Top Billing
Winners of a Pinnacle Award for excellence in Medicare billing share some secrets to their success.
By Mark Packer, M.D., and Laurie K. Brown, COMT, COE

The responsibilities of physicians today extend far beyond the ancient Greek injunctions that form the foundation of our professional ethics, and include not only doctor-patient relationships, but also relationships with industry, government and law.

The mutual understanding we achieve with our patients in terms of diagnosis and treatment must now be delineated in meticulously written informed consents. The actions we take in the clinic or the operating room may as well have occurred in a dream if they're not thoroughly and formally reported. And the accurate diagnoses and successful outcomes we achieve are sometimes irrationally boiled down to five-digit codes and value units.

Nevertheless, while providing the highest quality of care to our patients is top priority, so is satisfying the legal and ethical requirements of the enormously complex system called healthcare delivery.

In our view, the entire office staff, from physicians and technicians to managers, coordinators and receptionists, must strive together toward these common goals. That teamwork philosophy is at work in all areas of our practice, including the Medicare billing process. It can be seen as a physician and a front-office manager work together in the after-hours to find the correct diagnostic code; in the participation of all billing managers and clinicians in a lunch-time internal chart review; and in the easy and open access all staff members have to physicians to help sort out the daily dilemmas.

The positive results of our approach were recently recognized when we received one of three William E. Rose Jr. Pinnacle Awards for excellence in Medicare billing from the American Society of Ophthalmic Administrators.

PHOTO COURTESY OF THE AMERICAN SOCIETY OF OPHTHALMIC ADMINISTRATORS. On behalf of the practice of Drs. Fine, Hoffman & Packer, administrator Laurie Brown, left, accepted a William E. Rose Jr. Pinnacle Award for excellence in Medicare billing, which was presented by the American Society of Ophthalmic Administrators. At right is Ann Rose, president of Rose and Associates. The award is named after her husband, who founded Rose and Associates, a pioneer in the field of ophthalmic billing and coding consulting.

Winning strategies

In this article, we're happy to pass along what we've found to be useful in streamlining our compliance efforts. The following areas were considered part of the award criteria:

Forms and waivers. We color-code our Assignment of Benefits forms by year so that we can easily see whether patients have signed for the year when they check in for an appointment. Technicians understand when a waiver may be required and know to have the patient sign in advance of any special testing, such as corneal topography.

Claims submission. Timely and accurate filing of claims requires that all involved are motivated and educated. Employees clearly understand their roles and responsibilities. In addition, to help us maintain consistency within our practice, we created a billing policy manual for staff members to use as a reference. It contains protocols for each step in the billing process, processes to ensure all charges are accounted for, and guidelines for follow-up on outstanding claims. We follow-up on outstanding claims in a timely manner. The clearly defined protocols allow us to direct all payer requests to the staff member who can best track those requests.

Also, we follow trends and then make policy changes as necessary to increase efficiency and accuracy. For example, one of our chart review sessions revealed that we were not consistently meeting certain documentation needs for one insurance carrier. In response, we designed a color-coded, forced-entry exam card to use for patients in that plan.

Correct use of modifiers. We've added to our superbill the most commonly used modifiers and a descriptor for each. This makes them readily accessible to the physicians. We encourage them to use modifiers liberally. We can then research and omit a modifier if necessary before submitting the claim. It's much easier to remove an unnecessary modifier before a claim is submitted than to see that one is missing and risk having a denial.

To assist our physicians in seeing the possible need for modifier use, on the front of each chart, we list every surgical procedure the patient has undergone, the date of the procedure, and which eye is the operated eye. Inside the front of each chart, we place a pink card on which is clearly written which eye is the operated eye and the last day of the global period.

Correct coding initiative. We invest in ongoing continuing education, and all staff members work toward higher levels of certification. We encouraged our front-office manager, for example, to sit for the Certified Procedural Coder exam. She's highly motivated and interested, and she leads our staff in disseminating updated coding information to all appropriate personnel. She oversees all surgical billing and has full and immediate access to the surgeons for clarifications.

Documentation. All back-office and billing staff members attend formal quarterly chart reviews. Each participant reviews charts for accurate coding and documentation. The group then discusses the outcomes, addresses any concerns, and shares continuing education information on each subject.

Collections. We perform an annual practice pattern audit and evaluate the outcome, educating our physicians and making practice changes as necessary. We aim for the best/highest benchmark in collections and work tirelessly to ensure we meet it. We educate our patients as well as our staff on our collection policies and procedures.

Compliance. We have a compliance plan in place and orient all new employees to it. In addition, we hold annual staff training sessions on the plan. We subscribe to several sources, other than the Medicare carrier newsletter, to update and keep our billing and coding staff informed about guidelines.

Teach what you know; learn what you don't

While working as a team remains crucial to success in each of these areas, a team can't function without leadership. In the final analysis, the burden and responsibility of compliance falls on the ophthalmologist-in-chief. Providing positive leadership and insight from the top, while recognizing outstanding achievement among team members, engenders the trust and respect required for success.

We recommend that you take the time to teach what you know and learn what you don't. Everyone wants to grow, to achieve, and to be recognized for her or his contribution. We allow our employees and co-workers the opportunity for continual improvement, which allows our practice the opportunity for continued success.

Dr. Packer is in private practice with Drs. Fine, Hoffman & Packer in Eugene, Ore. Laurie K. Brown, COMT, COE, is the practice administrator.