Avoid These Five Common Billing Mistakes
This consultant sees them over and over in all types of practices.
By Joseph Fitzgerald

Identifying the five most common coding and billing mistakes is easy. Not making those mistakes requires a thoughtful, systematic approach to billing.

In this article, I'll identify each of the five errors and explain the specific action you'll need to take to prevent any of them from happening again. Because the rules are constantly changing and you're probably going to have some employee turnover, it's important that your employees are thoroughly trained and you have the proper office procedures in place to avoid the following mistakes:

1. Not documenting normal exam findings.

Many ophthalmology offices don't document examination findings when they're normal. The physician, technician or the front-desk person reviews only what's documented and bills for the level of what's noted.

Example: An established cataract patient comes in with a new chief complaint. The doctor performs a thorough exam. Seven of the exam elements are reviewed, but only three are documented. The office is compelled to select low-paying CPT code 99212 because only three elements are documented -- although four more elements of the exam were reviewed and found to be within normal limits.

The payment allowed under 99212 shortchanges the practice for the actual exam performed. If all the exam elements that were within normal limits were documented, the practice could have chosen codes 92012 or 99213 and received a much higher reimbursement.

To avoid this mistake, you must document all elements performed even when the findings are normal. It may take several more minutes, but you're billing the correct codes and your reimbursement will be correct.

2. Failing to use modifiers on office visits and surgeries during the postoperative period.

Example: When you perform a major or minor surgical procedure on either eye during the postoperative period of a prior surgery and it's unrelated to the prior surgery, don't forget to add the correct modifier(s). Say you're in the postoperative period of a cataract procedure on the right eye, and the patient complains that he has pain in the left eye. Upon examination, you find an ingrown eyelash and remove the eyelash with forceps.

This minor procedure requires a 79 modifier to get paid. To get the office visit paid during the postoperative period, you must append a 24 modifier to the office visit. Because you needed to examine the patient to find the cause of the pain, you must also add a 25 modifier to be paid for the exam.

Make sure you have a current "super bill" with modifiers and a brief definition for each. All physicians, technicians, and front-desk people must know and understand modifiers and the "global" period for every covered surgical procedure.

3. Not knowing the requirements of every payer to your practice.

Example: An HMO patient presents himself for an unscheduled visit. The patient is allowed to see the physician that day. This service is billed and later returned as denied due to the lack of a referral.

Avoid this error by setting up a matrix for all your insurance payers with the following information:

• Is a referral needed?
• What's the co-payment?
• What exactly is covered?

4. Holding Medicare as the standard for reimbursement for all other insurance companies.

Medicare's billing rules are unique in many situations. While many insurers have adopted the Medicare payment schemes, not all have adopted the overall global times and modifiers used to determine Medicare payments. Many offices that I visit believe they must charge the same fee(s) to all insurance companies as they do to Medicare. This isn't true. Medicare must be billed the lowest fee(s). In many instances, Medicare rules and fees don't apply to non-Medicare payers.

Example: Billing a second-eye A-Scan with the much lower Medicare fee and modifier 26. Medicare has taken the A-Scan (76519) and developed one the most obscure policies in existence. Medicare wants you to break down the A-Scan (76519) into two components: technical (T/C) and professional (using modifier 26). The technical is considered to be bilateral and the professional component is unilateral. What that means is you have a code that's divided into two parts, and those two parts have different values for Medicare only. Most commercial insurance companies don't require this breakdown. Therefore these commercial companies will pay for the professional and technical for both eyes.

5. Not collecting refraction fees and co-payments at the time of service.

One of the most difficult areas for the front desk is collecting money from Medicare patients for refraction. Many times, front-desk personnel are either new or haven't been properly trained as to what exactly a refraction is, why it's important and why it isn't covered by Medicare. In simple terms, refraction isn't covered because it's not considered a medical complaint and the end result of a refraction is usually a prescription for glasses or contact lenses. Once the staff is trained and understands how to explain this information to patients, the collection process becomes much easier.

The next difficult job for the front desk is collecting information regarding the patient's insurance coverage. Having a matrix with information detailing key information is critical to facilitate this step.

A good matrix consists of the names of all the practice's insurance company payers and their special provider codes. The matrix should also provide answers to these questions: Is referral required? What's the co-payment? Which physicians are on what plans? This information will be very helpful to the front-desk personnel and will have a noticeable, positive effect on your overall collections. 

Joseph H. Fitzgerald is president of J.H.F. & Associates, an ophthalmic practice management consulting firm in Laguna Niguel, Calif. His company specializes in reimbursement and day-to-day practice management. He can be reached by phone at (949) 495-4001, or via e-mail at jhfits@hotmail.com