Top 5 Compliance Issues for Ambulance Biller

Top 5 Compliance Issues for Ambulance BillerAmbulance service billing involves a host of unique compliance challenges. The ambulance industry has seen a significant number of false claim cases, fraud investigations, Medicare audit activity, and other types of billing-related cases. It is imperative that billers fully understand the nuances of ambulance reimbursement to be able to successfully sidestep these landmines.

Following are five of the most significant issues in ambulance billing. This is by no means an exhaustive list but includes some of the most common and serious challenges in the world of compliant ambulance billing.

  1. Medical Necessity

Medical necessity is established when the patient’s condition is such that the use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

Medical necessity for ambulance services continues to be the biggest compliance issue in ambulance billing. Like any other type of healthcare service, ambulance transportation must meet medical necessity guidelines in order to be covered. However, when it comes to ambulance billing, the medical necessity standards seem to be vague and less defined than in other medical specialties.

In other words, if a patient could safely be transported by car, wheelchair van, stretcher van, or any other means, then medical necessity is not met, and reimbursement cannot be made. It is important to note that when assessing medical necessity, only the patient’s condition matters; it is irrelevant if those other means of transportation are unavailable.

To put it another way, if the only reason a patient is being transported by ambulance is because they don’t have a car, or that the nursing home’s wheelchair van is out of service, that alone is insufficient to establish medical necessity for ambulance transport. The mere unavailability of other means of transport does not mean that ambulance transport will be covered.

The medical documentation from the ambulance crew at the time of service—the patient care report (PCR)—must clearly establish that the patient required transport by ambulance. This is vital, and ambulance billers will often find that ambulance PCR documentation is not sufficiently detailed or complete to allow for the level of specificity required under ICD-10 coding.

  1. Signatures

Medicare and other Payers require the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting the assignment and submitting a claim. If the beneficiary is unable to sign because of mental or physical conditions authorized person may sign the claim form on behalf of the beneficiary. Authorized person can be Beneficiary’s legal guardian, a relative or other person who receives social security on behalf of the beneficiary, a representative of an agency that provides assistance to the beneficiary, a representative of the ambulance provider or supplier who is present during an emergency and/or nonemergency transport.

A provider/ supplier (or his/her employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign. Medicare does not require that the signature authorize claim submission to be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment. (Note: There is a 12 month period for filing a Medicare claim, depending upon the date of service.) If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, then the ambulance provider/supplier may not bill Medicare but may bill the beneficiary (or his or her estate) for the full charge of the ambulance items and services furnished. If, after seeing this bill, the beneficiary/representative decides to have Medicare pay for these items and services, then a beneficiary/representative signature is required and the ambulance provider/supplier must afford the beneficiary/representative this option within the claims filing period, but this creates more work for ambulance billers and can cause significant delays in the ambulance revenue cycle.

  1. Advanced Life Support Billing

Another key compliance risk area in ambulance billing is the use of higher-paying advanced life support (ALS) codes in cases where lower-reimbursed basic life support (BLS) codes should be used. ALS levels of service can be billed only when the skills required to care for the patient exceed the scope of practice of an EMT-Basic in that jurisdiction. Therefore, an ambulance biller must know what the approved scope of practice consists of for EMTs in that jurisdiction, and what skills require licensing or certification above that level.

The biggest area of compliance risk with ALS services, however, has been in the application of the so-called “ALS Assessment” rule. Under this rule, Medicare allows the ALS-emergency level of service to be billed when the nature of the ambulance dispatch necessitates an assessment of the patient by an ALS crew, even if the patient does not end up needing ALS interventions. While this rule sounds straightforward on the surface, it has been the subject of much compliance enforcement activity in the ambulance industry in the past few years.

Some ambulance billers improperly conclude that all 911 calls are billable at the ALS level whenever there is a paramedic or other ALS provider responding on the ambulance. This results in significant overbilling, or “up coding,” of BLS claims to the ALS level. It is not the mere presence of an ALS provider that triggers the ALS assessment rule; an ALS-level emergency call is also required under the EMS system’s dispatch protocols. So, ambulance billers must not assume that every ambulance call with a paramedic on board qualifies for an ALS level of billing.

  1. Interventions

Earlier, we discussed the medical necessity for the ambulance transport itself. But the medical necessity for transport has a close relative, and that is a medical necessity for the clinical interventions performed by the crew.

Say, for instance, that an ambulance PCR documents a patient with no complaints, and with normal and stable vital signs, who is being transported to the hospital. The PCR indicates that the patient is ambulatory and that she walked unassisted and without difficulty to the stretcher. The PCR also indicates that the EMT administered two liters per minute (LPM) of oxygen via nasal cannula. A patient with no complaints and normal vital signs would ordinarily not require the administration of supplemental oxygen; though this particular intervention is often used by EMS providers even when there is no clinical indication for it.

In a case such as this, where the documentation provides no basis for the biller to establish medical necessity, the performance of a medical intervention—when there is no medical justification for that intervention documented anywhere in the record—should not be used to “confer” medical necessity on a claim where it does not otherwise exist. In other words, interventions themselves must be medically necessary, and it is the job of the EMS providers to document the clinical need for the interventions. It is not the job of the biller to “assume” that medical necessity exists merely because an intervention was performed.

In the event that there are no ALS interventions documented, review the PCR and/or dispatch records to determine if ALL of the following criteria have been met:

  • The initial dispatch required an emergency response; and
  • The dispatch center who handled the call stipulated that the patient’s reported condition at the time of dispatch required an “ALS level” response- based upon approved dispatch protocols; and
  • An ALS Provider arrived on scene and conducted an “ALS Assessment; and
  • The patient was transported to an approved destination such as a hospital; and
  • The transport meets Medicare’s reasonableness and medical necessity standards\

Transports which meet all of the above criteria may be appropriately billed to Medicare as an ALS1-Emergency even though no ALS interventions were provided.

  1. Training

Finally, an important part of an ambulance billing operation is to ensure that all billers are specifically trained in the unique world of ambulance billing and coding. It is dangerous to assume that billing and coding knowledge from other areas of healthcare is automatically applicable to ambulance billing. Ambulance coding and billing have its own quirks and idiosyncrasies, and billers should receive ambulance-specific training to maximize billing compliance.

Formalized and ambulance-specific coding and compliance training can also help your agency overcome the “whisper policies” that often occur in a billing office in the absence of formalized and standardized training.

Accurate communication is the key to an effective ambulance billing program. Patient care providers at all levels along with ambulance company administrators, supervisory staff and most importantly the billing office itself must be prepared and well-versed in sorting out these sometimes confusing scenarios.

As we are doing Ambulance Billing for years now, our clients can rest easy that they are protected by our informed knowledge at all levels. If that’s not the case in your world, then maybe it’s time to give us a call. You can reach us at 888-357-3226 or

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Easy Tips for Quick, Accurate and Simplifying the Provider Credentialing Process

Easy Tips for Quick, Accurate and Simplifying the Provider Credentialing ProcessMedical Credentialing is a process whereby insurance networks check to make sure that the provider meets the standards set out by the insurance company. In this process, they review a range of documents including medical licenses, malpractice insurance, schooling information, and background checks. Credentialing is performed on an individual state-to-state basis.

Whether you are adding a new doctor or opening your own practice, you need to start the credentialing process in advance to avoid potential problems. Provider credentialing an essential part of making sure your practice gets paid. If you ignore the significance of the credentialing process you will experience delayed cash flow, difficult scheduling because of patient restrictions, and repeated phone calls to and from payers.

Unfortunately, sometimes the actual credentialing process can be time-consuming and frustrating for everyone involved. However, there are a few ways that will simplify the credentialing process.

  1. Get credentialed early on:

Timeframes vary from three to six months, depending on payer and location. For example, at the beginning of the year, more doctors submit applications, and due to that influx credentialing can take up to five months. It’s important to be aware that this waiting time can affect your practice so get an early start.

  1. Make a good provider application:

First, make sure you begin with a good provider application. The application is the very first step in this process, and it requires providers to provide personal, education, and practice information. A good application should cover professional credentials, where they have practiced, professional experience, and more.

  1. Crosscheck the filled information:

After completing the application for the credentialing process, take time to verify the information filled. Make sure to keep all your documents up to date. Ensure these documents are up-to-date: Council for Affordable Quality Healthcare (CAQH), Drug Enforcement Authority (DEA), CLIA Certification, Any other ancillary services that require proof of accreditation, IRS Letter Confirmation of Established Tax ID Number, Articles of Corporation (LLC, PA, INC., etc.), License, Malpractice Insurance. If any of these documents have to be renewed annually, then ensure the document submitted to you by your physician is still valid. Malpractice expires annually, for example, so making sure it’s up to date will help you in the process.

  1. Conduct own background check

Many practices choose to conduct their own background check on new physicians, including verifying training, licensure, and employment history before making an employment offer. It may seem like overkill, but it can prevent hiring a physician only to run into problems with licensure later on.

  1. Send applications for review:

Once you’ve thoroughly gone through forms yourself, send applications in for review. Just keep in mind that there’s usually more to credentialing than sending in your forms and then waiting for approval. You’ll need to continue to answer questions and provide any additional information needed promptly or you may face rejection.

  1. Give adequate references:

Hospitals and other health systems often require three professional references before approving a medical practitioner. Make sure that all references must be physicians of the same specialty who are not related by blood or marriage, and none of the references may be members of the physician’s practice. However, the credentialing specialist who verifies the validity of these references will not waste time following-up a reference on file who is unresponsive. So, if you have listed only three references but one of them is hard to reach, it is most likely for your application to have a longer processing time.

  1. Follow up with insurance companies:

Write in dates for tracking and follow up. Regularly call and verify the status of the application to make sure you keep the process going. Some due diligence on your part can ensure the application gets through the process as quickly as possible.

  1. Expect plenty of time for the credentialing process:

While credentialing “should” take around 90 days, smart practices give themselves more like 150 days. Credentialing with payers must take place on their timeline, and each has its own credentialing timeline. Assume credentialing will take 150 days, and hopefully, you’ll be pleasantly surprised when it takes fewer.

  1. Consider outsourcing provider credentialing:

You may want to consider outsourcing provider credentialing to save your practice time and money. In fact, working with good credentialing service can often take weeks off the approval time by managing the process for you. Credentialing services already have established contacts within insurance companies, and they can save you from frustration and rejections. While outsourcing your credentialing is an investment, which allows you to begin billing and pulling in revenue faster.

Understanding how credentialing works can make a significant positive difference in how smoothly a practice runs and the pace of cash flow. Problems with credentialing can be expensive and drain productivity, so it’s important to have a process in place and a plan for ensuring credentialing always remains up to date.

Our credentialing team helps your practice complete all your required applications, manage your CAQH profiles and network contracts (including negotiations). We can also help you to expand your business by providing credentialing services at any new locations you have. To learn more about how we can help your practice with credentialing, medical coding, or medical billing, contact us today on 888-357-3226 or

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Time-Based Billing for CPT Evaluation and Management

Time-Based Billing for CPT Evaluation and ManagementWithin the guidelines of the CPT code book, CPT has stated; “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.

What this means to our physicians and providers, is that time alone can be used to select a level of care, and bill for our services regardless of the clinical documentation of history, exam and medical decision making. If these physicians and providers utilize the option of documentation of “Time” in the clinical notes, they still have to document the care given, but it can be noted that they spent “XX amount of time” at the bedside and/or on the unit in care of the patient and of that 50% of this time was spent in counseling, and coordination of care of “XXX diagnosis, testing, etc.”

Time-based clinical documentation does need to be very specific,  The face-to-face time spent in an outpatient or office type setting includes not only the time the provider spent counseling and coordination of the patients care but has to be rendered face to face with the patient.   Any pre or post time spent (when patient and provider are not face-to-face) cannot be included in the time component described in the CPT E&M codes.

From a revenue and denial standpoint, it is frustrating to have an auditor or insurance carrier review the clinical chart and down code the admission from a 99222/223 to a low-level admission 99221 due to skimpy history, exam, or medical decision notations.

  • The CPT code 99221(level 1 admit) requires a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity;
  • The CPT code 99222 (level II admit) requires a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity,
  • The CPT code 99223 (level III admit) requires a comprehensive history; a comprehensive examination; and medical decision making of high complexity.

Also within meeting these criteria, all three key components are to be met.  The only difference between a 99222 and a 99223 code is the medical decision making of moderate complexity vs. high complexity.

Not all CPT E&M services have a time-based component that can be utilized to represent the care provided.  Within the CPT codes outlined for usage in an Emergency Department, “Time” is not a descriptive component, and all three key components for each CPT code 99281 – 99285 must be denoted within the emergency department patient visit.

If the provider is providing care for a patient that is on a hospital unit or floor, the intraservice time for these codes is noted or defined as “unit/floor time” which includes the time present on the patient’s hospital unit and at the patient’s bedside providing services for that patient.   In this setting, this includes time to establish and review the patient’s chart, examine the patient, write clinical notes, documentation, orders and to communicate with other providers and the patient’s family.   In this hospital setting the pre and post time including time spent off that patient’s floor are not to be included in the time component noted in the CPT code descriptors.

Appropriate time statement examples:

  • Time in was 14:00, time out at 15:06, I spent 40 minutes of the 66 minutes in the encounter counseling the patient on their diagnosis of “xxxxx” and the remainder of the time was spent obtaining the HPI and examination of the patient.
  • I spent greater than 50% of my 30-minute visit with the patient discussing the options of surgery versus watchful waiting regarding their diagnosis of “xxxxxx”

Inappropriate Time Statement Examples:

  • I had a lengthy discussion with the patient.
  • I spent 20 minutes in supportive counseling.
  • I spent 15 minutes talking about the treatment options.
  • I spent 30 minutes with the patient

Medical Billers and Coders (MBC) have a team of certified coders who has diverse experience of E/M coding. To know about our coding services you can call us at 888-357-3226 or email us at


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How to Deal with Patient Responsibility?

How to Deal with Patient Responsibility?As patient responsibility balances climb, practice owners are seeking effective methods of collecting outstanding patient balances and ways to collect more payment at the time of service. Estimating patient responsibility prior to claims adjudication is tricky business. However, practices can absolutely figure out a payment estimation plan that suites their needs and supports the critical task of improving patient collections.

There are a few basic doubts about patient responsibility like:

  1. Am I allowed to collect at the time of service when the claim has not been adjudicated?

Practices are having a lot of confusion over whether they’re really allowed to collect the estimated patient responsibility at the time of service. This depends largely on your payer contracts as well as state laws. As more patients are covered by High Deductible Health Plans (HDHP), many payers have become more flexible in allowing the collection of coinsurance and deductibles at the time of service based on the estimated patient responsibility. However, this often requires that you include the amount paid by the patient on your claim when it is submitted. They also require that you process any refunds for overpayments as soon as the overpayment is identified.

  1. How to estimate the exact patient responsibility amount?

Many practices have been creating their own patient responsibility estimates for years, using a spread sheet and a sample of their most common CPT codes and the associated allowed amounts for their common payers. When you combine this type of tool with your current process of eligibility verification, you can create an estimate for what the patient’s responsibility will be for the visit, allowing you to have a conversation with them about their payment options. It’s important that your financial policy is up to date to reflect whatever requirements you have regarding payment at the time of service. It is also important that your staff is familiar with those policies and is trained to carry them out.

  1. Whether you should collect the full estimated amount?

The additional administrative burden of dealing with overpayments is one of the downsides to collecting the full estimated responsibility at the time of service. Unless the patient has a large deductible that is not even close to being met, you could end up having to refund the patient. You have to be well prepared to monitor your patient accounts for overpayments and issue refunds.  This can happen when a claim from another provider is processed before your claim and there is no longer a deductible owed.  There are also patients who have Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) that may be linked to their insurance payer and are automatically charged to pay for services. You may have seen these adjudicated on EOBs from some of the commercial payers, where the claim will be adjudicated and applied to a deductible on one line and then the next line down you will see another transaction paying the claim from the patient’s HSA or FSA. To collect the full estimated amount at the time of service, be sure you are familiar with your patients that have an FSA or HSA tied to their insurance. An effective alternative is to arrange permission to put a credit card on file with authorization to charge up to a certain amount automatically directly after adjudication.

Sometimes, practice owners confuse outstanding customer service with assuring patients that “we’ll take care of everything; including billing insurance and assuming financial risk. We have shared a few basic course of action that will help you to reduce your outstanding patient collections.

  • Managing insurance plan: Many patients have a primary and secondary insurance plan. Patients are solely responsible for managing these two plans. It is up to them to call each plan and let them know if they are a primary plan or a secondary plan. A physician’s office has no jurisdiction to make this differentiation. Since the patient is the owner of the plan, only he can make that phone call.
  • Educating them to read EOB: EOB’s are insurance company’s way of communicating with a patient. Most patients either throw them away or just don’t understand what they are reading. It is their responsibility to review the EOBs and make sure that the claim processed as it should have. If the EOB shows something different, it is their responsibility to call the insurance company to straighten out the problem.
  • Requesting to pay at the time of service: Request patients pay for co-pays, co-insurance, deductibles, or any other incurred cost before getting any service (You can educate them if required.) It’s a bit of a phenomenon that patients think they can walk in, obtain a service, and not pay for it. You would not be able to go to a restaurant or grocery store and walk out without paying, so why do practices have to suffer a non-payment mindset?
  • Requesting to provide updated insurance info: Those patients who know their insurance plan has changed, but they don’t have the new information yet, so they give you the old information. As the owner of the plan, patients are required to know their insurance information, and if they want you to bill the plan, they must provide accurate information.
  • Blowing your appointments? You have to pay: People just blow off appointments leaving gaps in your schedule, where you could have scheduled a paying customer. Consider assessing a cancellation or no-show fee ( $50 — hurts enough to “remember”), and if the patient does not have a legitimate reason for missing the appointment, send them a bill. Be sure this is clearly written in a cancellation policy that the patient signs at the beginning of treatment. If this is a new patient and you do not have their address, and they have not signed anything, it’s a great opportunity for someone to call the patient. By calling them, you might be able to reschedule that patient.

If you are looking for assistance in shaping up your patient collections process, you can contact us for an initial consultation at 888-357-3226/

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Essential Tips for Handling Cardiology Coding and Billing

Essential Tips for Handling Cardiology Coding and Billing Cardiology billing and coding comes with multiple procedure rules, complex contractual adjustments, and codes that change regularly. CPT code assignment has the potential to be challenging, particularly when modifiers are used, and staying up to date with new codes, code revisions, and deleted codes take a significant time investment.

Cardiology billing also offers a unique set of challenges. These challenges include human errors, lack of knowledge regarding current coding and documentation standards, working and charting in multiple care environments, and/or not coding to the highest degree of specificity.  As in any specialty practice, clear and accurate, detailed documentation is the best way to ensure proper coding. One of the most important things you can do to minimize claims denials and boost practice revenue is to stay current on billing and coding changes.

Tip 1:  Minimize Human Error

We all make mistakes, and when dealing with up to 7 numbers and letters per code it is easy to enter them incorrectly, especially when dealing with multiple codes with complex patients and procedures.  Whether you outsource your billing or manage internally, double checking codes are imperative.  As you become more accustomed to ICD-10 and CPT codes you will start to memorize frequently used ones and may quickly enter them into your system.  This leaves room for careless errors and potential loss of specificity which can affect reimbursement.

Tip 2: Stay Updated on Cardiology Coding

Always keep the most current ICD-10 CM and PCS, CPT, and HCPCS code books in the office. There are frequent changes and guidelines posted by CMS and various coding clinics. The AHA (American Heart Association) offers quarterly newsletters.  Refer to the CMS website for updates and subscribe to any publications offered by CMS, OIG (Office of the Inspector General) and state and local agencies that regulate billing practices. Always look up codes in the alphabetical AND tabular indexes.  At times code may appear to be the correct one in the alphabetic index, but once looking further at the tabular index you may find notes and disqualifiers such as “code first” or “excludes..”.

Tip 3: Don’t Overdo Symptom Coding

Don’t let the emphasis on related diagnoses lead you to report symptoms when you shouldn’t. As per the 2019 ICD-10-CM Official Guidelines for Coding and Reporting (Section I.B): If you’ve got a confirmed diagnosis, report that instead of a signs/symptoms code. Don’t assign additional codes for signs/symptoms typically associated with a disease (unless there’s an instruction specific to that code that says otherwise). You may report signs/symptoms not routinely associated with the disease process.

Tip 4:  Understand the Role of Comorbidities

For risk adjustment, a simplified explanation is that a patient’s health status and spending are considered in relation to outcomes and costs. So a patient with diagnosis X and significant comorbid conditions may yield higher reimbursement (because of higher expected costs of care) than a patient with the same diagnosis X but no comorbid conditions, assuming a risk-adjustment model is used. In other words, including diagnosis codes for relevant comorbidities that the provider documents help show the complexity of the case. For instance, if the cardiologist is treating a patient with congestive heart failure, you may see the documentation that the doctor had to factor the patient’s COPD, anemia, or arthritis into the patient’s treatment. Experts advise that coding the comorbidities lets the payer know the additional conditions the patient has so the payer can better estimate (and not underestimate) the expected costs for the patient.

Tip 5: Be Aware of Combo Codes

ICD-10-CM includes a lot of combination codes for cardiology conditions, so be sure you use them when appropriate to capture the patient’s conditions accurately. ICD-10 includes quite a few combination codes for various cardiology conditions. Make sure they’re being used when appropriate. It’s also important to follow a code’s instructions to “use additional code,” “code also,” or “code first” to make sure you’re giving a complete picture.  For example, compare what’s included in these two codes:

  • 0 (Hypertensive heart disease with heart failure)
  • 2 (Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end-stage renal disease).

Tip 6: Complete and Accurate Documentation is Key

Problems with documentation can slow down your practice’s revenue cycle, put you at risk for audits, and decrease your billable expense reimbursements. Coding for cardiac procedures, such as cardiac catheterizations can be especially tricky, and documentation gaps may lead to the loss of codable components and potential codes. It’s very common for changes in anticipated procedures to occur, so thorough and complete documentation is critical. If documentation problems exist, it will slow down the revenue cycle, decrease billable expense reimbursements, as well as leave room for coding inconsistencies which may become a red flag for auditors.

Tip 7: Focus on Diagnosis Instead of Symptom Coding

It’s vital to avoid reporting symptoms when they don’t need to be included. For example, if you have a confirmed diagnosis for a patient, that should be reported instead of using a symptoms code. Unless there are specific instructions noting otherwise, you shouldn’t use additional codes for the symptoms generally associated with a disease. Symptoms that aren’t usually associated with a disease may be reported according to ICD-10 official guidelines.

Tip 8:  Always Code to the Highest Degree of Specificity

A great example would be diabetes. Diabetes including any of its chronic manifestations carries 3 times the risk weight than that of an unspecified diabetes code. Physicians should completely chart all relevant comorbid and chronic diseases so that risk-adjusted outcomes accurately reflect the quality of care delivered.   Also, cardiologists need to remember some of the basics of coding and documentation. When appropriate, document the diagnosis rather than the symptom such as angina compared to chest pain. Also, chart to the highest degree of specificity such as systolic or diastolic CHF compared to CHF unspecified.  They are different diagnoses and the different code may impact how care is reimbursed or graded. In other words, this impacts revenue and risk adjustment. More complete and accurate documentation will leave less room for translation and coding errors such as mismatched diagnosis and procedure codes.

Tip 9:  Audit Frequently

Regular internal or external audits are encouraged to track common coding and documentation errors and to identify needs for further education of staff.  An open line of communication should exist between physicians, nurses, CDI, coders, and billers.  This will provide opportunities for questions regarding diagnosis, procedures, supplies used, etc to properly reflect the acuity and care of the patient. Maintaining current education, documenting properly and utilizing good coding practices will result in a faster return in the revenue cycle, decrease external audits, and overall improved compliance. As in all areas of healthcare, multiple parties are involved in painting an accurate picture of the patient’s overall care and level of acuity.  Frequent audits will ensure correct reimbursement and documentation.

Any mistakes can prove costly, which is why many cardiology practices are now outsourcing their billing and coding to professionals who have knowledge and experience in this specialty. Choosing to outsource billing and coding allows you to focus on patient care while enjoying improved profitability and cash flow for your practice.

Medical Billers and Coders (MBC) works with cardiology and other specialty medical practices around the country on billing, coding, contracting, and credentialing to help practices increase efficiencies and maximize revenue. Contact MBC today to learn more about how we can be the perfect partner for your cardiology practice.

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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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