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Medical Billing Guide Medical Coding Guide

Demystifying Medical Billing and Coding Part 2

In our last blog, we started the process of demystifying the complicated world of medical billing and coding. We’ve still got a bit more to go to fully provide a comprehensive guide to this field. But don’t worry–if this world seems to be a little too tough to understand on top of everything else going on in your life and in your practice, PractiSynergy is here for you. Instead of struggling to learn the process of medical billing and coding, we’re happy to handle it for you! Let’s dive in. 

The Significance of Coding Systems

There are three major coding systems used in the healthcare industry:

  • The International Classification of Diseases, 10th Edition (ICD-10) is used to classify diagnoses and illnesses.
  • The Current Procedural Terminology (CPT) is used to describe medical, surgical, and diagnostic services.
  • The Healthcare Common Procedure Coding System (HCPCS) is used to code services not covered by CPT, such as durable medical equipment and drugs.

Medical coding relies on standardized coding systems to ensure consistency and clarity in communication. The International Classification of Diseases, 10th Edition (ICD-10) categorizes diagnoses and illnesses, while Current Procedural Terminology (CPT) codes describe medical, surgical, and diagnostic services. Healthcare Common Procedure Coding System (HCPCS) codes cover services not included in CPT, such as medical equipment and drugs.

The Coding Process: Ensuring Accuracy

The coding process involves meticulous attention to detail. Coders collaborate closely with healthcare providers to gather accurate information about procedures and diagnoses. This information is then translated into the appropriate codes, which are submitted for billing. Accuracy in coding is paramount, as it directly influences the reimbursement process and prevents claim denials or underpayments.

Collaboration for Accurate Coding

Effective communication between medical coders and healthcare providers is essential for accurate coding. Coders seek clarifications when needed to ensure that codes accurately reflect the provided healthcare services. This collaboration guarantees that claims are submitted with precision, enhancing the chances of proper reimbursement.

The Medical Billing Process: Submission to Reimbursement

The medical billing process extends from claim submission to reimbursement. Medical billers play a crucial role in this journey by meticulously preparing and submitting claims to insurance companies. This process demands an in-depth understanding of insurance policies, proper documentation, and compliance with regulatory standards.

Challenges and Solutions in Billing and Coding

The realm of medical billing and coding isn’t without its challenges. Claim denials, coding errors, and communication breakdowns can hinder efficient revenue management. However, solutions exist. Thorough documentation, continuous training, and open communication between providers, coders, and billers can mitigate these challenges and optimize the revenue cycle.

Regulatory Compliance: Upholding Industry Standards

Adhering to industry regulations such as the Health Insurance Portability and Accountability Act (HIPAA) and the Stark Law is paramount. Non-compliance can lead to legal repercussions and disruptions in the billing and coding process. Ensuring patient data privacy and adhering to legal standards are critical components of the revenue cycle.

The Impact of Technology

Technological advancements have revolutionized medical billing and coding. Electronic Health Records (EHR) store patient information digitally, enhancing accuracy in documentation and coding. Automated coding tools assist coders in assigning appropriate codes efficiently. However, maintaining a balance between technology and human expertise is crucial to prevent errors and ensure accurate reimbursement.

The Role of AI and Machine Learning

Artificial Intelligence (AI) and Machine Learning (ML) are reshaping the landscape of medical billing and coding. These technologies can analyze vast amounts of clinical data to assist coders in selecting the most accurate codes, reducing errors and enhancing reimbursement optimization. Additionally, predictive analytics offer insights into revenue management and potential risks, enabling proactive measures.

Preparing for the Future: Trends in Medical Billing and Coding

As the healthcare industry evolves, so does the landscape of medical billing and coding. Artificial intelligence, machine learning, and telehealth are emerging as significant influencers. AI and ML technologies promise improved accuracy in coding, while telehealth’s rise necessitates adaptation to coding practices for new service delivery models.

While technology continues to make headway in many different fields, it can never replace the human touch. At PractiSynergy, we know how to utilize these technological advances; but we also know the right questions to ask, the correct steps to take, and of course, to make relationships and connect with other people. 

As telehealth reshapes healthcare delivery, adapting coding practices becomes paramount for precise reimbursement within this evolving service. Amid these dynamic changes, the mastery of these essential processes remains pivotal for sustainable revenue management and top-tier patient care. For comprehensive medical billing and coding services that prioritize seamless payments, consider exploring PractiSynergy—a partner empowering practices to concentrate on quality care while we handle the intricacies of payments…so you don’t have to. 

Contact us today to learn more!

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Medical Billing Guide Medical Coding Guide

Demystifying Medical Billing and Coding Part 1

In the intricate world of healthcare, the seamless functioning of medical billing and coding is essential for both providers and patients alike. This crucial process involves translating complex medical procedures and diagnoses into standardized codes, ensuring accurate revenue management and reimbursement for healthcare services. In this comprehensive guide, we’ll delve into the fundamental aspects of medical billing and coding, its significance, key coding systems, processes, challenges, and future trends–and how PractiSynergy fits into it all. 

What is Medical Billing and Coding & Why is it Important for Providers?

Medical billing and coding are integral parts of the healthcare revenue cycle. Medical billing and coding is the process of translating medical diagnoses and procedures into codes used in medical records and claims submitted to payers for reimbursement. It is a complex and specialized field that requires a deep understanding of medical terminology, anatomy, and disease processes. This symbiotic process ensures healthcare providers receive proper compensation for their services and contributes to efficient revenue management within the healthcare industry. By properly coding and submitting claims, providers can secure timely reimbursement, which is vital for sustaining operations, offering quality care, and investing in advanced medical technologies. This process also helps prevent revenue leakage due to errors or improper documentation.

 It sounds pretty complicated, right? On top of running an effectively functioning practice, managing staff, and of course, treating your patients, correctly getting your billing and coding done can seem like quite the feat. That’s why PractiSynergy exists–so that you can focus on what’s most important, instead of having your hands full with your payments. 

Medical Billing vs. Medical Coding

Medical billing and coding are often used interchangeably, but they represent distinct stages in the revenue cycle. Medical coders are responsible for translating complex medical information into standardized codes, while medical billers focus on submitting these coded claims to insurance companies for reimbursement. Both roles require a keen understanding of medical terminology, anatomy, and coding systems. As a medical provider, learning coding systems on top of the rest of your responsibilities is a taxing undertaking. 

Role of Medical Coders

Medical coders are akin to language translators in the healthcare world. They convert medical procedures, diagnoses, and services into codes from coding systems like ICD-10, CPT, and HCPCS. This translation process ensures that healthcare services are accurately represented, enabling efficient claim submission and accurate reimbursement.

Role of Medical Billers

On the other hand, medical billers are the liaisons between healthcare providers and insurance companies. Their responsibilities include verifying patient information, ensuring proper documentation, navigating insurance policies, and submitting claims. The precision of their work directly impacts the timeliness and accuracy of reimbursement.

Accurate coding and billing not only ensure fair compensation but also contribute to the overall sustainability and success of healthcare practices–it’s absolutely critical to the productivity and profitability of your practice. At PractiSynergy, we know how complicated this field is, and how hard it can be to get it right. That’s what we’re here for! In our next blog, we’ll continue our comprehensive guide so that you can get a better understanding of everything we do. 

Contact us today to learn more.

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Medical Coding Guide

How to Make Wellness Screening Codes Work for You

Did you know that you can earn additional revenue for your healthcare practice by utilizing wellness screening codes? Medicare and various insurance companies provide coverage for preventive services beyond the annual wellness visit in a primary care setting. By taking advantage of specific wellness screening codes, you can bill and get reimbursed for services like alcohol misuse screening, depression screening, and counseling for tobacco cessation. Here’s how PractiSynergy can help your practice identify and maximize billing opportunities.

 

Alcohol Misuse Screening & Counseling:

Alcohol dependence is a prevalent issue that affects many individuals. Medicare and other payers cover an annual screening for alcohol dependence. This screening is defined by certain criteria, including tolerance, withdrawal symptoms, impaired control, and preoccupation with alcohol use. If a patient meets the criteria, your practice can bill for this service once per year. Additionally, for those who screen positive for alcohol dependence, brief face-to-face behavioral counseling can be provided. Behavioral counseling interventions should follow the 5 A’s approach: Assess risk factors, Advise on behavior change, Agree on treatment goals, Assist with behavior change techniques, and Arrange follow-up or other treatment. This counseling service can be billed up to four times per year.

Depression Screening:

Depression is a common mental health condition that often goes undiagnosed. Medicare and other payers offer coverage for annual depression screenings lasting up to 15 minutes. To ensure accurate diagnosis, effective treatment, and follow-up, staff-assisted depression care supports, such as nurses or physician assistants, should be in place. Your practice can bill for this service once per year, allowing you to provide crucial mental health support to your patients while receiving reimbursement.

Counseling to Avert Tobacco Use:

Smoking and tobacco use cessation counseling is an essential service for patients using tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related diseases. Medicare Part B and other payers cover up to eight counseling sessions per year. By offering counseling to help patients quit tobacco, you not only improve their overall health but also increase your practice’s revenue through reimbursable services.

 

Utilizing PractiSynergy:

Identifying and maximizing billing opportunities for wellness screening codes can be a complex process. This is where PractiSynergy can assist your practice. PractiSynergy is a comprehensive healthcare management solution that helps practices optimize their revenue cycle management. With its advanced features and tools, PractiSynergy can identify the services you’re already providing that qualify for reimbursement and ensure proper billing. By leveraging PractiSynergy, you can streamline your billing processes and focus on delivering quality care to your patients while maximizing revenue.

 

Take advantage of the wellness screening codes offered by Medicare and other insurance companies to increase revenue for your healthcare practice. By billing and getting reimbursed for services like alcohol misuse screening, depression screening, and counseling for tobacco cessation, you not only provide essential preventive care but also optimize your practice’s financial performance. With PractiSynergy’s assistance, you can easily identify these billing opportunities and streamline your revenue cycle management. Start leveraging these reimbursement options today and see the positive impact on your practice’s bottom line!

Contact us today!

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Medical Billing Guide Medical Claim Adjustments

Top Three Reasons Your Claim Has Been Denied

When it comes to medical billing, the coding network can get quite tricky. There are many reasons your claim may be denied. This fault could fall on the provider or the payer. The more informed you are, the easier the claim process will operate. It’s important to cooperate with your medical coding professionals and give them the most accurate information possible to avoid a denied claim. The best way to avoid errors is to communicate efficiently.

Having a claim error can negatively impact your practice and harm revenue cycles. To achieve an optimum experience with patients, it’s important to make this process seamless and smooth. We’ve all heard the “a bad foundation builds a weak house…” analogy. Think of your medical billing system in such a way. The well-being of your business is one of your main priorities. It’s essential to maintain a strong base of medical coding to keep everything on the front lines running as it should. At PractiSynergy, our highly trained staff works closely with you to build that foundation. This way you can get back to what’s important, rather than stressing about coding errors. 

Furthermore, we’re here to divulge common errors leading to claim denials. Using our years of experience, we’ve gathered our knowledge to reveal the top three reasons we see claims get denied – and how to avoid them. 

  1. Claims not filed on time
    • Provider contracts with Insurance companies dictate how long from the date of service a claim can be filed
    • Traditional Medicare is 1 year
    • Many insurers have drastically shortened time to 90-180 days
    • You can appeal denials with proof you filed on time – these appeals also must be filed timely
  2. No Authorization or Exceeded Authorization Denials
    • Providers must know which procedures require prior authorization from the insurance company
    • Most insurers allow providers to submit for emergency authorization when procedures must be done – or allow for post-service review and authorization
    • Most insurers DO NOT allow providers to bill patients if the provider neglected to get a prior authorization
    • The authorization typically states a time frame when the procedure must be completed as well as the number of procedures or visits allowed
    • Appeals may be done if there is documentation that information received from the insurance company stated an authorization was not required.
  3. Claim errors and patient demographic errors
    • Coding errors happen – but there are ways to minimize these errors by building edits or macros into a practice management system
    • Patient intake forms – these forms are typically filled out by patients. As these forms have become electronic they tend to feed directly into the practice management system. This causes an immense amount of error since most patients do not know exactly what information they need off an insurance card or they may put a nickname that does not match the insurance database
    • All demographics need to match what insurance companies have on file or there is a high probability of claims being rejected or denied

By making sure your claims are authorized, reported on time, and fully reviewed before submission, you’re able to avoid the most common faults we see as medical billing professionals. Taking these proper precautions can help the well-being of your practice and its backend process. 

Using this data, we’ve formulated our business in a manner to avoid such errors. We ensure our clients get none of the stress and all of the cash flow. When we work together we’re able to take the stress of coding errors off your back. Get back to what you do best. It’s our passion to help you, so you can help others. To get informed about our medical coding and billing services, Call Katie at PractiSynergy or reach out via Email

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Medical Billing Guide Medical Claim Adjustments

Claim Adjustments In Medical Billing

Claim Adjustments In Medical Billing - PractiSynergy

What are the adjustments codes do on the payers’ explanations of benefits and what do they mean? These codes tell the provider why all the money charged was not paid.

I have three categories for these adjustments: Contract Related, Process Related, and Patient Liability. From these categories, you should examine whether there is a payer error (not abiding by contracted rates or agreements), a billing error (something on the claim was not correct), or if the amount is owed by the patient

Payer Error and Contractual Adjustments:

  • The maximum amount was paid by the insurance company based on the contract the provider holds with the insurance company – This means what the amount charged by the clinic was more than the allowed reimbursement in the provider’s contract.
  • No prior Authorization – Provider contracts spell out the responsibility of the provider to acquire any prior authorization required by a policy or their payment may be reduced or denied
  • Billing Guidelines – claims may be denied due to the provider not following the proper rules to bill a particular medical procedure. For instance, providers may not be paid for cosmetic procedures. The definition of “cosmetic” is usually determined by a patient’s diagnosis coded and is spelled out in coverage documents for the plan. Providers are expected to review these and submit claims appropriately.

Medical Billing And Claim Adjustments

Billing Error and Process Related Adjustments:

  • Non-covered benefit – Providers are expected to check benefits for patients before they perform a procedure on a patient. Even a simple sick visit may be denied, or the payment may be reduced if an out of network provider give these services and the patient does not have out of network benefits. Another example may be when the insurance company expects a certain type of provider to perform a service (a physical therapist should not submit a claim for a throat culture for strep)
  • Patient does not have active coverage – Providers must verify a patient is eligible for their insurance as of the date the service will be provided. If the service happens before, after, or during a gap in coverage, the provider is not eligible for reimbursement from the insurance company. The beginning of the year is most common for these adjustments.
  • Incorrect coding – medical codes on a claim are critical to payment. Providers are ultimately responsible for which codes go on a claim. They may delegate this duty to certified coders to do a thorough job. Providers should always use current codes and not rely on Google to find the right code since there are many codes which are expired that swirl around cyberspace. For reliable codes please visit PractiSynergy.

Patient Responsibility:

  • Insurance companies may not pay a claim or only partially pay a claim if the patient has some cost-share responsibility. This may be in the form of co-pays, deductibles, or co-insurance. These amounts are deducted from the amount owed by insurance companies. Providers collecting these amounts up front would be best practice.
  • An insurance company may designate a patient owes the full amount charged if a provider is out of network or if the patient is not eligible for coverage on a particular date of service.

Providers should review these adjustment reasons on a regular basis to evaluate a payers’ performance (or the billing company performance). A quick check monthly on your most utilized procedure codes is also an easy way to make sure you are capturing all the revenue owed to you. PractiSynergy helps its clients with this analysis. Please contact Katie Fergus Call or Email to assist your practice review your payments and adjustments to make sure you are not missing any cash.

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Medical Billing Guide

Payer Credentialing and Contracts In Medical Billing

Payer Credentialing And Contracts

Payer credentialing and contracting process – Yawn! The most boring topic – Yet one of the most important for medical providers. The process is laborious and tedious.

Gathering paperwork, filling out forms, and negotiating is not how most professionals want to spend their time, unless of course they are attorneys or accountants 😉

The process is meant for the payers to “vet” medical providers and make sure they are legit. (Wiki: Credentialing)

The process also allows the provider, to align themselves with different employer groups or accountable health organizations for exposure and marketing of their practice.

Why are some networks so narrow? These networks are aiming for a truly patient centered experience. The primary care provider and the patient would make decisions together for the best course of treatment. Specialists need to decide what groups might have the biggest impact on your bottom line.

That is where the negotiating comes in. In a narrow network, the specialists need to prove their worth and may have to jump through extra hoops or make certain concessions in contract negotiations to become an in-network provider.

Is it so bad to be out of network? If you are out of network, most commercial insurance plans have an entirely separate set of benefits. Patients typically have separate (and large) deductibles and out-of-pocket maximums for out of network providers.

While the insurance company may “allow” the full fee of your service instead of a negotiated discount that an in-network provider might receive – this balance typically falls on the patient.

The patient becomes responsible for the entire balance. Large medical bills are extremely scary for patients.

payer credentialing and contracting

Scary may not even be the correct term – if they don’t know it is coming, they can be outright mad. Collecting money from patients is typically much more difficult than collecting from an insurance company.

Why aren’t there set fee schedules which all insurance companies just pay the same [Pay transparency]? That is a discussion we all need to continuously be asking our legislators. Until the “system” changes this is the game – if you don’t play, other will. PractiSynergy understands and knows how to play this game. We guide providers in revenue cycle management to maximize their profits. This all starts with contracts and credentialing.

Want to get in the game and learn more about credentialing and contract negotiations?

Call Katie at PractiSynergy or reach out via Email to receive a FREE CONSULTATION on how PractiSynergy might help your practice maximize revenues through payer contracting and credentialing strategies.

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Medical Coding Guide

Medical Coding Commodity : Why Medical Coding Is Essential?

Medical Code Commodity

The Merriam-Webster dictionary defines commodity as “something useful or valued.” In healthcare, coding is the most important yet silent commodity in the revenue cycle. So, what is Medical Coding Commodity and why is it essential? Let’s understand it…

With over 68,000 ICD-10-CM medical diagnosis codes and over 87,000 ICD-10-PCS procedure codes for providers to comb through, selecting the right combination of diagnosis and procedure codes can be a daunting task.

Medicare and other major insurance companies have their own “billing guidelines” which must be followed to get paid. Certified coders know where to look for the information to find what diagnoses may be used to determine medical necessity for various procedures.

For instance, Botox®, this drug is covered by Medicare and most insurance companies for Migraines, but they will not pay for it if you want to smooth out your facial wrinkles.

Most providers do not have the time to look up if a specific diagnosis is payable for each appointment, certified coders are essential to getting providers paid.

Electronic Medical Records (EMR) and Practice Management systems are supposed to assist with coding however, the EMR does not have the experience working with insurance companies who may have different policies on how to code a single procedure. Some insurers may require a modifier – while some may not.

Some may only pay when a procedure is paired with a certain diagnosis – while some may be flexible. Each insurer is different, and each state may also have different guidelines.

Certified professional coders added into a revenue cycle allows a critical view on a patient encounter prior to being sent to payers.

Coders can focus on certain specialties such as orthopedics, podiatry, optometry, etc. garnering experience from the different insurance companies and maximize payment for the providers on the first pass of a claim.

When a provider is searching for the right code that is time they are not spending with their patient. Any process improvement program would tell you wasted time/wasted resources is inefficient. Inefficiency can cause a debilitating effect on a medical practice. 

Investing in an experienced coder will more than pay for itself by maximizing reimbursement and decreasing claim denials.

PractiSynergy has Certified Professional Coders (CPC) on our team reviewing procedure notes and providing education on documentation to providers to ensure compliance.

The combination of a CPC and experienced biller will improve compliance and increase cash flow, maximizing a clinic’s profits.

To tap into this “Coding Commodity”:

Call Katie at PractiSynergy 515.635.5531 or email katie@wordpress-799426-3758877.cloudwaysapps.com

Receive a Free Consultation on how PractiSynergy might help your practice maximize revenues and boost your cash flow.