Correct Coding for Pre-operative Clearance

Correct Coding for Pre-operative ClearancePrimary care physicians are often asked to evaluate a patient prior to surgery at the request of the surgeon. Patients at an advanced age and those with significant medical problems face increased risk for surgical morbidity and mortality, and preoperative evaluation will depend on the extent of the patient’s condition and the type of surgery. In fact, medical billing and coding companies are well aware that evaluation and management (E&M) services before surgery can be denied reimbursement if reported incorrectly. Insurance carriers will pay only if they determine the services to be “medically necessary.”

A primary care physician’s preoperative evaluation of a patient scheduled for surgery will include:

  • History – documentation of the past medical history, a review of current symptoms, a list of medications, allergies, past surgical history and family history
  • Physical exam – height, weight, vital signs, and documentation of any abnormal findings on the exam of the entire body
  • Assessment – a list of medical problems and a plan for each problem identified

Medicare does not consider all pre-op clearance to be medically necessary and will not routinely reimburse these services. Some pre-operative evaluation and testing services may not be covered under Medicare and that coverage and payment are determined by whether or not the service is:

  • A covered benefit identified in the Social Security Act (SSA)
  • Not specifically excluded from Medicare by the SSA, and
  • “Reasonable and necessary” for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, or
  • A covered preventive service

According to an article published by the Georgia Academy of Family Physicians in 2016, documentation when billing a preoperative medical evaluation should include the following:

  • Reference to the request for a preoperative medical evaluation
  • The specific medical condition that the family physician was asked to address during the preoperative evaluation (such as from a cardiovascular or respiratory point of view)
  • Proof that the physician has returned his/her opinion and recommendations to the requesting provider.

For example, suppose a patient who has diabetes and hypertension comes in for preoperative examination for carpal tunnel surgery on the right wrist and the surgeon has ordered laboratory tests. The procedures involved are as follows:

  • Document the requesting provider’s name and the reason for the preoperative medical evaluation.
  • Forward a copy of the findings of the evaluation and management service and recommendations to the surgeon clearing the patient for surgery.
  • Assign diagnosis code Z01.812 for the primary diagnosis.
  • The secondary diagnosis should be the reason for the surgery: G56.01, Carpal tunnel syndrome, right upper limb.
  • Code any other diagnoses and conditions affecting the patient related to the preoperative evaluation. For instance, depending on the patient’s condition, other findings to be reported may be: E11.9, controlled, type 2 diabetes and hypertension: I10, hypertension, benign.

A preoperative examination to clear the patient for surgery is part of the global surgical package, and should not be reported separately. You should report the appropriate ICD-10 code for preoperative clearance (i.e., Z01.810 – Z01.818) and the appropriate ICD-10 code for the condition that prompted surgery. All claims for preoperative evaluations should be reported using the appropriate ICD-10 code:

  1. Z01.810: Encounter for preprocedural cardiovascular examination
  2. Z01.811: Encounter for preprocedural respiratory examination
  3. Z01.812: Encounter for preprocedural laboratory examination
  4. Z01.818: Encounter for other preprocedural examination

A recent AAPC blog points out that the primary care physician can bill for the standard preoperative care if the surgeon reduces his package payment. However, Medicare does not support the regular breaking of the surgical package. Unless geographic distance or other factors prevent the patient from reasonably receiving preoperative care from the surgeon, the preventable extra costs and risks caused in processing two claims (one for the surgeon and one for the primary care physician) would be regarded as abuse by Medicare.

Putting It All Together

Let’s say an ophthalmologist requests a preoperative clearance from you for a patient who has diabetes and hypertension and is scheduled for cataract surgery, right eye. You document the requesting provider’s name and the reason for the preoperative medical evaluation. Then you perform an evaluation and management service and forward a copy of your findings and recommendations to the ophthalmologist clearing the patient for surgery.

When you bill for this service, the primary diagnosis on the claim and the one attached to the EM code on the line item will be a Z code (e.g., Z01.818, “Encounter for other preprocedural examination”). The secondary diagnosis will be the reason for the surgery, the cataract in the right eye (e.g., H25.031, “Anterior subcapsular polar age-related cataract, right eye”). Finally, if appropriate, you would also code the patient’s diabetes (e.g., E11.9, controlled, type 2 diabetes) and hypertension (e.g., I10, hypertension, benign).

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What is the Insurance Credentialing Process?

What is the Insurance Credentialing Process?

Credentialing is a process that the insurance companies use to verify your education, training, and professional experience and to ensure that you meet their internal requirements for serving as an in-network provider on their panel. The goal of the insurance credentialing process is to become in-network and prevent your patients from having claims go towards their out-of-network deductible.

The process of credentialing with an insurance network actually consists of two phases- Credentialing and Contracting.  The contracting phase is where the company issues you a participating provider agreement that defines the terms of participation for receiving in-network reimbursement for your claims. Without a participating provider agreement, you will not receive in-network reimbursement.  Until your credentialing and contracting are complete you may have the option to bill the network as an out-of-network provider, but there is no guarantee of your claim being processed.  Government health plans such as Medicare and Medicaid will not pay for any out-of-network services.

Checklist items for credentialing and contracting preparation:

  • Establish a business entity under which to practice (LLC, S-Corp, PC, etc) and obtain your tax ID
  • If operating as a sole proprietor, consider obtaining a federal tax ID to operate under instead of your SSN
  • Obtain your professional liability insurance policy
  • Obtain an NPI number for you individually (type 1) and your business entity (type 2)
  • Be fully licensed in the state where you will provide services (including prescriptive authority)
  • Create a profile with CAQH and keep it current
  • Have your practice location ready
  • Know which insurance networks you want to participate with

Out of so many insurance companies which insurance to credential with is the most common question we receive? You can ask a peer in practice in your area or an office manager who handles billing in your area what insurance companies provide the most patient base in your area.  Their practical knowledge of local insurance companies can be valuable.  Major national plans to consider include Aetna, Blue Cross Blue Shield, Cigna, United Healthcare, Humana, Medicare, and Medicaid.  There are many Medicare Advantage plans as well as managed Medicaid plans for consideration as well.  There are also some major national PPO plans that rent their network such as Multiplan that can be important in certain areas.

The general process of credentialing:

  • Contact the network provider services department to inquire about their credentialing process and obtain a credentialing application. Most plans have applications and information on their website such as here with Aetna
  • Take time to fully complete your application listing all service locations for your practice, sign and date your application, and include copies of all required documents
  • Ensure that your CAQH profile is up to date with all information particularly practice location information and includes copies of all required documents such as license, insurance, board certifications
  • Verify with the insurance company that your credentialing application was received, and follow up with the insurance network on a regular basis until your credentialing is complete and you have a network effective date with a participating provider agreement
  • Respond to any requests for additional information that the insurance company may have
  • Document all of your follow up activities as you go through the credentialing process
  • Review your participating provider contract for details of your requirements as a network provider, claims submission procedures, fee schedule for your services, timely filing limits, and all other important contract terms
  • Keep copies of all credentialing applications and contracts submitted. Be sure to retain a final copy of your network contract

When your credentialing process is complete, you are ready to begin billing the network for services.

Here are a few key things to remember about maintaining your credentials:

  • Access the network website so that you can confirm you are listed in their directory. Most networks also have access to claims filing, benefits verification, claims follow-up, and other revenue cycle activities on their website
  • Record all contact information for the insurance company related to claims filing, contracting, and credentialing
  • Record your provider id, effective date and when your next re-credentialing process will be due
  • Maintain copies of all your network contracts in one central location for ease of management
  • After a year of service, evaluate which networks are providing patient volume and compare reimbursements to identify carriers to eliminate or renegotiate reimbursement rates
  • Maintain your CAQH profile by quarterly attestations and document updates any time you renew items such as license or malpractice insurance
  • Maintain your NPPES records so that your NPI numbers always reflect the accurate name, address, and other information
  • Do not neglect re-credentialing requests from plans or requests for renewed or additional documents. Failing to respond to a request can lead to the network termination

Confused about insurance credentialing process? Well, just wait until you actually start the process. Fortunately, if you’d rather delegate this task to someone else, you can! You can delegate it to us. If a provider is trying to run their private practice and be credentialed at the same time, it can overwhelm them to the extent that they are missing deadlines for the applications, or missing appointments filling out applications.

Our credentialing specialists will use their education, training, and experience to get the job done for you so that you can focus on providing your customers with quality healthcare. To hear more about our services, you can reach us at 888-357-3226 or visit drop a mail at to find out additional information.

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CAQH and Insurance Credentialing

CAQH and Insurance Credentialing

What is CAQH?

Council for Affordable Quality Healthcare, Inc. (initialized as CAQH) is a non-profit organization incorporated in California as a mutual benefit corporation. It is essentially an online portal that stores provider information in a secure, collaboration database.  This secured information is granted to health insurance companies during the credentialing process to make acquiring up-to-date provider information more efficient.  Instead of calling your office for your work history or a copy of your Medical License, they can go in and pull it directly from your file.  90% of the National Health Insurance Companies use CAQH and it is a prerequisite for the insurance enrollment process in most states.

The mission of CAQH is to improve health care access and quality for patients, and at the same time, reduce the paperwork and hassle for health care providers and their office staff. The objective is to only fill out your credentialing information one time through this universal application and eliminate the need to fill out applications for each individual insurance company. Most insurance companies now require you to have a CAQH id prior to initiating the credentialing process.

There are no fees to physicians and other healthcare providers to use the database. Participating in CAQH health plans and healthcare organizations pay the costs of developing and maintaining the system. The CAQH system is secure so that only healthcare organizations authorized by a physician or other healthcare provider have access. Providers have access only to their own data—not that of others.

CAQH and Insurance Credentialing

As you know, the insurance credentialing process can be a painful one with all of the various credentialing applications and insurance carriers.  It’s stressful and time-consuming to go through each insurance companies unique credentialing process.  This is where having all of your information in a central database becomes so helpful to the various organizations you work with.

Physicians and other healthcare providers submit their credentialing information to the system database online, or via fax. Organizations requiring provider credentials access the system for the information they require. The CAQH database administrator contacts physicians and other healthcare providers quarterly to update or validate the information via email or fax and will provide information only to organizations the provider has authorized. Plans will automatically be notified of any updates or changes to provider information.

A typical physician or other healthcare provider contracts with as many as 10 to 20 healthcare organizations, each of which requires a time-consuming credentialing application. The amount of time associated with the credentialing application process is dramatically reduced through the use of a standard application submitted to a single source. In short, this system means one doctor, one application, and one secure database for all participating health plans. It represents a move from paperwork to more efficient online information gathering.

Attesting your CAQH profile is the process of signing off on your CAQH application at the end of the application process.  In addition to initially attesting, you have to go back in and attest every 90 days which keeps your application active and provides your contracted insurance carriers with up-to-date credentialing information.  Failure to attest your CAQH application will result in your credentialing/re-credentialing applications with the payers being delayed or rejected.  It’s critical that you keep up with CAQH and ensure your information is accurate.  Every time you receive a new malpractice policy, license, DEA certificate, W9 or address, it’s critical that you get this information updated in CAQH.

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Prominent Ambulatory Surgery Center medical billing functions are affecting your practice revenue

Prominent Ambulatory Surgery Center medical billing functions are affecting your practice revenue

Compliance guidelines that govern the Ambulatory Surgery Center’s reimbursement are wide-ranging, complex and ever-changing. Hence, it’s important for ASCs to hire or partner with Ambulatory Surgical Center billing and coding management consultants who understand the legal rules placed on ASCs, including the specialized coding, accreditation, documentation and reimbursement care contracts.

Here are prominent billing function affecting your practice revenue

Rise in number of Accounts Receivable (AR) days

AR basically refers to the average number of days that an ASC takes to collect payments for the services provided. Days in AR are one of the main methods that ASCs use to measure their financial performance. The factors impacting the AR days are procedure scheduling, patient pre-registration, insurance verification, patient financial counseling, patient payment plans, and patient collections. An important tip here would be setting up a patient financing solution that pays within just a few days of the service provided that can reduce days in A/R.

Surgery Cancellations

Surgery cancellations have always been a major cause of concern for ASCs. Facing high out-of-pocket costs for a certain surgery, many patients whose surgery is canceled, may not rearrange as they think that would incur more expense. Same-day cancellations of a scheduled surgery have a tangible, negative impact on your facilities bottom line. Another suggested strategy is implementing patient financing options. Providing a secured loan to patients to cover their surgical costs can reduce cancellations, grow surgery numbers, lower the AR days and increase cash flow.

Surprise Billing is a national problem

It has become common for patients to receive extra bills from out-of-network providers. This even after they have settled their copays and deductibles. Remember that surprise billing is a national problem and many states in the USA have passed laws to curb this practice. We as a dedicated ASC medical billing and coding organization caution that providers operating in these states should understand the laws to avoid lawsuits. ASCs should also be wary of surprise billing or risk losing patients.

Managing payer contracts

Managing payer contracts is a tough task and ASCs face many challenges which are subject to frequent changes. With regard to care plans, local coverage determinations (LCDs), preventive care, and bundled payments, payers also have different rules and conditions.

A recent report offers the following tips:

  • Breakthrough narrow networks by letting the payer know why it is good for them to have the surgical center in their network. Highlight unique service benefits, geographic advantages, clinical/treatment benefits, and out of network patient counts and referrals.
  • Think of blending direct commercial payer agreements and both primary and secondary complementary payer agreements.
  • Put emphasis on any concerns about contracts’ language.
  • Analyze the contracts periodically to keep track of alterations and contract expiry dates.
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ASC Medical billing and coding: The fastest growing Healthcare service!

ASC Medical billing and coding: The fastest growing Healthcare service!The Ambulatory Surgical Center (ASC) as a healthcare service market has grown rapidly in recent years. As insurance limitations get more stringent and health costs increasing by the day, more and more people are now turning to the outpatient facilities for quality surgery at affordable rates. Outsourcing your ASC medical billing and coding helps you with many of the financial fears and increases profitability. But, recent reports indicate that even though ASCs continue to become the fastest growing healthcare service, there are many challenges when it comes to improving revenue performance.

For an outpatient surgery center to bill services, it must qualify and meet the requirements laid down by the Centers for Medicare and Medicaid Services (CMS). Remember that ASCs are either independent physician-owned or they are associated with a hospital or medical center.

Payment procedure of Ambulatory Surgical Centers

For ASC to get reimbursed the service provided has to be a medically necessity. The medical procedure performed need to meet certain requirements decided by both the patient and the provider.

Does ASC require any specialty billing?

Ambulatory surgery service charging typically does not focus on a specific medical specialty, also it does not revolve around particular procedures, services, and diagnoses. So, billing is unlike any medical specialty billing. But, ASC medical billing uses the same techniques, codes, and guidelines as other medical entities. For example, ASC bills use CMS-1500 claim forms, while hospitals use UB-04 claim forms for reimbursement.

What type of services get covered?

Depending on the status of the medical facility the ASC guidelines for covered services are charted out. When an ASC is fully credentialed, it is able to perform numerous procedures, thus making it the fastest growing healthcare service.

Services not covered in ASC are:

  • Non-implantable durable medical equipment
  • Artificial arm, leg, and eyes
  • Physician services
  • Independent laboratory services
  • Ambulance services
  • Leg, back, neck, and arm braces
  • Prosthetic devices

Are procedural codes different?

As far as medical billing for ASC is concerned, the procedural codes must be precise in order for efficient and sufficient reimbursement. These codes change according to the procedures being performed and the kind of medical facility where services are provided. The two vital codes used here are the ICD-10-PCS, which covers inpatient procedures, and the Current Procedural Terminology (CPT) that gives information regarding services rendered. These are applied along with ICD-10 diagnosis codes.

 Multi-specialty billing

Multiple specialties point towards a variety of underlying causes, diagnoses, and procedures. Keep in mind that charging for ASC multi-specialty procedures is complicated, but it is one of the fastest growing healthcare services. To function efficiently, the billing personnel should be knowledgeable in charging and coding, filing claims, manage customer service, and also perform payment posting. Along with this, A/R follow-up has to be done, which comprises denial management.

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Get positive ROI on every patient through outsourced optometry billing services!

Get positive ROI on every patient through outsourced optometry billing services!Every moment when you think that your optometry billing and coding prerequisites are under control, new reimbursement and claims submission guidelines, coding alerts, or dedicated staffing roadblocks occur. When you as a practitioner are continuously managing claim denials and rejections, along with eligibility and benefits verifications, plus the claims submission and payment posting, looking into AR cleanup, and billing issues, it all compounds to heavy workload that may impact your patient interaction.

According to the Medical Group Management Association report the average cost of reworking on a medical claim is somewhere around $25 to $30 and that 50-65% of rejections or denials are never re-worked.

Here the key financial metric to focus on is to make sure all the claims submitted are clean and free from errors. Do keep in mind that knowing how to prevent rejections or denials in the first place is the best Return on Investment (ROI) for your optometry facility.

Here are some vital evaluation that optometrist needs to consider in order to keep adequate cash flow and ROI for their practice.

The real cost of your Optometry billing and coding

Typically, healthcare providers will see an 8% to 12% increase in their net collections when they align their charging services with a Revenue Cycle Management (RCM) specialist. To help you define the real cost of your billing and process, let’s look at some perilous financial and operational processes that are part of your ROI.

Analyze fixed costs

  • Clearinghouse fees.
  • Stationary, postage and statement fees.
  • Staff hourly wages and payroll costs.
  • Workers’ compensation insurance and payroll taxes.
  • Employee benefits.

Analyze the variable costs

  • Evaluate and pinpoint key decision points for outsourcing billing.
  • Are your accounts receivable (AR) for more than 50 days?
  • Is the AR percentage over 120 days more than 15%?
  • Patients are increasing, but there’s a decline in the revenue.
  • Rise in rejections and denial rate.
  • The decline in cash flow and net revenue.
  • Increase in bad debt
  • Unexpected staff sick leave or vacations
  • Is the collection rate declining?
  • Do you see a higher percentage of bad debt write-offs due to delinquent patient accounts?
  • Is the in-house staff spending more time on claim follow-ups and calling insurance companies instead of on patient care and services?

Overcoming the ROI issue through able billing partners/organization

  • Recover the patient collections process through regular and efficient communications.
  • Educate patients on optometry benefits and patient financial responsibilities, which directly tackle the ROI issue.
  • Act as a connection with your billing service provider to learn more about non-covered benefits, collecting deductibles, and more.
  • Provide more efficient patient care and get more time for marketing your practice on social media, patient relationship management services, and promotional campaigns.

Why choose us?

Many optometrists lose profits due to poor first-pass ratio and claim re-work due to the never-ending healthcare changes. You can lose a big chunk of your revenue margins if you consistently re-work claims or you process outstanding AR as denials.

It’s essential to look at the number of days in AR and your net collections together. Connect with us with and feel the difference of a positive ROI along with higher growth rate for your practice and satisfied staff.

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How to use Modifier 25 Accurately for Medicare

Blog-How-to-use-Modifier-25-Accurately-for-MedicareModifier 25 is used when a minor procedure (one with a 0- or 10-day global period) and a significant and separately identifiable evaluation and management (E/M) service are performed during the same session or day. Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other services) is the most important modifier in CPT.  It creates the opportunity to capture physician work done when separate E/M services are provided at the time of another E/M visit or procedural service. This allows for more efficient use of your time and may save the patient another visit. However, use of this modifier has been associated with frustration because many payers, including Medicaid, do not recognize it.

The Office of the Inspector General (OIG) and Medicare have identified the use of modifier 25 as an area of potential overuse and misuse. This is not a new issue; problems with the use of modifier 25 have been known since 2005 when the OIG published an analysis showing that 35 percent of Medicare claims with modifier 25 did not meet program requirements.

Understanding the correct use of this modifier and the required documentation is key to avoiding problems and adjudicating inappropriate claim denials or underpayments. We have shared current rules and guidelines and provide clinical scenarios as examples.

Key Points:

  • Physicians and qualified non-physician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.
  • Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately identifiable evaluation and management (E/M) service. It should be used when the E/M service is above and beyond the usual pre- and post- operative work of a procedure with a global fee period performed on the same day as the E/M service.
  • Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other services with a global fee period. Modifier -25 is added to the E/M code on the claim.
  • Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.
  • Your carrier will not retract payment for claims already paid or retroactively pay claims processed prior to the implementation of CR5025. But, they will adjust claims brought to their attention.
  • Carriers will not pay for an E/M service reported with a procedure having a global fee period unless CPT modifier -25 is appended to the E/M service to designate it as a significant and separately identifiable E/M service from the procedure. Such payment will be denied with the reason codes 97 (Payment is included in the allowance for another service/procedure) or remittance advice remark code M144 (Pre-/post-operative care payment is included in the allowance for the surgery/procedure)

Clinical scenarios:

The following clinical scenarios provide examples of when it is or is not appropriate to bill an E/M service with a minor procedure.

Example 1:
A 45-year-old male new patient is seen for assessment and management of shoulder pain. The physician completes an evaluation consisting of a detailed history and detailed examination. Radiographs of the shoulder are ordered and personally viewed. A working diagnosis of rotator cuff tendinitis is formulated.

The E/M service meets the criteria of a level 3 new patient (99203). Because the E/M work of the office visit is above and beyond that included in the procedure, the visit is considered separately reportable. The same diagnosis can be used for both the office visit and the procedure. It is strongly recommended that the documentation have a separate “procedure” report or paragraph for the injection. The procedure note should routinely include the specific elements of pre- and post-service detailed above.

Example 2:
A 52-year-old woman with knee pain returns to her surgeon 2 years following arthroscopic medial meniscetomy. The physician completes a detailed history and examination. The operative report and photographs are reviewed. The images from a recently performed MRI are viewed and compared to the official report. Plain radiographs of the knee are ordered and personally viewed. The diagnosis of knee arthritis is formulated.

The E/M service meets the criteria of a level 4 established patient (99214). Because the E/M work of the office visit is above and beyond that included in the procedure, the visit is considered separately reportable. Again, the same diagnosis can be used for both the office visit and the procedure; a separate “procedure” report or paragraph for the injection is recommended.

Example 3:
A 56-year-old female is seen for evaluation of knee and shoulder pain 18 months after the most recent visit. The physician completes an expanded, problem-focused history and examination. Radiographs of the knee and shoulder are ordered and viewed. The assessment and diagnoses are rotator cuff tendinitis and knee osteoarthritis.

The E/M service meets the criteria of a level 3 established patient (99213). The procedure is for the rotator cuff tendinitis, whereas the E/M visit is for both the rotator cuff tendinitis and knee arthritis. Because the E/M service is for a different diagnosis than the procedure, the office visit is considered separately reportable. The diagnosis for the E/M visit should be only knee osteoarthritis and the diagnosis for the injection procedure is rotator cuff tendinitis.

Understanding the correct use of modifier 25 and the required documentation is critical to avoiding problems and adjudicating inappropriate claim denials or underpayments. The key requirement of a “significant and separately identifiable” E/M service is that the work for the E/M service is substantially more and different than the typical preoperative and postoperative E/M work included in the minor procedure.

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