Increase monetary profits by practicing evidence-based medicine

Physicians & managers believe incorrectly that we are about to enter a pay for performance (PFP) payments structure & that we are starting to go through Health Care Insurance Reform. I would venture to say that there has always been some level of PFP ( payment for performing a service) . In the last 9 years, Medicare (and other payers) have moved money from procedures & visits into Evidenced Based Medicine (EBM) without too much of a notice. Amounts paid were reduced on procedures and that money moved into diagnostics, clinical lab & as well as a small amount of imaging. If your medical practice runs as it always has you have had to see more patients to make the same amount of money – or see a decrease in monthly deposits. To combat this situation and practice better medicine by capturing problems in patient health at an earlier stage, it is important to start migrating to an EMR that allows you to practice evidence-based medicine. I have seen the average income for a typical family or internal medicine practice increase by $150K  to $400K per year once they converted over to using EBM.

Posted in Miscellaneous | 2 Comments

Some tips on front-desk protocol

Remember each office functions differently but here are some thoughts that may help things run a little smoother

1. Make sure that the staff is pleasant at all times.

2. Booking your appointments for the day should usually only include 2 – 3 new patients per day per doctor due to the amount of time required for these visits.

Please have the patient fill out all forms prior to arriving in office. If you do not wish to do that then if they have an appointment at 10:00 am, have them arrive at 9:30. Explain that there are forms to be completed and it could take 20 minutes or more and you would like them to see the doctor at their scheduled time. Remind them that it is their responsibility to bring their insurance cards, ID , and any referrals, films, reports etc.

If they don’t have the necessary documentation, ask them to either get copies or have the other office fax to your office prior to their appointment. Doing this gives the doctor the information he or she needs as a background for the patients visit and cuts down on calls made by your office to other offices when the doctor comes out of the room and asks the front desk to obtain the information right then. As we all know if you are handling 10 different things at the time, answering the phone, pulling charts, taking co-payments, the last thing you need is to now sit on the phone with several offices.

3. When entering information into the system make sure you are as accurate as possible. Remember you are the foundation for the accuracy of the system. Always double check the insurance information to make sure it is current.

4. Scan the insurance card as well as the referral and get some type of ID. A lot of the practices I have been in actually take photos of the patients and include in chart. With so many people out of work and not having insurance sometimes others will use someone else’s insurance. Should that happen to you having taken a photo and a copy of their license it removes any issues from the practice.

5. Insure that you take the co-payment prior to the patient being seen by the doctor, it is very expensive for the practice to send out a statement for patients for $10 and $20. This co-payment is the patients portion of paying for services. Remind them that their co-payment is due at time of service. Patients need to be educated as to how the practice is run.

6. Confirm appointments 48 hours in advance, not the night before. MyOnlinePractice automatically does this for you by sending them an email or an SMS. This gives them time to cancel if something came up or they forgot to call to cancel, and time for the office to rebook that time with another patient.

7. When the patient is checking out, give them their next appointment, and clarify any questions they may have.

8. Reconcile your co-payments against your money box prior to your going home and you turning in to your manager or billing staff (whoever is responsible for it at the end of the day). Insure that it is correct before you leave for the night.

9. Keep your work area clean as possible

10. Try to not eat or drink at the desk, and if you must do so, not where the patients can see the food or drink.

11. The good old golden rule applies, treat the patients how you would like to be treated, its nicer and easier to get through the day pleasantly.

Posted in Staff Training, Workplace Efficiency | 1 Comment

Additional information for Medicare educational purposes

Some offices with a large number of Medicare patients may like to use the Medicare Fiscal Intermediary Standard System (FISS) system directly. At the following link you will find the manual giving you instructions on how to use the system for eligibility and claims, claim correction etc. (as you can tell, this site is for New Jersey physicians, but each state has their own site as well).

The form must be completed and sent in prior to allowing any access. Please note that everyone who uses the system must have individual access, requiring each staff member to complete and file an individual form.

For additional training for your staff on Medicare Protocol, Coding, Courses and Certifications, you can check out the following FREE link:

This site gives all options for training and certification of completion if the course if passed, and usage and training for several areas of billing and office management etc. The Site is called Medicare Learning Web Based Modules.

The site serves several purposes by educating staff and for obtaining certifications, but can also help meet compliance guidelines for staff and ongoing education.

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Correct use of modifiers and their importance

Sending a clean and accurate claim is critical. Billing in incorrect units is a frequent problem I have encountered in so many offices.

Rather than billing out the service or medication with the correct units (lets say 3 units of some code),  coders will list out 3 separate lines of services instead of the procedure code and then specify 3 units. Doing it correctly means that it does not get rejected as a duplicate that way.

As a concrete example, let us say that the patient has received 25 mg of HCPCS code J8700 TEMOZOLMIDE, ORAL, 5 MG. Quite often on claim forms that have been denied as duplicates I have found the reason to be that each line was entered separately. For proper reimbursements it should be as follows:

Code Description Units Each Price Total Price
J8700 TEMOZOLMIDE, ORAL, 5 MG 5 $1.00 $5.00

Below you will also find another example of why putting the correct modifiers is critical to maximizing payments and how to bill out multiple procedures for the same date same surgery correctly and why the format is so important.

The following example illustrates the standard reimbursement rule for multiple procedures. Four surgical procedures are shown. When performed during the same operative session and billed with modifier -51, the reimbursement is determined as follows:

Procedure/Modifier Full-Fee Rate Reimbursement Formula
41150/-AG $ 973.19 100% of full fee rate
38720/-51 $707.37 50% of full fee rate
15120/-51 $409.53 50% of full fee rate
31600/-51 $201.04 50% of full fee rate

Please realize that I placed the reimbursement fee to show how multiples are reimbursed. A lot of billers just enter the codes and forget to note that they should be billed out with primary and most expensive first and then in declining monetary order. Insurance companies are not kind and just reduce the payment for this claim. If 38720 was billed as primary and 41150 as secondary the practice would have lost $265.82 just for this one situation. Multiply this by a few hundred episodes for the year and the practice would have lost thousands.

Probably, the modifier that should be used most often is modifer 25. Modifier 25 denotes the evaluation and management service is separately identified from any procedures performed or rendered on the same day. Many practices are still not correctly using this modifier, but they do not realize it is a problem, since they do not charge for an office visit, if they are doing a procedure on the same day, an extreme loss of money for the office. A lot of times patients come in for one thing and another DX is found and procedure is done, but because of the procedure no one bills for the reason patient came to the office. If you do a procedure in your office for a different reason than the office visit, then you should be charging for the office visit AND the procedure, and making sure you pay attention to 2 (two) things:

  • Modifier 25 is on the Office Visit, and
  • You use a different ICD9 code for each service

Please note I am not telling you to bill improperly, but properly in a way that supports the notes in the patients charts.

You can find modifiers at the following link:

Posted in Claims Billing | Leave a comment

Hiring New Employees for a medical practice

In this time of so any billing schools and persons unemployed, it is absolutely critical to develop your own protocol for hiring to help all concerned. I have found that when hiring new employees it is best to include the existing staff. They are actually the ones who will be in constant contact with the new hire and this helps two fold. First it makes the staff feel that their opinion is important . I also ask the applicant to come in and work for a few hours to:

A. See how quickly they pick up on functions in that particular office

B. The interaction of the staff and the applicant, and hearing the input from those who would be working with the applicant and their feelings if the applicant will make the grade.

C. This also gives the applicant the opportunity to decide if this is a place they would like to work, and that the position is what they expected, eliminating hiring someone only to have them leave in a few days.

I also like to give a brief test for those joining the Billing Staff. I have found recently that some of the Coding and Billing Schools are testing for Coding and Billing and they are receiving a National Certification but when given a very easy test that they should have aced I have had them leave, and fail the test. At one practice I gave the test to 14 applicants, three left, ten failed and one passed. These were people that should have been on the top of their game since they had recently graduated and passed the National Tests.

It is important to develop a standardized and objective set of test questions specific to your specialization that you can use – after all, you would not expect to hire any professional based solely on the strength of their resume or what they say – they actually have to perform at a high enough level, and there is no better way to do this than an objective test you’ve put together.  Hiring the right person may be one of the most crucial decisions you make in the success of your medical practice, and creating such an objective test would save you hours of later grief.

As an example, here are a couple of simplified questions that I put together for pain management to give you a flavor of how to put this together:



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Links to great sites for coding information

I have attached a few links that I depend on a great deal for Audits, and verification of codes for procedures as well as verification, checking for payments etc.

Below is the link for Local Coverage Determination for Medicare part A and part B. This site allows you to bill Medicare appropriately and send clean claims for immediate reimbursement. It also gives all other information you may need for new codes, Bulletins etc.

I also use the Insurance sites such as Aetna, Horizon Blue, Cigna, Medicare and countless other insurance companies by logging on to Navinet This is a site where everyone must be registered as well as all staff members must have their own sign in codes.

Great site where you can do everything including checking for payments, copies of EOB’s etc. You can also log on and check eligibility for Medicare patients, and any of the other insurance companies enrolled. Basically this site can supply you with most of the information you need to run the office administratively.

For Additional Coding Purpose I use While there is a fee involved for this site I feel that it is worth it, as well as eliminating the need for purchase of new coding books every year which can be expensive for the practice.

Posted in Claims Billing | Leave a comment

Avoiding common errors in medical billing

There are some common errors in billing that can readily be corrected, such as outdated claims, improper codes, no modifiers, units being billed out improperly.  In future blogs I will try to handle each in further detail, but now I would like to list some sites that may be of help.  There is the Medicare Learning site, Find A Code, Coding News etc.
Being up to date with coding knowledge is self-explanatory but a good example follows about Consults for 2010. ***Medicare will consider the consult codes (99241-99255) invalid codes for payment, effective Jan. 1. Code 99251 doesn’t crosswalk to 99221
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.
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. 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).
Posted in Claims Billing