Maximizing Reimbursement

Strategies for a Winning Medical Practice

Building the Foundation

• Building on the Basics of Proper CodingKNOW how to properly code the office visits and services your practice

provides. The CPT Code book is THE reference for coding procedures.

CPT® is Current Procedural Terminology, and was developed by the American Medical Association in 1966. Each year, an annual publication is prepared, that makes changes corresponding with significant updates in medical technology and practice.

The 17-member CPT Editorial Panel meets 3 times a year and considers proposals for changes to CPT. The Editorial Panel is supported in its efforts by the CPT Advisory Committee, which is made up of representatives of more than 90 medical specialty societies and other health care professional organizations.

Office Visits

• New Patient• 99201• 99202• 99203• 99204• 99205

• Established Patient

• 99211• 99212• 99213• 99214• 99215

Required Elements• Each visit must have the following elements documented.• History-• Chief complaint, • History of present illness, past medical, family, social history, • Review of systems.• Physical Examination-• Body systems,• Exam elements• Medical Decision Making-• Number of diagnosis patient was treated for and or that entered into

the decision making process or management options,• Amount and complexity of the information to be reviewed• Risk complications (and/or morbidity or mortality)

Can You Take It To The Next Level?

By knowing what elements are required for each level of E&M service, you will be better equipped to code the proper level of service provided.

• 99201- Is the lowest level of E & M coding for a new patient and/or family. • Typically 10 minutes face to face time is spent with the patient addressing a

problem(s) of minor complexity.• Required documented elements include-• Problem focused history• Problem focused examination• Straightforward medical decision making Usually the problems are self limited or minor. Physicians typically spend approximately

10 minutes face to face with the patient and/or family.

• 99211- Is the lowest level of E & M coding for an established patient. • The presence of the physician is not required so this is sometimes referred to as a

“nurses visit”. • Typically 5 minutes face to face time is spent with the patient addressing a

problem(s) of minimal complexity.

Can You Take It To The Next Level?

• 99202 Required Elements (Must have all three)• Expanded problem focused history• Expanded problem focused examination (1-5 AND• Straightforward medical decision makingUsually the problem(s) are of low to moderate severity. Typically

physicians spend approximately 20 minutes face to face with the patient and/or family.

• 99212 Required Elements (Need ONLY two of three)• Problem focused history• Problem focused examination • Straightforward medical decision making Usually the problem(s) are self limited or minor. Physicians typically

spend approximately 10 minutes face to face with the patient and/or family.

Can You Take It To The Next Level?

• 99203 Required Elements (Must have all three)• Detailed history• Detailed examination AND• Medical decision making of low complexityUsually the presenting problem(s) are of moderate severity and the

physician Typically spends 30 minutes face to face with the patient and/or family.

• 99213 Required Elements (Requires only two of three)• Expanded problem focused history• Expanded problem focused examination• Medical decision making of low complexityUsually the presenting problem(s) are low to moderate severity and

physicians typically spends approximately fifteen minutes face to face with the patient and/or family.

Can You Take It To The Next Level?

• 99204 Required Elements (Must have all three)• Comprehensive history• Comprehensive examination• Medical decision making of moderate complexityUsually the presenting problem(s) are of moderate to high severity.

Typically the physician spends approximately 45 minutes face to face with the patient and/or family.

• 99214 Required Elements (Requires two of three)• Detailed history• Detailed examination• Medical decision making of moderate complexityUsually the presenting problem(s) are of moderate to high severity.

Typicall the physician spends approximately 25 minutes face to face with the patient and/or family.

Can You Take It To The Next Level?

• 99205 Required Elements (Must have all three)• Comprehensive history• Comprehensive examination• Medical decision making of high complexityUsually the presenting problem(s) are of moderate to high severity.

Typically the physician spends approximately 60 minutes face to face with the patient and/or family

• 99215 Required Elements (Requires two of three)• Comprehensive history• Comprehensive examination• Medical decision making of high complexityUsually the presenting problem(s) are of moderate to high severity.

Typically the physician spends approximately 40 minutes face to face with the patient and/or family

Bulleted Elements-Who’s Shooting?

• History• Examination 99211- N/A99201 99212- Problem focused exam 1-5 elements99202 99213- Expanded problem focused exam with at

least 6 elements99203 99214- Detailed exam with at least two elements

from each of six areas/systems or at least twelve elements in two or more areas/systems

99204 9921599205 - Comprehensive exam with at least two

elements from each of nine areas/systems

Bulleted Elements-Who’s Shooting?

E/M Code Number of Dx Amt and/or Risk of Complications Type

or Mgmt Optns Complexity of data and/or morbidity or mortality Desc

to be reviewed making

99211

99201 99212 Minimal Minimal or none Minimal Straightforward

99202 99213 Limited Limited Low Low Complexity

99203 99214 Multiple Moderate Moderate Mod.Complexity

99204 99215

99205 Extensive Extensive High High Complexity

• Medical Decision Making

Modifiers

Modifiers provide additional information about the services provided. There are many but these are most common to family practice.

• 24, -25, and -57 are all used to show that the CPT code they modify was a separate procedure and should not be bundled with other procedure codes or should not be limited because of a defined global fee period.

**The complete list of modifiers is located in Appendix A of the CPT Code book.

• 24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period (make certain that you DO NOT show the diagnosis that is under the global period)

• 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

• 57 Decision for Surgery

ICD-9 Codes Specificity Use the 4th and 5th Digits where applicable Additional disease – Is there an underlying cause that must be used

with this diagnosis? Always code left to right, underlining associated code with description. DO NOT USE unspecified codes unless nothing else more appropriate

exists

Don’t let your office superbill dictate what diagnosis you use, consider writing out the diagnosis in full AND legibly so that your billing person will know which diagnosis to use.

Keep medical necessity in mind. The diagnosis used should support the service(s) provided There is a huge difference in 250.00 and 250.02 in terms of medical necessity.

Your Office-From the Outside In

• Who answers the phone in your office? • Are they polite, courteous and give the impression that

reflects your goals for the practice?• Who does your data entry?• Are they productive, accurate, attentive to details,

knowledgeable?• Who files the insurance claims and related

responsibilities?• Are they productive, work well with other staffers and

patients who have billing questions?• Who manages your office?• Are they productive, cooperative and supportive of

others?

Receptionist-First Impressions

• Typically the receptionist is the lowest paid staff person-yet carries the first and lasting impression of the practice.

• Does this person have a pleasant personality?• Do they treat you, your patients and your staff in a

courteous manner?• Could this person put your practice at risk for a lawsuit - -

the answer is YES!• Does this person have too much or not enough

responsibility?• Do they receive proper respect from the physician and

other staff?

Front Office Collections

• It is critical to the success of your practice that the front office personnel are friendly, polite and helpful to your patients.

• It is critical to the financial success of your practice that they get full and complete patient information and keep this information current.

• Train your staff to have patients to pay their co-insurance payments before they are seen.

• Train your staff to review patient account balances the day before the next scheduled visit so outstanding balances can be kept in check.

• Maintain respect and courtesy in your practice-both staff to patients and patients to staff (and don’t leave yourself out of the loop).

Data Entry – The Backbone

• Typically another of the lowest paid staff positions

• Have a tremendous responsibility to work quickly and accurately.

• Does this position have too much responsibility or nor enough?

• Do they have the proper work environment to allow for productivity?

• Is this person reliable and productive?• Do they work well with other staff such as the

insurance billing clerk and the receptionist?

The Buck Starts Here

• Data entry personnel should always have the most current patient information to work with.

• Hold staff accountable to get the proper information from your patients and give it to those who enter the data.

• Make sure your staff has the proper training needed to accurately enter the services your practice provides.

• It is the responsibility of the provider to properly code for the services they provided – NOT the data entry clerk.

• Make it acceptable for your staff to ask questions about what they are entering. A greater understanding of the services provided leads to more accurate data entry.

Insurance Billing Clerk

• Frequently this person handles all aspects of the accounts receivables process. Posting payments, following up on unpaid balances, handling patient statements and in many cases also managing all or part of the office.

• Does your billing clerk have too many responsibilities or not enough?

• Is this person courteous and respectful to you, your patients and your staff?

• Does this person provide you the financial reports and documentation you ask for promptly.

• Does this person perform all the duties of the position to your satisfaction?

Pivot Point• The financial success of your practice depends heavily on the insurance billing clerk

(accounts receivable personnel).• Structure and routine are critical. This position should have clearly defined

responsibilities that are contained in a written job description. *Are claims billed out several times a week? *Does your practice enjoy a steady cash flow? *Are patient statements sent out each month? *Are payments received in the office posted promptly? *Is there an office policy on payment plans, collections and uncollectible

balances? *Does the person posting the payments also receive the mail? *Does this person have/make the time to follow up on unpaid balances on a

regular basis? *Is the work space full of clutter and insurance statements? • Communication is critical to this position. You should receive regular reports about

the status of your practice’s finances. You should know the status of funds coming into the practice and outstanding accounts.

Office Manager

• This is typically the highest paid staff position.

• Does your office manager have enough responsibility or too much?

• Are they courteous and respectful of you, your patients and your staff?

• Are you pleased with their performance and level of productivity?

Cross-training Helping Staff See Others

• Every office should cross train staff.• Builds a team mentality and respect of others.• No one should be above completing any task and be

able to take a shift when another is out. • Every staff member should know your office protocol for

answering the phone, making an appointment and taking/delivering messages.

• Every data entry person should know how to read an insurance explanation of benefits and post payments.

• Every office manager should know how to fill in for the receptionist, data entry and insurance billing clerk.

Parting Comments• Hold Regular Staff Meetings-This ensures that everyone

understands the expectations for the practice, encourages productivity in the office and creates a team mentality.

• Review Financials-It is critical that the owner of the practice have a solid understanding of the business finances. Even though you may delegate this task, the financial responsibility cannot be delegated. Insist on receiving regular reports. Then be sure to review them yourself. Be aware of the mail concerning your claims as it comes through the practice. No one else is going to care more about the long term success of your business than you.

• Change-don’t allow your practice to fall behind, keep up with the changes in technology, billing and coding and other key areas. You don’t have to be the first to take a leap but don’t be the last either. Wait for stability and then keep your practice upwardly mobile