This ACOInformation series on practice management issues has been created in response to member requests for information that will help you more effectively manage your practice. The series is prepared by the ACOI Clinical Practice Committee. ACOI members are invited to suggest areas for discussion in the series.
Coding and billing for health care services provide the basis for physician reimbursement. Coding systems are a means of communicating to third-party payers exactly what was done to or for a patient by the physician and why the service was provided. Correct utilization of the codes will help the practice receive, in a timely manner, the full reimbursement allowed for work performed by the physician. Correct coding and documentation will also prevent charges of fraudulent billing that can result in significant fines, penalties and jail time for the physician.
CPT codes tell the insurance carrier what service was provided to the patient and determine the amount of reimbursement. Accuracy in documentation of services performed and choosing the correct code is important. For example, if you coded a 99212 (level II visit) and your documentation supports a 99213 (level III visit), not only is this considered fraudulent billing, but you also were reimbursed $15.16 less (per Medicare) than you should have earned. Diagnosis codes tell the carrier why a service was provided and determine whether that service will be paid or denied. Certain services are payable only for certain diagnoses. If a covered diagnosis is not provided, the service is denied.
Modifiers give the carrier additional information to use when processing the claim. For example, modifier 50 indicates a bilateral procedure and increases the payment amount. Modifier 25 added to the office visit or consultation code tells the carrier the E&M service is not bundled into the procedure billed on the same day and allows separate payment for visit/consult.
To assist in coding accuracy, practitioners need to avail themselves of a variety of educational opportunities. These include:
The accompanying chart (download chart) illustrates the normative billing practice for primary care visits versus a sample individual group. Clearly, opportunities exist to improve coding and reimbursement. Many groups continually audit, monitor and educate physicians on proper coding and revenue enhancement, such as getting reimbursed for patient counseling, nursing home calls, etc. In addition, on an on-going basis, practice managers should monitor changes by specialties and inform the physician members of these changes to stay on top of approved coding and billing issues. Another good source for coding and billing information is from your specialty societies.
Please contact our ACOI staff if you have any questions or suggestions.
It is always difficult making an employment decision when there are so many different opportunities presented at once. Considering whether or not to join a physician group or which group to join can be confusing. Besides compensation and benefits, there are many other variables to consider.
Variables to consider are:
It depends on what stage in your life you are at and what is important to you at the time of your job search. If you are a new physician just coming out of training, it is highly recommended to bring employment opportunities to someone you trust. One of the best sounding boards would be one of your teachers, a knowledgeable mentor. They should have worked in the medical field and know some of the landmines to watch for. Always have an attorney review any kind of employment agreement. You need to be aware of what you are committing yourself to. All physician groups offer a compensation package. This is where many variables come into play. When looking at compensation, ask yourself, is it a guaranteed income? If so, for how long and what happens after the guarantee runs out? Are you paid on production? If so, is production compensated on collections, or a formula of relative value units (RVUs)? Is administrative time compensated? Are there expected performance standards, such as number of office visits and hours that have to be met? What happens if you don’t meet those standards? All physician groups will charge an overhead rate. Is the overhead a fixed percentage, is it based on actual expenses you use, is it market driven, can it be changed at any time? Don’t be afraid to ask these questions for clarification. If needed, ask for the clarification in writing so that you will have something to reference in the future. The benefit package. What kind of pension plan does the group have? Is it a contributory plan, 401K, tax sheltered annuity? At times it is difficult to take advantage of the tax free contributions, but it is highly recommended to save what you can. Health and dental is another major benefit to look at. What is the coverage and deductible? Is it an HMO or a PPO? Is a cafeteria (so-called IRS 125) plan available that allows you to personalize your benefits? What other benefits does the organization have? If the group does not offer a benefit plan, obtain quotes on coverage prior to making your decision. The cost of the coverage may surprise you.
Another area of concern is legal protection. What is the malpractice coverage? Is it enough coverage for your specialty and area? Who pays for malpractice? Who is responsible for tail coverage? Does the physician group have a compliance plan to protect you as an employee? Is the physician group meeting the federal regulations, such as Stark and HIPAA? As you can see, there are a lot of difficult questions to be answered. As mentioned above, talk with your teacher/mentor. Check with an attorney before signing anything. Some of our leadership have been asked in the past to assist in reviewing contracts. We have and will continue to do so to provide assistance to the physician. Contact the ACOI office for further information; however, any help we may provide does not eliminate the need for an attorney’s review. Take the time to gather all the facts. It is important to look at the TOTAL employment package before making any employment decision.
There have been recent clarifications by Medicare regarding Teaching Physician (TP) documentation guidelines. Some physicians may not be following the Medicare teaching physician documentation guidelines. Medicare continues to audit teaching physician documentation. Inadequate documentation can result in significant fines and penalties from the Office of the Inspector General.
The TP is required personally to document the following: a) that they performed the service or physically were present during the key or critical portions of the service when performed by the resident; and, b) their participation in the management of the patient. You should not submit a bill for a service if the TP is not physically present.
These are examples of unacceptable documentation:
Such documentation is not acceptable because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.
The following documentation examples are taken directly from the Medicare Carriers Manual. You should ensure that your documentation follows one of the examples listed below.
“I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.” “I saw the patient with the resident and agree with the resident’s findings and plan.” “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”