Coding Strategy

Uncircled vaccines, administrations could cost your practice 10%.

Think increasing payments in 2010 is a fairy tale? Your magic wand is right at your front desk.

“Check-out coding can have a significant financial impact,” reported Norman “Chip” Harbaugh, MD, in “Vaccine Reimbursement — Quite a Quandary” at The Coding Institute’s December 2010 Pediatric Coding and Reimbursement Conference in Orlando. Not having the check-out person make sure the pediatrician circles all performed services and procedures can cost a practice with median collections of $556,000 between 2.2 percent to 10.2 percent or $12,340 to $57,000.

To shore up those payment holes, train your front desk staff to spot two signs of overlooked coding opportunities.

#1:Verify 90476-90749, 90465-90474 on Crying Departees

If you have a well child age two or younger who comes to the check-out window crying, there’s a good chance he’s just received his needed shots. The pediatrician may have circled the appropriate preventive medicine service code — 99381 (Initial comprehensive preventive medicine evaluation and management of an individual … infant [age younger than 1 year]) or 99382 (… early childhood [age 1 through 4 years]) for new patients or 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual … infant [age younger than 1 year])or 99392 (… early childhood [age 1 through 4 years]) for established patients. She, however, may have forgotten to code the vaccines (90476-90749, Vaccines, Toxoids) or the administrations (90465-+90474, Immunization Administration for Vaccines, Toxoids). “Our coder has been reporting only the vaccines without the administration,” one physician conference attendee reported.

Tip: “The more eyes you have watching the charge ticket and entry, the more likely you are to avoid missed codes,” Harbaugh pointed out. On a less than two years of age well visit check-out in which the toddler is crying, you can train your check-out staff to ask, “How did the vaccines go?”

Let’s say the mother responds, “No, Suzie didn’t receive any vaccines.” The checkout person knows, “OK, 99381, 99382, 99391, or 99392 as the only CPT code is right,”explains Harbaugh, a primary care pediatrician practicing in Atlanta.

If the mother responds, “Three at one time is so hard,” the check-out person can then check with the nurse or medical technician to find out which vaccines the patient received. On the charge ticket, the check-out person can then add the appropriate administration and vaccine codes.

Example: Suppose the child received MMR, DTaP, and Hib at her 15-month preventive medicine service. The check-out attendant would circle:

For the vaccine products:

• 90707 — Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use
• 90700 — Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use
• 90648 — Hemophilus influenza b vaccine (Hib), PRPT conjugate (4 dose schedule), for intramuscular use.

For three shots with physician counseling given to a child less than 8 years of age:

• 90465 — Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day (0.58 relative value units [RVUs])
• +90466 — … each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure) (0.29 RVUs)
• +90466.

$avings: Catching the vaccines and immunization administrations saves the practice approximately $224. Missing the administrations alone costs you approximately $42 using the 2009 Medicare Physician Fee Schedule and conversion factor (CF) of 36.0666. The breakdown includes $20.92 for the initial administration and $10.46 for each of the two subsequent administrations. Combined with losses of $107.25 for the vaccine products (based on average reimbursements) and $74.28 in capital vaccine investment using Harbaugh’s calculations, you would have had a total loss of $223.53.

#2: Let Your Ears Alert You to Injections

Eavesdropping may not be de rigueur, but you can use overheard conversations to catch missed services. “In the ideal (prepayment) coding process, the doctor checks off the code and diagnosis on the superbill and the staff reviews it and catches any errors,” explains Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J.

Let’s say a pediatrician evaluates a patient for croup and the check-out staff heard the physician tell the nurse to give the patient a Decadron shot. The pediatrician didn’t mark “Injection” on the charge ticket. The checkout person checks with the nurse who concurs that the patient received a shot, and the staff then codes the:

• injection administration with 96372 (Therapeutic,prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular)
• drug supply with J1100 (Injection, dexamethasone sodium phosphate, 1 mg).

$avings: Catching that the patient received an injection adds a deserved 0.58 relative value units or approximately $21 to the claim, according to the 2009 Medicare Physician Fee Schedule, which uses a national conversion factor of 36.0666. Most payers adopt this resource-based relative value system in some fashion. The Medicare payment limit for J1100 is $0.09.

@ Pediatric Coding Alert, Editor: Leigh DeLozier, CPC

Want to know more? Sign up for the upcoming live audio conference, Take the Sting out of Coding Infusion and Injection Services, or order the CD/transcripts.

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5 tips help you recover deserved pay.

Collecting money from patients, especially during a recession, can be challenging. If your front desk is responsible for collecting copays and sometimes old balances, its success or failure has a dramatic impact on the practice’s bottom line.

Check out five ways you can improve your front desk collection efforts:

1. When calling to remind patients about their visit date, also remind them of their co-pay amount and any old balances so they come prepared to pay at the visit.

2. When a patient complains about paying a bill, send her to a manager so the bill can be reviewed and explained.

3. Most practice management software will allow front desk staff to view outstanding balances. Your front desk staff can politely remind the patient that there is a balance and say something like, “How would you like to pay your bill today?” Assume that the patient is planning to pay.

4. If the patient has a problem paying their balance or paying for the visit that day, do not discuss this at the front desk. Respect his privacy. Staff may wish to take him to a manager’s office where a payment plan or other arrangement can be established.

5. Ask your manager about offering discounts to patients with no insurance if they pay for the visit at checkout instead of sending them a bill.

And one extra tip: Involve Your Supervisor. Pearl Stafford, front office manager for an internist and gastroenterologist in Naples, FL, who also once worked for a psychiatrist where she assumed the role of the receptionist from time to time, acknowledges that old or really old AR can be difficult to collect. “A lot hinges on the physician,”says Stafford. “In this particular office, my physician provided incentive. Since the AR was so old in many cases, he offered me 25 percent of anything I collected. Most collection agencies charge 50 percent, so this was beneficial to the practice and also worked as an incentive for me.” If something is really old, it’s better to collect some money as opposed to nothing and wipe it off the books.

Carol Gibbons, CEO of CJ Consulting, helps management to set up collection targets for the front desk and then rewards staff when they reach that goal. “In one practice with seven physicians, the front desk as collecting $500 per day at the front desk. After doing training with the front desk staff, we started pushing up their collection goal and then bought lunch each time they reached a new goal. Today, at the front desk, that office collects $2,500 to $3,500 per day in co-payments, co-insurance, and old balances. The manager still buys pizza when they reach a new high in daily collections or rewards individual employees with gift cards.”

Again, your specific role in collections will vary, but these are some ideas that you may wish to present to your manager or physician if they are not yet implemented in your office.

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Verify co-pay early to save time, money

Question: A patient came to our office for a routine exam with the same insurance card she’s had for years. We charged her the standard copay of record. Then I found out her employer changed the terms of the insurance, so the copay she paid was short by $20. What went wrong?

Answer: You might easily assume that when a patient has the same insurance company, the copay is the same as it has always been. But unless you check first, you won’t know the patient’s coverage has changed until after the fact.

Best practice …Set up a process to verify each patient’s insurance information before every visit. The ideal time to verify with a patient or her insurance company is either before the appointment or when she arrives at your office. Devise a plan for how you will obtain patient information early on. Your options include connecting with the patient, a software program, or through the payer directly.

Finally, copy every patient’s insurance card every time. This simple step will put you in the clear for those times when a patient’s terms, copays, or precertification contact numbers have changed.

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No foolin'. We'll use new ABN modifiers on April 1st.

We’ve got the new instructions you’ll need to follow.

CMS will update the ABN modifiers effective April 1, according to MLN Matters article MM6563, dated Oct. 29.

The ABN descriptors will read as follows:

• Modifier GA — Revised to read, “Waiver of liability statement issued as required by payer policy.” You’ll use this when a required ABN was issued.
• Modifier GX — New modifier defined as “Notice of liability issued, voluntary under payer policy.” You’ll append this modifier to claims when you’ve issued a voluntary ABN.

Currently, you can append modifier GA when you issue the ABN for either required or voluntary reasons, says Zia Clarkson, a coding, reimbursement, and practice management consultant in Long Island, N.Y.

Keep in mind: When you know an item is statutorily non-covered, you don’t have to issue an ABN and submit the claim to your carrier with a modifier appended, but you can.

You can collect for these services at the time of the visit, says Shelly M. Kirk, CPC, with Tennessee Orthopaedic Clinics in Knoxville.

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How to use technology to speed up new patient check-in.

Not enough hours in the day? Are you always looking for ways to save time? Many medical offices report that sending out new patient packets in advance of the patient’s visit greatly reduces the number of incidents at patient check-in and saves time.

“Normally, it would take patients 15-plus minutes to complete the forms,” says Stephanie Mayer, front desk receptionist for a pediatrician in Queens, NY. “Also, there is the distraction of other patient activity in the waiting room, which could keep patients from concentrating on forms they are supposed to complete.”

Put forms online

If you are not already doing so, talk to your practice administrator about putting new patient packets online.

“Sending or having a patient access our packets from our Web site gives the patient the opportunity to input the information leisurely and accurately, and if needed, the time to research dates, reference medications, and obtain past medical history, says Suzanne E. Keith, practice administrator at Michael W. Goodman, MD, PC, in Chattanooga, TN. “Also, bringing or e-mailing the information in advance allows our office to make a chart and reduces the patients’ wait time.”

Their new patient packet is available online and the patient may download and print the forms and email, fax or carry them to their appointment. Patients can open forms directly from the Web site, or they can download the forms to their computer and open from there. Right now, 30 percent of their patients are using the online forms.

Other site benefits:

• saves on postage, paper and envelope costs;

• provides a resource for patients for medical information;

• answers most questions that a patient may have about the practice and their doctors; and

• cuts down on calls about office hours, location, and directions.

New patient packets should include:

• A demographic sheet with insurance information, medical history, and assignment of benefits;

• HIPAA privacy practices and receipt; and

• Release form for protected health information

Note: If you mail new patient packets, you should send them out at least five days prior to the patient’s appointment.

What’s left to do?

According to Klein, when a new patient packet is received, you should:

1. Double check to make sure that everything is filled out properly and signed.

2. Confirm insurance information.

3. Input information into the system and start a new chart. If it is a patient referral, you should already have a copy of the chart from the referring physician.

4. After reviewing the packet, scan or copy the patient’s insurance card and driver’s license.

“In our office, we ask the receptionist to paperclip the medical history to the front of the chart and then call the nurse to make her aware the patient is there and ready to be seen,” Keith adds.

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