It is not enough to list the symptoms, diagnosis, procedures, medication given and prescribed and follow up. when it comes to medical billing and coding, a set of codes are required for the Physician or doctor to get paid. The matter of medical coding is a complicated one and require skills, to assure proper billing and payment. Not coding a visit properly may result in denial of payment or decreased payment.
There are different set of codes used for hospitals, Doctors offices, and equipment, some medication and prosthetics.
The first set of code comes from, ICD, International Classification of diseases. ICD Now the tenth version, ICD-10, are a set of codes assigned to classify certain diseases, injuries and diagnosis. The tenth revision, became effective, in the United States in 2015. These sets of codes took effect by the world Health Organization, in 1940s. There has been many revisions. The last revision took effect in the United States in 2015. ICD-10.
These sets of codes include a total of seven (7) characters. The expansion in the ICD-10 codes leave room for expansion. The prior version included 14,000 codes the tenth,(10) version includes. 68,000 codes. some rare diseases, such as Ebola, was not included in the 9th edition.
CPT, Current Procedure Terminology. These codes are used to identify Illnesses and treatment that takes place in a doctors office. CMS developed these codes. However, the AMA, American Medical Association, maintain and update them annually. CPT codes consist of five (5) digits and include three categories. The first deals with different ranges of medical treatment, which include, evaluation, anesthesia, surgery, radiology, pathology and laboratory and Medicine. The second, consider performance measurement and the third consist of, Medical technology.
HCPCS, Health Common Procedure Coding System. HCPCS, consist of codes that are not included in CPT. The use of ambulance, prosthetics, Medicare and Medicaid, to name a few.
Medical facilities will need a knowledgeable, Certified Coder or coding company who understand how to apply the correct codes and extensive knowledge of restriction, exception and primary diagnosis. A Coder’s job is to take the written treatment plan, diagnosis and patient complaint and translate it in codes. These code must be accurate and maintain compliance with HIPAA. We pride ourselves on hiring and developing the best. which includes, continuing education, and maintaining knowledge of changing compliance policies. It takes a strong team and the right technology to do this accurately.
For a Medical facility to thrive, while providing outstanding patient care, one need a reliable, competent and experienced coding company. One that can process claims quickly but more important, accurately. We pride ourselves on doing just that for our partners. www.Lightspeedrcm.com work with over 850+ Certified Coders and process claims in 24 hours. Healthcare facilities must change the way they are use to doing business. As we move toward as technology based, telehealth system facilities will need a trusted billing and coding partner that can deliver and streamline the A and R. Accounts Receivable. When Good enough is not enough, the solution is www.Lightspeedrcm.com.
Telehealth refers to providing medical care to patients at a distance using telecommunications equipment. With telemedicine, doctors can evaluate, diagnose and treat patient via Skype or similar live video conferencing equipment.
Telehealth is the natural evolution of healthcare in today’s digital world. This way of delivering healthcare is extremely useful as it can reach patients in rural areas or be used in areas that have a shortage of medical professionals and clinics, such as in lower-socioeconomic communities. Telemedicine is especially helpful for patients who might not have regular transportation to get into doctor’s appointments or elderly patients who are housebound.
Telemedicine has undergone an incredible amount of growth in the last decade or so. It is becoming an increasingly important way for doctors and other healthcare providers to deliver healthcare to patients.
Mordor Intelligence estimates that the global telemedicine will be worth more than $34 billion by the end of the year 2020. Wondering what’s new in telehealth? Here are some trends that will help spur the growth of telehealth in 2019 and beyond.
#1 Greater Capabilities
Thanks to technological advancements, medical providers will be able to diagnose and treat patients much easier via telehealth. Insurance companies and health care providers are already using wearable technology to collect patient data. The same technology can be used to help physicians more easily deliver care via telehealth. For instance, the newest Apple Watch has an ECG feature, so users can take a single-lead ECG anytime using their smartwatch. If a patient wearing an Apple Watch receives an alert that their heart rate is abnormal, they can then send this alert to their primary care physician. A chronic heart failure patient can share the results of their Apple Watch heart monitoring with their cardiologist. This technology cannot replace the expertise of a physician or the capabilities of a fully-staffed clinic, but it can be used by telehealth practitioners to provide better care.
#2 Greater Access To Specialty Care
Access to specialty care is out of reach for many patients. This type of care can be very expensive. Many people who need to see a specialist cannot — either because they can’t afford it or they don’t have insurance. In certain areas of the country, there is a shortage of specialists. Additionally, many specialists don’t like to take lower-income patients because the reimbursement rates are so low. So, patients struggle with incomplete care.
In the future, telehealth will provide a greater opportunity for patients to access care from a specialist. Psychiatrists and mental health specialists are already providing a range of services via telehealth, including psychiatric evaluations.
The opportunities for specialist care are numerous. Nephrologists can manage chronic kidney patients using remote healthcare monitoring. Gastoloigsts can treat chronic conditions, such as inflammatory bowel disease, and Endocrinologists can manage patients with diabetes and other chronic illnesses via telemedicine.
#3 Better Security
Data security is vital when it comes to telehealth. The risk of unauthorized access to medical data keeps many health care clinics and practitioners from utilizing telemedicine. The good news is that telehealth security keeps improving all the time. As more and more medical professionals and clinics use telehealth to deliver care, expert to see even better security over time. In the future, things like encryption of data on all portable devices and secure cloud storage will help enhance security.
Telehealth is the future of healthcare delivery. Having a good electronic medical records solution and utilizing an online patient portal for payments can help you implement telehealth in your practice. These things can help you streamline your practice and better deliver telehealth services to patients. For more tips on how to increase your productivity and enhance your practice, check out our website.
Why Are Doctors and Hospitals Leaving Neighborhoods That Need Healthcare The Most?
Healthcare providers are pulling out of poor inner-city neighborhoods where the sickest populations live.
There is a huge health inequality in America. Adults who live in lower socioeconomic areas in the U.S. are a lot more likely to be in poor health than those in more affluent communities. According to a recent report, people with lower socioeconomic status experience heart disease, obesity, high blood pressure, diabetes, mental illness, and other health problems at a higher rate than others. Americans who are at the bottom of the socio-economic ladder are three times as likely to experience premature death than those at the top.1
There are many reasons for this disparity in health among the rich and poor. For those people just scraping by, going to the doctor might seem like a luxury. Another reason for the difference is a lack of insurance coverage. The Affordable Care Act (ACA) of 2010 made health care more accessible to a lot of people who previously lacked coverage. However, there are still significant holes in the system that limit the benefit of this program. In 2012, the Supreme Court ruled that states could opt out of Medicaid expansion. This decision left more than four million people without adequate coverage.2 Recent cuts to tax credits will put Obamacare plans even further out of reach for many people.3
One of the biggest reasons why America’s poor struggle with health problems more often is because they lack access to high-quality health care. Family doctors, clinics, and hospitals are the cornerstone of health care. However, more than 60 million Americans don’t have a primary care doctor.4 This is because there have been more and more health providers abandoning poor neighborhoods. Coincidentally, these are the areas that need their services the most.
The Pittsburgh Post-Gazette and Milwaukee Journal Sentinel recently analyzed data from the largest United States cities. They found that people in poor neighborhoods were less healthy than their more affluent neighborhoods. They were also more likely to live in areas where hospitals had closed down and physicians had left.5
The Journal Sentinel reports that health care providers have been following patients who are privately insured to more affluent areas instead of staying in communities that have the greatest need for high-quality health care.6 According to the Association of Health Care Journalists, the number of hospitals operating in the 52 largest cities had fallen from 781 in 1970 to 426 in 2014.7
The fact that hospitals and doctors have been leaving poorer communities at a high rate is terrible for both the residents who have been abandoned and the providers who are leaving. This leaves low-income neighborhoods without a safety net. It is also unfortunate for providers as they are losing an opportunity to treat patients who need it the most.
So, what things can help improve health care access in poor communities? One of the biggest obstacles to care is the cost of treatment. The United States has notoriously high healthcare costs. Healthcare in the U.S. is nearly twice as expensive as in any other developed country.8
One of the main reasons for the high cost of healthcare are the administrative costs of running a practice.9 As a health care provider or administrator, you’ve probably encountered plenty of examples of unnecessary administrative costs— from rejected insurance claims to complex medical billing practices. These things add to the high price tag of healthcare in the U.S.
Lowering the administrative costs of providing healthcare can help more hospitals and providers stay in areas that need health care the most. A good healthcare coding and billing partner is one way to reduce the burden of high practice costs. Choosing the right billing service lets providers focus more on providing care to those who need it most and less on paperwork. At Lightspeed Revenue Cycle Management, we offer an efficient and cost-effective billing and coding solution for healthcare providers and hospitals. Contact us today to learn more.
Changes in MIPS and MACRA in 2019
Healthcare facilities should be aware of changes in the requirements regarding the treatment of patients covered by Medicare and Medicaid. The (MACRA) Medicare Access and Reauthorization Act of 2015 and (MIPS), Merit-based Incentives must be followed in order for healthcare organizations to receive compensation from the Government. MACRA require healthcare providers accepting Medicare covered patients to use an Electronic Health Record Software. The paper-based system or an outdated EHR, will need to be updated to a current EHR, in order to maximize compensation for Medicare patients.
There are changes for 2019, made to MACRA, that you and your staff will need to know, to qualify for compensation for Medicare patients.
- (MIPS)-Cost-category increase
Center for Medicare and Medicaid Services, (CMS) suggest that the weighting of MIPS cost category should increase from 10% to 15%, per the report from the advisory board. CMS also lowered the weighting of the quality category from 50% to 45%. Categories, promoting interoperability and improvement activities will remain the same as last year, at 15%.
- (MACRA)-Expansion of low-volume thresholds
If a healthcare facility has less than $90,000 or less than 200 patients in part B allowable charges, they are excluded from MIPS requirements. Your Electronic Health Record software or billing company should update this information. Be sure to verify with your billing company. Our company, Lightspeed RCM automatically updates with all changes and is designed to maximize MACRA/MIPS compensation. Healthcare organizations should check with their billing company for this update, as it will affect your compensation.
- (MACRA)-0 to 10% increase for cost category weighting.
Center for Medicare and Medicaid Services, (CMS) increased the cost-category to 10% for 2019, to get Physicians started. The cost-category will account for 30% of your composite MIPS score by 2022, according to clinician Today. For an easy transition, practices should get ready for mean or median scoring. This means a decrease in the quality-category at a corresponding level.
- (MACRA)-Immunity for extreme and uncontrollable Circumstances.
Center for Medicare and Medicaid Services, (CMS) will exempt practices working in 2017, that were affected by natural disasters or extreme weather conditions that disrupted the health services you provide, conditions beyond their control.
Proper Medical billing is time consuming and arduous. It often takes the attention of medical providers from their core expertise. Why? Because they often end up processing the billing themselves, or at the very least, being heavily involved in the process. We believe that medical Providers should spend their time doing what they love, and that is patient care, not medical billing.
Constant changes in the healthcare industry, medical billing procedures, ICD-10 codes as well as HIPAA regulations can affect the revenue or cash flow for the practice. It can get worse with the wrong billing company. This means there’s a lot to keep up with. When you consider healthcare providers in private practice as well as large organizations, it is inevitable for errors to occur.
Healthcare organizations can choose one of two options. Establish an in-house medical billing department in the practice Or, you could outsource your medical billing to experts. Experts such as Lightspeed RCM, Revenue Cycle Management. Let’s review the cost analysis of both options below. This information will help those looking to find a reputable and reliable (RCM), Revenue Cycle Management company make the right decision.
Let us compare the data below provided by, www.MTBC.com.
They have included industry averages to compare:
In the scenario listed below, from WWW.MTBC.com, the Practices is loosing approximately, $250,000 in cash flow, for in-house billing.
- Three physicians
- Two medical billing experts
- 80 insurance claims/day
- $125 bill per claim:
Explanation of the data, are specified below:
Billing Staff Expenses
In-house: The billing staff expenses are based on approximate average costs in the US.
1 Medical billing employee = Salary + healthcare + state taxes + training cost
= $40,000 + $4500 + $6000 + $1000
Also included $15,000 for office space, office equipment and other related expenses.
Outsourced: 5 hours are included to process the medical billing. On an average it is $15 per hour. Other circumstances may require additional hours. Which can cost up to $4000 annually.
Software & Hardware Cost
In-house: Practice management software costs about $7000 per system annually and $500 for computer hardware.
Outsourced: If you take into consideration, printing and other minor charges, it can cost $500.
In-house: If you face on average of 20,000 claims per year then it would cost you $3600 annually.
Outsourced: Medical Billing companies typically, charge a percentage of the collected amount as their fees range from 4% to 7%.
Percentage of Collected Amount
In-house: For the most part, only 60% of the bill is collected (if you have an in-house billing department).
Outsourced: It costs up to 15% if you outsource your medical billing.
If you’re looking to improve your cash flow or revenue cycle and provide more time for you and your staff to have more time for patient care, based on the data above, outsourcing your medical billing is your best option for achieving your goal.
1. “https://wwWhy Should You Outsource Your Medical Billing?” MTBC Official Healthcare Blog, 2 Oct. 2018, www.mtbc.com/learningcenter/outsource-medical-billing/.
2. MarketScreener. “MTBC Medical Transcription Billing : Why Should You Outsource Your Medical Billing?” MarketScreener.com | Stock Exchange Quotes| Company News, 10 July 2018, www.marketscreener.com/news/MTBC-Medical-Transcription-Billing-Why-Should-You-Outsource-Your-Medical-Billing–26905483/.
Claims Denial and Management
Ruth B. Garcis | November 19, 2018
Medical billing is an important factor in determining the financial success of a practice. The claims rejection rate has a serious effect on the cash flow of any practice. Claims denial is one that does not meet the set criteria of the insurance company. Claims that does not meet the HMO’s criteria will be denied. The health care provider will then refuse to pay. Clean Claim are claims that are processed successfully and are paid at first submission. Lightspeed have a 98% success claims rate from the first submission.
In medical practices, the claim rejection rate typically varies from 15-30% depending on the quality and capabilities of the billing team. A practice with a lower quality billing system, face a higher denial rate. A denied claim requires additional work and staff time. That cost approximately $20-$25 per claim, and its success rate for resubmission is from 55%-98%. If resubmission fails, the practice usually write-off the claim, which can cost 1-5% of net patient revenue. For Doctors in private practice, 15-30% rejection rate can have a detrimental impact on revenue.
Causes of Claim Rejection
According to the 2013 American Medical Association National Health Insurer Report Card: These are some of the reasons for claims rejection
1. Incorrect Coding: Use of an incorrect codes, is a key reason for claim rejection. Recent change from ICD-9 to ICD-10 codes, further complicates, the coding process , adding to these challenges.
2. Incorrect Patient Information: Incorrect DOB, wrong insurance ID, and/or incorrect or missing demographic information, are some other common errors that lead to claim denial.
3. Eligibility: Patients not eligible for certain treatment or has no insurance coverage.
4. Duplicate claim submission: Submitting the same claim twice, will allow the insurance company to reject the claim.
5. Wrong POS: Hospital, emergency room, office, or nursing home have a different 2 digit code that must match the CPT code used.
5 Tips to improve rejection rates
Everyone submitting bills and utilizing ICD-9 or ICD-10 codes, to Insurance companies, must pay attention to the details and review every bill before submission.
Here are some suggestions, to help you minimize the claim rejections.
1. Proof-Read Before Submission
When you are working to process claims on time, be sure to check your codes. If you miss a digit in an insurance ID or make a mistake while entering the number in the system, the your claim to be rejected. Remember to proof read every claim, to reduce such mistakes. Double check your work before you submit.
2. Information Collection From The Front Desk
Typically, the front desk is responsibility to collect and enter the patient information and insurance. Lightspeed communicates directly with the HMO’s/Insurance carriers. We began the patient chart with information directly from the insurance carrier. our system result in a 98% success rate from the first submission of the bill to the insurance company.
3. Eligibility Verification
Your billing software should verify patient eligibility within 30 seconds, at each visit so you have the correct insurance information to bill the claim.
4. Submit To Correct Insurance
Patients with multiple carriers, must submit the claim to the correct carrier. Submitting a claim to the wrong insurance often results in a speedy rejection.
5. Updated Insurance Requirements
Changing rules from HMO’s and ICD-10 codes can lead to multiple claim rejections. That’s why it’s important to keep a close eye on industry changes and update the information and procedures of your billing team. At Lightspeed, we update our system as changes occur. These changes are at no additional cost to the Practice.
These tips can help you minimize claim denials and improve collections, ( as low as 2%), but many practices lack the technology and experienced staff to effectively manage their medical billing, especially in light of constantly changing payer rules. Outsourcing your medical billing to experts like Lightspeed Revenue Cycle Management (RCM) is a great option. Lightspeed gives the Doctor complete transparency of billing activities 24/7.