Coding Strategy

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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Sample ICD-9 codes to support medical necessity for trigger point injections.

Counting the right items, knowing insurer-allowed diagnoses, and documenting affected muscles will get your trigger point injection (TPI) claims paid while protecting you from paybacks.

Further, knowing each insurers’ covered diagnoses for TPIs is vital to healthy coding.

√ Do Count Muscles Injected

Coders should report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscles) when the internist injects one or two muscles, confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver.

When the internist injects three or more muscles, opt for 20553 (… single or multiple trigger point[s], 3 or more muscle[s]).

Remember, “coding is based on the number of muscles injected, not the number of trigger points in those muscles OR the number of injections into those muscles,” Hammer relays.

√  Do Check for Acceptable ICD-9s

Patients suffering from muscle pain receive TPIs for relief; however, the types of pain that justify TPIs are entirely up to the payer. Diagnoses that prove medical necessity for TPIs vary greatly. Some insurers cover only 729.1 (Myalgia and myositis, unspecified), while others have expanded the list of ICD-9 codes that support medical necessity for TPIs.

Best bet: Check with your payer for its specific list of acceptable ICD-9s on TPIs.

In addition to 729.1, 728.85 (Spasm of muscle) and 729.4 (Fasciitis, unspecified) are also common diagnoses for TPI, Hammer explains.

Here is a sampling of other acceptable ICD-9s for TPIs from the local coverage determination [LCD] for First Coast Service Options, a Florida Medicare carrier:

• 726.30-726.39 — Enthesopathy of elbow region

• 726.70-726.79 — Enthesopathy of ankle and tarsus

• 727.00-727.09 — Synovitis and tenosynovitis

× Don’t Skimp on TPI Documentation

When reporting TPI encounters, experts recommend including a list of the muscles the internist injects. “Since the coding is based on number of muscles, the provider should absolutely document the specific muscles injected,” Hammer explains.

“Otherwise, the most that you could code is 20552, as the documentation could not support that three or more separate muscles were injected,” she says.

Providers should also include documentation of the drug(s) that were injected to clarify that the procedure was an injection and not “dry-needling,” which some payers do not cover, says Hammer.

You should check with your carrier if you are unsure of the specific substances your payer will accept on TPIs.

Use these J codes for drugs the internist might inject during TPI:

• J1020 (Injection, methylprednisolone acetate, 20 mg) for Depo-Medrol

• J1030 (Injection, methylprednisolone acetate, 40 mg) for DepoMedalone40, Depo-Medrol, or Sano-Drol

• J1040 (Injection, methylprednisolone acetate, 80 mg) for Cortimed, DepMedalone, DepoMedalone80, Depo-Medrol, Duro Cort, Methylcotolone, Pri-Methylate, or Sano-Drol.

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Plus, experts at the AMA meeting in Chicago tell you what to do if you can’t get H1N1 vaccine for PQRI Measure 110 or other vaccine measures.

Question: My internist decided not to put a patient on Coumadin because the patient has a higher risk of falling than from having a stroke. Our group participates in PQRI easure 33 for risk of clotting. How can I indicate performing the measure wasn’t appropriate so that the physician isn’t penalized for not prescribing the anti-blood clotting medication?

Answer: You should report the measure and append the denominator exclusion indicator 1p. This indicator shows the physician chose not to prescribe the drug due to the art of medicine, or factors that make performing the measure not clinically appropriate.

If, however, the internist prescribed Coumadin but the patient isn’t taking it because she can’t afford the medication, you instead would use 2P. Your group can then have the patient referred to a social worker to help the patient figure out her financial hardship and find a way to obtain the medically necessary drug.

The third denominator exclusion in this group is 3p, which shows the medication was not available. Read on to learn what to do when you can’t get H1N1 vaccine supply …

For instance, if you’re reporting on giving H1N1 vaccine, but no product was available since delivery mechanisms sent the vaccine to clinics, not your practice, you could use the universal vaccine measure 110 with 3P for no vaccine available.

These three exclusion denominators show why things like art of medicine, education, or economic reason prevented the physician from performing a given measure, explained Susan Nedza, MD, MBA, FACECP, at the final session of the AMA CPT 2010 symposium. The patients who fall under these reasons do not effect physician’s quality of care percentage as shown in a registry for an individual’s or group’s measure.

“Physicians for the most part are receptive to using these now,” reported Ronald A. Gable, MD, CPT Performance Measures Advisory Group, in the PQRI presentation in Chicago. Denominator exclusions used to be a negative allowing physician to say why opted out of a measure. Now they are a positive that indicates why performing the measure was not appropriate so that quality of care percentage not negatively impacted.

—by Jennifer Godreau

AUDIO TRAINING EVENT: 2010 Primary Care Coding & Reimbursement Update. With Jill Young.

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New rules for consult coding straight from the AMA Meeting in Chicago — plus where your practice will gain and lose reimbursement.

If you can’t figure out how to match a low level consult to an initial hospital care code, you’re not alone.

Code 99251 doesn’t crosswalk to 99221, agreed William J. Mangold, Jr., MD, JD, Noridian Administrative Services’ (Arizona, Montana, Utah, Wyoming) Medicare contractor medical director in the carrier response section to Day 2’s opening session at the CPT and RBRVS 2010 Annual Symposium in Chicago. “They don’t have the same criteria.”

Medicare will consider the consult codes (99241-99255) invalid codes for payment, effective Jan. 1. Experts expect some large carriers, including Blue Cross Blue Shield, Aetna, and Humana to adopt the same policy for uniformity. For carriers and private payers that no longer recognize consult codes, let these examples help you decide what code to instead use.

1. Apply Patient Status Rules to Outpatient Encounters

“CMS is saying the consult codes are going away,” Mangold explains. Instead, you should choose the appropriate code based on the applicable guidelines.

Example: An internist asks for a cardiologist’s opinion on a patient’s hypertension. The cardiologist saw the patient two years ago. There’s no documentation in the internist’s chart to confirm the request for opinion. How would you code the service per Medicare 2010 guidelines?

Answer: You would waive the referral requirement since standard coding rules apply, Mangold says. The physician has treated the patient within the past three years, so you would apply new/established patient definitions, and assign an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …).

2. Focus on Split/Shared Visits’ Total Work

You can ignore one requirement of a shared/split inpatient visit thanks to Medicare’s invalidation of the consult codes. Even if the physician does not duplicate the key components that the nonphysician practitioner (NPP) performed, you can count all medically necessary history, examination, and medical decision making that the and physician each individual performs and documents on a calendar day.

Example: An NPP shares a consult with an MD who does not perform the key components. With the existing guideline, you could not code the service as a consult. The encounters do not meet a shared/split consult’s requirement that the physician perform and document the key components.

Answer: Since there’s not a consult option using the new guidelines, the shared service would be allowed, Mangold says. Report the encounter with the appropriate hospital care code. “This is good news,” one conference attendee raved.

3. Look at Time When Choosing Inpatient Code

At the higher levels, consults’ transfer to hospital care codes will benefit your practice’s bottom line. For 99244 and 99245, you would gain approximately 30 percent in pay if you also report the prolonged services, said Peter A. Hollmann, MD, the AMA CPT Editorial Panel, Vice Chair in his “Evaluation and Management” presentation at the AMA symposium.

“The lower level reimbursement impact will mostly be negative,” Hollmann related. At the low consult levels, the hospital care codes do not match up well.

Example: On a patient’s initial day in the hospital, a nonattending physician performs only a medically necessary problem focused history and problem focused examination. This would not support 99221’s requirements of a detailed history and detailed exam, points out Joan Gilhooly, PCS, CPC, CHCC, Vice President, Audit Services and Compliance for Health Management Resources, Inc. in Salisbury, N.C.

Look to the hospital care code that appropriately describes the service, stresses Mangold. The Medicare Instructions need to be clarified on what to do when low level consult allowances don’t support 99221 or 99231.

Consider using time to line up the services , suggests Hollmann. The following possible match ups are “strictly from a CPT crosswalk - not official from CMS” (Do not use them to code exactly but as a guide).

—by Jennifer Godreau

How will this consult mess affect your specialty? Get focused coverage in a specialty Coding Alert.

Hear the bad jokes that won’t stay in the Windy City by joining my audio conference in December.

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New rules for consult coding straight from the AMA Meeting in Chicago — plus where your practice will gain and lose reimbursement.

If you can’t figure out how to match a low level consult to an initial hospital care code, you’re not alone.

Code 99251 doesn’t crosswalk to 99221, agreed William J. Mangold, Jr., MD, JD, Noridian Administrative Services’ (Arizona, Montana, Utah, Wyoming) Medicare contractor medical director in the carrier response section to Day 2’s opening session at the CPT and RBRVS 2010 Annual Symposium in Chicago. “They don’t have the same criteria.”

Medicare will consider the consult codes (99241-99255) invalid codes for payment, effective Jan. 1. Experts expect some large carriers, including Blue Cross Blue Shield, Aetna, and Humana to adopt the same policy for uniformity. For carriers and private payers that no longer recognize consult codes, let these examples help you decide what code to instead use.

1. Apply Patient Status Rules to Outpatient Encounters

“CMS is saying the consult codes are going away,” Mangold explains. Instead, you should choose the appropriate code based on the applicable guidelines.

Example: An internist asks for a cardiologist’s opinion on a patient’s hypertension. The cardiologist saw the patient two years ago. There’s no documentation in the internist’s chart to confirm the request for opinion. How would you code the service per Medicare 2010 guidelines?

Answer: You would waive the referral requirement since standard coding rules apply, Mangold says. The physician has treated the patient within the past three years, so you would apply new/established patient definitions, and assign an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …).

2. Focus on Split/Shared Visits’ Total Work

You can ignore one requirement of a shared/split inpatient visit thanks to Medicare’s invalidation of the consult codes. Even if the physician does not duplicate the key components that the nonphysician practitioner (NPP) performed, you can count all medically necessary history, examination, and medical decision making that the and physician each individual performs and documents on a calendar day.

Example: An NPP shares a consult with an MD who does not perform the key components. With the existing guideline, you could not code the service as a consult. The encounters do not meet a shared/split consult’s requirement that the physician perform and document the key components.

Answer: Since there’s not a consult option using the new guidelines, the shared service would be allowed, Mangold says. Report the encounter with the appropriate hospital care code. “This is good news,” one conference attendee raved.

3. Look at Time When Choosing Inpatient Code

At the higher levels, consults’ transfer to hospital care codes will benefit your practice’s bottom line. For 99244 and 99245, you would gain approximately 30 percent in pay if you also report the prolonged services, said Peter A. Hollmann, MD, the AMA CPT Editorial Panel, Vice Chair in his “Evaluation and Management” presentation at the AMA symposium.

“The lower level reimbursement impact will mostly be negative,” Hollmann related. At the low consult levels, the hospital care codes do not match up well.

Example: On a patient’s initial day in the hospital, a nonattending physician performs only a medically necessary problem focused history and problem focused examination. This would not support 99221’s requirements of a detailed history and detailed exam, points out Joan Gilhooly, PCS, CPC, CHCC, Vice President, Audit Services and Compliance for Health Management Resources, Inc. in Salisbury, N.C.

Look to the hospital care code that appropriately describes the service, stresses Mangold. The Medicare Instructions need to be clarified on what to do when low level consult allowances don’t support 99221 or 99231.

Consider using time to line up the services , suggests Hollmann. The following possible match ups are “strictly from a CPT crosswalk - not official from CMS” (Do not use them to code exactly but as a guide).

—by Jennifer Godreau

How will this consult mess affect your specialty? Get focused coverage in a specialty Coding Alert.

Hear the bad jokes that won’t stay in the Windy City by joining my audio conference in December.

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