Keeping Your Billing Department Up-to-Date
Review these areas to avoid problems ranging from extra work to sanctions.
By Linda R. Georgian, San Bernardino, Calif.

If your practice's coding and billing processes aren't current, you're dealing with the consequences -- extra work and lost revenue -- every day. Furthermore, if you don't examine your coding and billing processes and fix any problems, you may not be able to avoid the next level of consequences, which could include being ordered by government agencies to pay fines and restructure the way you manage billing and coding.

In this article, I'll highlight coding and billing issues that most often suffer from a lack of attention, and offer some practical advice for avoiding problems.

Physician credentialing

To minimize problems and expedite payments, keep a list showing all contact information for third-party payers (contact persons, addresses, phone numbers, and fax numbers). Make sure the list specifies which of your physicians are enrolled (or pending) in each plan.

This information must be readily available to employees who schedule appointments. When new physicians aren't added to all of your contracted insurance companies, or if a provider panel has closed without all of your physicians being enrolled, claims may be filed erroneously and processed as non-contracted. Your unhappy patients will be left with higher co-insurance and deductible amounts.

This list will also be useful when you need to notify third- party payers because you're changing a mailing address, adding a practice location or adding a physician to the practice.

Updated forms

Make sure your signature-on-file and medical necessity forms are current and legal.

Signature-on-file forms. Signed by the patient, these will save you the trouble of getting the patient's signature every time he visits your office.

The Health Care Financing Administration (HCFA) 1500 form has a box for patient's signature authorizing the physician to submit a claim and receive payment on behalf of the beneficiary. Typing "signature on file" in box 13 indicates that you've obtained the patient's signature on the appropriate form. (Not actually having the signature on file could lead to false claim allegations.)

Make sure your form contains all the required elements and proper wording, as outlined in the Medicare Carriers Manual Part 3, section 3047.1.A. (For an example, see "Sample Signature-on-File Form" on page 80.)

Note: Medicare accepts a lifetime signature-on-file form, but some third-party payers may not. Check with your carriers and update the form as necessary for those patients.

Enforceable advanced beneficiary notice (ABN). When you perform a procedure that may be considered cosmetic, such as a blepharoplasty, Medicare could deny payment. To ensure that you can collect from the patient, you must have him sign a waiver stating that he was notified that payment could be denied. The waiver must use language specified by the HCFA. (For more information, contact your local Medicare carrier.)

• Make sure your staff understands the need for such a waiver and knows how to approach the patient with it. (Training may be a worthwhile investment.)
• Make sure the related Medicare claim includes the -GA modifier. This indicates that you have an ABN on file.
• Statutory exclusions -- procedures such as routine eye exams and cosmetic procedures that are never covered by Medicare -- don't require an ABN. In these cases, you're not required to file a claim unless the patient specifically asks you to. However, having patients sign a waiver is always a good idea, even when a procedure is excluded.

CPT and ICD-9 coding mistakes

Proper coding of diagnostic and therapeutic services is crucial. The HCFA imposes stiff fines and penalties for insufficient documentation and incorrect billing for such services. To minimize these types of errors:

Get adequate training. Many physicians always choose the same two or three exam codes over and over again, ignoring the higher and lower complexity codes. For example, some physicians only use ophthalmic codes (92004, 92002, 92014, 92012) for all eye exams, and neglect the Evaluation and Management codes (992xx) altogether. Consult codes are also frequently overlooked.

Overutilization of the same codes is a flag that draws Medicare's attention and increases the likelihood of an audit.

Also, even though the ultimate responsibility for selecting the correct CPT code rests with the physician who provided the service, administrative and technical staff members can help -- if all staff members who work with charts or claims have a basic understanding of coding, documentation and the potential ramifications of mistakes or omissions.

Perform chart audits. Have a staff member or an outside firm analyze your coding, documentation and practice patterns. Find your practice's areas of weakness and correct them through education, training, and frequent monitoring.

Pay attention to history and chief complaint. Typically, these are the weakest areas in charts. A mistake in the documentation of the patient's complaint can cause an overpayment determination during postpayment review.

Prohibit unauthorized changes in coding. Many practices create their own billing department or hire an outside billing service. Frequently, the doctor doesn't interact directly with the billing staff or review the claims or appeals sent out on his or her behalf.

Billing departments, whose objective is "to get the claim paid" sometimes make well-intentioned -- but erroneous --coding changes. For example, a young patient was sent to a practice to rule out amblyopia. After a careful examination, the physician found no abnormality or pathology and recorded "normal vision" in the chart. The original claim code V72.0 (normal vision) was denied as noncovered.

After the patient's parent complained about receiving a bill, an inexperienced staffer resubmitted the claim, changing the code to 368.00 (amblyopia) because the patient was referred by a primary care physician who was concerned about that condition. This change constituted a false claim.

The solution? Enforce policies that dissuade staff from making unauthorized changes to what the doctor or back-office technician has written.

Correct errors immediately. If the physician forgets to annotate the charge ticket, have the back-office technician or cashier verify completion of the charge ticket before the patient leaves the office. Prompt action will prevent delays in posting to the computer system and filing with payers.

Keep physicians involved in practice management issues. The doctor's name is on the claim form -- and it will appear on the postpayment inquiry if something goes wrong.

Appropriate fees

Updating fees can be an onerous task, and some practices put it off for years. But because additions and deletions to CPT occur annually, periodic re-evaluation is important. Furthermore, reimbursement rates for exams, consultations, diagnostic tests and minor procedures have increased, so you could miss out on additional reimbursement.

How can you tell if your fees are too low? Take a look at your Explanation of Medicare Benefits (EOMB). Is Medicare allowing your full charge for any codes? If so, Medicare's fees are higher than yours.

The best fee schedule takes into account both Medicare and private insurance reimbursements. Some private insurance companies still reimburse providers at rates higher than Medicare's. If your fee schedule only reflects expected Medicare payments, your private carriers will pay your billed charges -- and you'll miss the extra revenue available from them.

Conversely, some outdated fees may be too high. While you and your staff understand the concepts of contractual adjustments and accepting assignment, most patients have only a vague notion about these things. Extraordinarily high charges cause "sticker shock" and fearfulness which result in unexpected cancellations, lost patients and poor perceptions of your practice. Reducing fees that aren't allowed in full won't cost you anything -- those are "pie-in-the-sky" fees. Instead, charge reasonable fees that everyone can live with.

To make sure you don't miss out on income unnecessarily, evaluate your fee schedule every year.

Fighting the good fight

Billing and coding may not be something you enjoy devoting time and energy to. However, the right protocols and procedures will keep your practice on track without too much suffering. Following these suggestions should help.

Linda Georgian is an associate consultant with Corcoran Consulting Group. She's spent the past 17 years working with eyecare professionals. Her experience includes accounts receivable management for large groups, managed care contracting, optical management, and administration. You can reach her at (800) 399-6565.