Coding Strategy

Participation can put extra bread in your basket.

Back again for 2010 is Medicare’s incentive-driven physician quality reporting initiative (PQRI), aimed at tracking quality metric or patient care services that physicians provide. When the practice treats enough patients in the same category, some PQRI dollars might be only a few codes away.

If you know the basics and focus your efforts, PQRI reporting can be a breeze and a boon to your bottom line.

Anyone confused about PQRI — or with questions about setting up a PQRI program in a specialty setting — should go immediately to the CMS PQRI tool kit.

Where? Check out the tool kit here.

“This kit includes valuable resources to assist eligible professionals in the successful integration of PQRI measurement into their practice. CMS suggests that eligible professionals review and discuss the following materials with their staff,” Medicare says.

The kit lists three PQRI “tools” designed to help practices comply with PQRI:

1. 2009 Implementation Advice for 2009 PQRI and E-Prescribing — A publication that introduces the coding and reporting principles underlying successful PQRI reporting.

2. 2009 PQRI Code Master Single Source — A numerical listing of all codes included in PQRI intended for incorporation into billing software.

3. 2009 Data Collection Worksheets — You should use measure-specific worksheets that walk the user step-by-step through reporting for each measure. “These worksheets may be used by the practice on a concurrent basis to collect PQRI data,” CMS says.

Missed the “2010 PQRI: Preparing for Performance” audioconference? Order a CD.

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Want to know what RAC contractors will be looking for next? Here’s the link.

Recovery audit contractors (RACs) are working hard to expand their lists of approved issues, and you should keep a close eye on your services in these areas as well.

Health Data Insights (HDI), the RAC contractor for Region D, posted 66 new approved issues for review in January, with the following just a small sample of what HDI plans to review going forward:

• Global surgery pay versus technical component (TC)/professional component (modifier 26) and

• New patient versus established patient cases.

Keep in mind: When a RAC lists its open issues, it also lists the applicable states where it is reviewing them. Some issues are under review for all states that fall into a particular RAC’s purview, while others may be applicable to just one or two states.

Bottom line: To stay on top of the issues that your RAC is reviewing, check in on the applicable Web site from time to time.

To learn more about what the RACs are doing in YOUR region, go here.

© Part B Insider. Download your 2 FREE sample issues here.

If you think the RACs are the only auditors you need to worry about, think again. Meet the MICs.

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This 3-step checklist will boost your bottom line.

With fewer patients following through on procedures because of economic and financial struggles, and an increasing number of patients not paying their bills, your practice needs to find ways to improve your A/R and bring in deserved money. Adapting an up-front deductible collection policy is one proven way to do both — and setting up a policy can be as easy as 1-2-3.

1. Confirm the Deductible With the Payer

Insurance verification services now make it possible for practices to find out if a patient has met his deductible yet. Some services can tell you how much of the deductible remains unpaid. Because this information is available online, your practice can get this information last-minute, the day of, the day before, or several days before the patient is scheduled to come in for a service or procedure.

“I have started to look up insurance deductibles and copays on Web sites,” says Joy Bloodworth, CPC, CCS-P, office manager and coder for Surgical Associates in Cordele, Ga.

Pointer: Check with your benefits verification services, as some offer real-time information on how much of a patient’s benefits have been used to date, the deductible to date remaining, number of hospital days remaining, skilled nursing facility (SNF) days remaining, and if the patient has Medigap coverage that will cover a portion of the payment.

2. Contact the Patient Before the Procedure

Once you have the information from the payer about what the patient’s responsibility will be, you should contact the patient. Most practices are more successful when they contact the patient several days before the procedure, rather than the day of the procedure, experts say.

“We are calling patients about one to two weeks in advance if possible requesting the deductible or their percentage of the allowable of their insurance for the procedure being performed,” says Lori Owens, CPC, CGIC, insurance supervisor at Ohio Valley Surgical Specialists in Owensboro, Ky. “It is working fairly well.”

Be clear: Make sure you tell the patient where you got the information about her deductible and let her know that the amount is an estimate based on the services your physician expects to perform, Bloodworth cautions. Otherwise, you may get calls from patients after procedures “saying they paid up front and don’t owe any more after the insurance pays,” she says. “When I get the information from the insurance company, I tell the patient it is just an estimate and after insurance pays we will adjust the payment form accordingly.”

3. Consider Rescheduling When You Can’t Collect

If you cannot collect up front from a patient, you’re left with two options: Cancel the procedure or perform the procedure and hope the patient pays you afterwards when you send a bill.

“If there’s no emergency, we ask that the patient pay the copay and deductible up front,” Bloodworth. “We will reschedule if the patient does not have it and the physician says it is elective.”

Some patients may get upset that you’re asking for their money before you perform a service, especially if they don’t feel they can pay their deductible. “We feel that these patients would probably not pay anyway and it makes room for patients waiting to have procedures performed,” Owens explains.

Other patients, however, may simply need additional time to pay you. Even when you don’t collect up front, making an attempt can still help you collect eventually. A patient will know before having the procedure exactly how much she will owe your practice.

“You may not collect from all,” Owens says. If her practice doesn’t cancel the procedure, the call “just lets the patient know how much to expect” when the practicesends a bill.

Set up a payment plan: Some patients cannot come up with the entire deductible amount up front and will ask to make payments, Bloodworth explains. “They have to come up with at least half of it and sign a form showing the balance due and payments less than $200 will be paid by three months and over $200 will be paid by six months.”

Bottom line: At least attempting to collect deductibles up front is beneficial for your practice. “Our A/R is more in line now and we definitely have seen a difference,” Owens says. “It is worth the hassle.”

© Medical Office Billing & Collections Alert. Download your 2 FREE sample issues here.

Available on CD: Billing & Collections Reference Pack, Updated for 2010. Buy individual recordings, or purchase the entire series for a discount.

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Follow our links and advice to put more plusses in your claims column

Back again for 2010 is Medicare’s incentive-driven physician quality reporting initiative (PQRI), aimed at tracking quality metric or patient care services that physicians provide. When the practice treats enough patients in the same category, some PQRI dollars might be only a few codes away.

If you know the basics and focus your efforts, PQRI reporting can be a breeze and a boon to your bottom line. Check out this rundown on “The Whats?” of PQRI.

What’s In it for Me?

Coders can garner an extra payout for PQRI-eligible patients that your group treats and you code correctly; for 2010, Medicare will fork over a 2 percent bonus if you meet certain criteria.

Lowdown: In order to qualify for the PRQI bonus, you have to report on at least three of 179 PQRI measures in 80 percent of the eligible cases, explains Alice Marie Reybitz, RN, BA, CPC, CPC-H, CHI, a healthcare coding and billing consultant based in Belleair, Fla.

What Extra Coding Work Is Involved?

The devil’s in the details with PQRI reporting. To properly report PQRI measures, you need to report a series of codes that corresponds to a PQRI numerator and denominator, explains Eileen Lane-Coffill, CPC, PCS, senior compliance auditor at Boston’s HMFP Compliance.

Breakdown: “The numerator is the ICD-9 and CPT category I code, and the denominator is the CPT category II code[s],” Coffill says. This category II code is usually an F code — or “PRQI code.”

Get to know the PQRI codes, which you’ll find on this PQRI Web site. The PQRI codes represent the measure that you are reporting on; leave these off a claim, and you cannot count it toward PQRI.

Example: An ED physician provides a level-four ED E/M service to a patient complaining of chest pain; final diagnosis is precordial chest pain. This encounter qualifies for PQRI measure 54 (12-lead electrocardiogram [ECG] performed for non-traumatic chest pain).

Patients who qualify for measure 54 will be common in many EDs, confirms Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. To qualify for PQRI, code this claim as follows:

• Numerator: 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity …) for the E/M with 786.51 (Precordial pain) appended to represent the patient’s condition.

• Denominator: 3120F (12-lead ECG performed [E/M]) to represent the PQRI measure. Each measure has its own set of diagnosis requirements. Coders are allowed to report on measure 54 for patients with a diagnosis of precordial pain (786.51).

Some other acceptable diagnoses for measure 54 include:

413.0 (Angina decubitis), 413.1 (Prinzmetal angina),

413.9 (Other and unspecified angina pectoris), 786.50 (Chest pain, unspecified).

Use this: Coding for PQRI without using the PQRI Tool Kit is as futile as flying a kite with no string. Bookmark this site and visit it often to learn how to code each measure.

Adapted from ED Coding Alert. To read a longer version of the article, sign up for a FREE trial on Supercoder and select ‘Emergency Medicine’ as your topic area.

PQRI 2010: Field-tested ways to choose the measures that yield the most dollars for your practice. An audio training event.

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We’ve got the links you need to keep up with these bottom-line changers from HHS, CMS.

While most of us were celebrating the last few days the Old Year and preparing to welcome the New Year, the federal regulators had one last, little rulemaking frenzy for 2009. The result is a 555-page proposed rule implementing the HITECH portion of the ‘ARRA’ stimulus bill, as well as a last-minute change to the Medicare Physician Fee Schedule.

Why you should care about the proposed HITECH rule: Remember ARRA, that economic stimulus bill Congress passed last February? In the mammoth bill is the HITECH Act, which mandates a $44,000-per-physician incentive for practices that adopt electronic medical records early. To obtain the incentive, practices must meet certain criteria, which the feds have outlined in this 555-page proposed rule published December 30th.

Not exactly light reading, so if you want a quick fact sheet, go here and stayed tuned to Coding News for alerts to the important stuff you need to know. Example: We’ll let you know the minute we figure out exactly what the feds mean by “meaningful use.”

The public has 60 days to comment on the proposed rule before federal regulators go back to the drawing board to finalize it.

The Medicare Physician Fee Schedule News: CMS made some last minute changes to the Medicare Physician Fee Schedule Database for 2010. ”Over the Christmas holiday, Congress froze the conversion factor at the 2009 rate ($36.0666) until Feb. 28,” explains Part B Insider sage Torrey Kim. “As of March 1, it will supposedly go down to the proposed 2010 rate, but I’m sure there will be another vote blocking it by then.” You can read all about it in this issue of MLN Matters and access the revised fee schedule here. (Click ‘2010′ and download the schedule that comes up.)

Can PQRI boost your practice’s bottom line? Find out in this audio training event.

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