DRG Coding Advisor
Fear of federal fraud police may be costing you a lot
Uncertainty leads to underpayments
More physicians are being extra-cautious when billing Medicare, afraid of drawing the attention of the federal fraud police. Add to this the services that are often unknowingly undercharged by many practices, and you can end up missing out on a sizable amount of legitimate payments.
Being cautious in today’s regulatory environment is prudent. However, there’s no reason you should not be paid full freight for legitimate services. Next time you review your back-office practices, check to see if you are making any of the following common billing and coding mistakes that can leech the lifeblood out of your practice’s cash flow:
• Underbilling for office visits. Intimated by the idea of being red-flagged by government bean-counters, more physicians are taking the cautious approach and down-coding office visits for fear that claiming levels four and five visits will prompt an audit.
Is billing inconsistent with normal patterns?
Sadly, there is some truth to that thinking. But the real smoking gun auditors look for is a constant billing of higher evaluation and management services across a wide array of patients in a manner that seems inconsistent with normal practice patterns. In turn, if you do a properly documented (documentation is very important ) multisystem exam of a moderately ill patient that requires multiple diagnoses and you only bill for a level three service instead of level four, you are just denying yourself appropriate payment, which in a busy practice can quickly run into the thousands of dollars. On the flip side, billing a level four service for a hypertensive patient who comes in every month could get you into trouble.
• Mismatching ICD-9 codes and procedure codes. Too many physicians simply mark ICD-9 and CPT codes on a superbill, assuming the billing office will take care of the rest. The problem is that this can mean CPT and ICD-9 codes get mismatched or left off the bill altogether — a sure-fire way to get a claim denied or questioned.
Private codes can prevent mismatching
One way to avoid this problem is to have the physician place his or her own private code (a number or letter) matching each diagnosis with the corresponding CPT codes on the superbill to eliminate confusion about which ICD-9 goes with which CPT. While many experts say it is easier for physicians to use a superbill or fee slip that already lists the practice’s most frequently used CPT and ICD-9 diagnostic codes, others argue that offices should just do away with the superbills and have physicians write out their diagnoses while more experienced billers fill in the most appropriate diagnosis-related codes.
• Not using the most specific and recent ICD-9 codes. Despite the fact many four-digit ICD-9 codes have been replaced with more specific five-digit codes, many physicians still use the older four-digit format without thinking. Unfortunately, Medicare is now more likely to challenge these four-digit claims. Some examiners, for instance, will question why a simple code for abdominal pain was used instead of a code specifying the exact location of the pain.
• Not using modifiers. At first glance, coding rules prohibit billing a patient for an office visit and a minor procedure on the same day. But it is allowed to bill for both an office visit and a minor procedure provided the physician does enough to justify both charges, the services are properly documented, and a modifier -25 is used to let the payer know more was done than just giving the patient an injection. The catch: If the patient was only scheduled to receive a joint injection, for example, and that’s the only service you provided, you cannot charge for both the procedure and the office visit.
• Not billing for injections. According to the ProStat Resource Group in Shawnee Mission, KS, physicians often forget that they can bill for administration of an injection as well as for the drug or vaccine itself. Remember that charging for both an injection (a minor procedure) and an office visit on the same day without using a modifier is generally prohibited. But there are exceptions. For instance, when giving a vaccination for pneumonia, influenza, or hepatitis B, physicians can bill for the office visit, the injection, and the vaccine.
• Confusing new patient visits with consultations. A patient consultation pays more than a new patient visit. To justify billing for a consult over a new patient visit, the patient must have been sent to you for a consult by another physician, and you must provide the referring physician with an opinion or advice — preferably in writing, which should then be included in the file.
• Not billing for counseling. When a physician spends more than half of his or her face-to-face time counseling a patient or coordinating care — calling other physicians, making arrangements for diagnostic tests, etc. — he or she can bill for a higher level of service, even if the physician doesn’t perform an exam or make a new diagnosis, says Orlando, FL-based practice consultant Leslie Witkin.
For instance, if during a visit a physician sees a patient recently diagnosed with cancer and does nothing but counsel the patient, talk to family members, and make arrangements for further treatment, the doctor is still entitled to code the visit as a level five, provided that more than half of the visit — 20 minutes minimum, because level-five visits must be least 40 minutes long — was spent counseling the patient and coordinating care.
• Not billing for the nurse’s time.
A level one code can be used for office visits if nursing staff provide routine services when a physician is not present. However, it is best to bill only for when the nurse does those small extra things like showing a patient how to use insulin or giving the patient some other kind of detailed instructions.
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