care plan for a patient. However, principal care management focuses on a single condition (rather than two or more). In the year 2022, Medicare will accept CPT codes 99424, 99425, 99426, and 99427, and discontinue HCPCS codes G2064 and G2065. 2022 Revised Codes for Principal Care Management CPT 99424: Principal care management services, for a single high-risk disease, with the following, required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at  signi

  EDI in medical billing helps doctor’s offices, hospitals, labs, pharmacies, and other healthcare facilities to communicate with each other. In today’s world of electronic claim submission, electronic data interchange (EDI) has become an essential component of medical billing processes. EDI enables healthcare providers and insurance companies to exchange crucial billing information efficiently and securely. This article will explore the details of EDI in medical billing, exploring its significance, working mechanism, and benefits in medical billing. What Does EDI Stand for in Medical Billing? EDI stands for electronic data interchange. In the context of medical billing, EDI refers to the electronic exchange of standardized healthcare transactions between healthcare providers and insurance companies. It involves the transmission of data in a structured format, allowing for seamless communication and streamlining of billing processes. Electronic Billing and EDI Transactions Electr

  The Centers for Medicare & Medicaid Services (CMS) is resuming the Targeted Probe & Educate (TPE) audit, effective September 1, 2021. Based on data analysis of claims payment, CMS will identify areas with the greatest risk of inappropriate program payment. CMS’s Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. Let’s focus on the basics of Medicare TPE audits. A TPE audit is a close examination of the billing practices that a healthcare provider uses for its Medicare claims. The provider’s Medicare Administrative Contractor (MAC) conducts the auditing process. If unusual billing practices, mistakes, or discrepancies are found between the Medicare claims and the healthcare services that were provided to the patient, the MAC will help the provider fix the problems and show them how to avoid making them in the future. Even though the MAC conducts the audit, the  Centers for Medicare an

  Vagus Nerve Stimulation (VNS) is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the generator to the left vagus nerve. Electrical signals are sent from the battery-powered generator to the vagus nerve via the lead. These signals are in turn sent to the brain. VNS provides indirect modulation of brain activity through the stimulation of the vagus nerve. The vagus nerve, the tenth cranial nerve, has parasympathetic outflow that regulates the autonomic (involuntary) functions of heart rate and gastric acid secretion and also includes the primary functions of sensation from the pharynx, muscles of the vocal cords, and swallowing. It is a nerve that carries both sensory and motor information to/from the brain.  Medicare coverage  for many tests, items, and services depends on where you live.  Nationally Covered Indications  VNS treatment is reasonable and necessary for patients wi

  PAR and non-PAR Providers with Medicare The Center for Medicare & Medicaid Services (CMS) is a federal agency within the Department of Health and Human Services that manages and oversees the Medicare program for beneficiaries. Physicians are required to comply with numerous laws and regulations related to various aspects of their practice within the Medicare program. Each year physicians have the opportunity to review and modify their contractual relationship within the Medicare program. Participating providers are referred to as ‘PAR’ while non-participating providers are referred to as ‘Non-PAR’. Providers need to understand their options within the program to ensure proper reimbursement. The primary difference between being a PAR and a non-PAR Provider lies in how fees will be collected. The three Medicare contractual options available for physicians are as follows: Participating (PAR) providers can sign a participating agreement and accept Medicare’s allowable charges as

  Let’s always keep in mind that patients come with some problems that they hope will be solved quickly and without any hassles. So, how does one keep the patients happy? While keeping a smiling face makes good sense, giving the patients a great experience is an art in itself. Here are a few valuable tips that can help you do just that.  Outsourcing your medical billing can seem scary. The more empowered you are, the easier will be to make the right decision for your practice´s medical billing needs. In our webinar  “Five reasons to outsource your medical billing” , Health Prime´s Strategic Account Manager, Caroline Balestra, reviewed the main reasons to outsource your billing and some benefits for your medical practice. 5 Things About Better Medical Billing and Happier Patients Give them the right to have a better choice Being transparent is probably the first step in giving healthcare to patients in distress. Allowing them to make the right choice, or rather giving them the righ

  Importance of A/R Follow-up Medical billing is a complicated process that requires special skills in medical billing, coding, denial, and AR management from experienced and well-trained staff. The financial health and success of any medical practice are dependent on maintaining positive cash flow. In order to provide patient care and cover expenses, it’s important that payments are not delayed, lost, or denied. With the understanding of billing guidelines and a highly trained staff in place, you’ll start to reap the benefits of high first-pass acceptance rates and shorter billing cycles. But even when everything goes right, some claims will still be rejected or denied. The accounts receivable (A/R) follow-up team in a healthcare organization is responsible for looking after such denied claims and reopening them to receive rightful reimbursement from the insurance carriers. Even though these claims could be held up by simple mistakes, you will be surprised to know that over half of

  Provider-Based Physician Services Providers may retain physicians on a full-time or part-time basis in, for example, the fields of pathology, psychiatry, anesthesiology, and radiology, and in many instances (especially in teaching hospitals) in other fields of medical specialization as well. Any one of these physicians may be engaged in a variety of activities including teaching, research, administration, supervision of professional or technical personnel, service on hospital committees, and other hospital-wide activities, as well as direct medical services to individual patients. The provider’s arrangement may be with a single physician or a group of physicians who assume joint responsibility for discharging agreed-upon duties. Provider-based physicians may include those on a salary, or a percentage arrangement, lessors of departments, etc. (whether or not they bill patients directly). The services to the patient are known as the professional component. The services to the provid

  Understanding False Claims Act As a healthcare practice, you can typically submit claims to Medicare or Medicaid. Your claims are bills for goods you provide and services you conduct for patients. These federal health insurance programs cover the costs associated with your services. The False Claim Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded directly, in whole or in part, by the United States Government or any state healthcare system. In other words, healthcare practices must not bill the government for things they did not do. Examples of false claims include billing for services not provided, billing for the same service more than once, or making false statements to obtain payment for services. Penalties under the False Clai

As a healthcare provider, during your residency, you probably are not focused on who pays for your patients’ care. Once you start practicing, it is important to understand who the payers are. The U.S. healthcare system relies heavily on third-party payers, and, therefore, your patients often are not the ones who pay most of their medical bills. Third-party payers include commercial insurers and the Federal and State governments. When the Federal Government covers items or services rendered to Medicare and Medicaid beneficiaries, the Federal fraud and abuse laws apply. Many States also have adopted similar laws that apply to your provision of care under State-financed programs and to private-pay patients. Consequently, you should recognize that the issues discussed here may apply to your care of all insured patients. The topics discussed in this article will help you in avoiding fraudulent billing as you have just started your new medical practice.  Accurate Coding and Billing Gover

Receiving accurate insurance reimbursement for delivered services is always been a challenge for healthcare providers. Practice owners spend most of their time and energy on doing administrative tasks of medical billing to receive sufficient insurance reimbursements to cover overhead expenses and provide quality care. But often they make this task even harder by doing sloppy coding and billing which leads to delayed or incorrect reimbursements from insurance carriers. Providers can follow some practice management guidelines to improve coding and billing accuracy. It will help reduce denials and rejections, ultimately helping to enhance practice collections. These guidelines will help receive timely and accurate reimbursements and avoid the chances of external payer coding or billing audits.  Practice Management Guidelines to Improve Practice Collections Front Office Issues Leading to Claim Denials  Most practices only focus on submitting claims quickly but no one pays attention to

Understanding External Payer Audits An external payer audit is an examination of a healthcare practice’s finances or processes conducted at the will of payers. These payers are either the government or a commercial insurance company looking to ensure correct payments were provided to the practices for past cases. Government audits can be broken down even further into Medicare, Recovery Audits, and Medicaid audits. Whenever the payer has concerns about medical coding and medical billing, they may initiate an external audit process. In this blog, we discussed basic guidelines to avoid external payer audits. Reasons for Initiating Payer Audits There are a number of reasons why any payer might initiate an external audit, the most common reason is a medical necessity. The providers may feel that his or her treatment recommendations are medically necessary. But if they are not documented properly, it’s an issue. The provider may explain all the reasons why the treatment was medically ne

  “Although, in-house medical billing, owing to its proximity to the physician’s supervision, can work relate itself better than the outsourced solutions, yet, it is beset with inherent adequacies” Outsourcing medical billing services are composed of experts who have the time to carefully process your billing accurately. Although physician’s practices have equally been divided between in-house medical billing and outsourced solutions, there has been considerable migration to the latter in the last 5 years or so. The pattern, amidst an interesting debate over which is better – in-house or outsourced – assumes greater significance. Whereas the trend may enable us in concluding outsourced medical billing is financially more viable, coming to a hasty conclusion without making a relative study of the two might prove to be premature. Therefore, amidst the prevailing scenario, there should be an impartial comparison of the relative merits and demerits of the two available recourses. Outsou

  Healthcare Revenue Cycle Management Healthcare Revenue Cycle Management professionals use information technology to keep track of claims through their entire lifecycle. This is necessary to ensure payments are collected and denied claims are addressed. However, some hospitals struggle to put information technology and billing infrastructure in place in a way that successfully manages claims as well as large outpatient networks. In today’s healthcare environment, effective health information technology is essential. Unfortunately, not all hospitals and clinics have the capital or infrastructure to invest in new technologies or even required technologies, such as  EHRs . If you have ever come across or worked in a healthcare organization, you must be aware of the importance of medical claims and how they can put financial constraints on your revenue cycle when rejected. The administrative work of a healthcare facility is different from other industries as clinical treatment is not a

Answering a few questions will help you code correctly for laceration repairs (such as staples, sutures, or similar closure materials):  Was the repair limited to the epidermis, dermis, and subcutaneous tissue, or did you need to probe more deeply?   Use simple repair codes for superficial wounds (epidermis and dermis) that need just a single-layer closure. On the off chance that the provider fixed a deeper layer of subcutaneous tissue or superficial fascia, however, then assign intermediate repair codes. Remember that these codes don't include repairs to muscles. Such cases are generally referred to as surgical specialists.  Where on the patient's body was the repair made?   The codes inside the simple and intermediate categories are further characterized by the location of the injury. For instance, refer to simple repairs on the scalp, neck, axillae, external genitalia, trunk, and/or extremities, the face, ears, eyelids, nose, lips, and/or mucous membranes.  How long is the i

  There may be a requirement for medical equipment or supplies for kids with disabilities or having uncommon health care needs. When you identify your kid's needs then, you will consider the various alternatives well as the approaches to pay for durable medical equipment. In any case, insurance is one of the answers to your concern as both Medicaid and other health insurance which are often covered a few or the entirety of the expenses for these medically necessary things.  Following tips are important stroll through for insurance system including Medicaid:  Durable Medical Equipment (DME) and Supplies for Kids  DME is a sort of medical equipment, which is for the most part utilized for a more extended timeframe. Majority of the durable medical equipment foreseen to keep going for more than three years.  A portion of the DME's are as per the following:  Hospital beds  Hearing aids  An augmentative communication device particularly for youngsters who can't talk or having a t

All the healthcare providers are looking for a smoothed out DME billing operation team that may handle their DME billing process absent a lot of issues.  As indicated by MarketWatch, the worldwide marketplace for Durable Medical Equipment (DME) is anticipated to accomplish up to USD 246.6 billion continuously in 2026. This ascent is anticipated in view of the favorable circumstances that DME items like a wheelchair, nebulizer, canes, crutches, walkers, and so forth wear people groups. Aside from making patient's life simple, the DME items likewise help these patients carry on with an existence absent a lot of torment making them autonomous.  Other than the above benefits, technological advancement inside the DME medical equipment is furthermore another explanation behind the expansion of the DME market and truth be told, the rising geriatric population. As elderly folks individuals are more inclined to constant sicknesses, requiring broadened care that includes a greater amount of

As indicated by the analysis of GAO, CMS's prior authorization programs for durable medical equipment (DME) made an expected $1.9 billion in Medicare reserve funds.  CMS's prior authorization programs for durable medical equipment (DME) and mobility devices have controlled superfluous spending, as indicated by another Administration Responsibility Office (GAO) report. This was made somewhere in the range of $1.1 and $1.9 billion in Medicare reserve funds from 2012 to 2017.  Prior authorization is a payment approach utilized by private guarantors that for the most part requires health care providers and providers to initially exhibit consistency with the inclusion and payment rules before specific things or services are given to patients, as opposed to after the things or services have been given. This methodology might be utilized to reduce uses, pointless use, and inappropriate payments.  The Places for Medicare and Medicaid Services (CMS) has started utilizing prior authoriz

Ambulance Billing Services Is it turning into an increasing number of hard to chase after-payments and low fee or no rate collection from the uninsured? Is your crew locating it difficult to manage up with the common repayment rule changes? Then it is high time you outsource ambulance billing services to a skilled carrier company. EMS groups that do not outsource billing and series offerings, locate themselves having to allocate highly-priced assets closer to billing and collections in addition to in the direction of compliance necessities. MBC is one such service provider that may be a one-prevent-store for all of your ambulance billing services. we have the specified knowledge and experience to provide the required services at inexpensive costs and within a brief turnaround time. Ambulance Billing offerings supplied by using MBC We're a complete-provider offshore ambulance billing agency, committed to enhancing revenue recoveries for governmental and privately-owned ambulance of

Our billers specialized in Ambulance Transportation billing offerings for numerous years adhere to complex necessities from diverse agencies, maximum substantially Medicare. Failure to inappropriately processing or assigning your Emergency Medical Services (EMS) claims submitting to general clerks who are not aware of the regulations makes your service at risk of prices of fraud, payments of vast penalties, and pending receivables. Our medical billing services expertness in understanding the current guidelines and the commonplace errors which can be encountered while billing for ambulance transport services maintains them in a great function to avoid the maximum common mistakes of: Price Schedules Coding  Inner Strategies Rate Time Table Mistakes Our Ambulance Transportation billing services are properly aware of all 4 strategies of billing allowed by means of providers currently. They examine whether or not your price agenda permits a fully itemized billing or the only one that lets