Training a Medical Biller

Training to become a medical biller can be overwhelming. Whether you are an employer who needs to train employees or you are looking to become a medical biller, good training is crucial. When we have a new employee the training process is intense. It is important that the new employee learn how we do things, and become as self sufficient as possible as quickly as possible.

Of course in the beginning mistakes are going to be made. We start out by having an experienced biller sit directly with the new employee and have the new employee watch what the experienced biller is doing. The whole time, the experienced biller is explaining step by step what they are doing, why they are doing it, how they accomplish it, and every other detail that the new employee may need to know. They are also explaining our practice management system, our filing system, our system of receiving information, and how we communicate with our providers. There is so much to show them.

Once we feel that they have observed enough, the experienced biller switches places with the new person and gives them a chance to try things out for themselves. The amount of time that a new person watches before they are ready to try it varies greatly depending on their previous experience and how quick of a learner they are. Once they switch places the experienced worker watches every keystroke to make sure they truly understand. Many times they give verbal instructions the whole time until they are sure the new person has grasped the task.

Once they are able to observe without having to give verbal assistance they will allow the new worker to complete a task and then check it over after they are done. This is still time consuming as it’s being done twice basically. But we feel it is necessary in order to be sure the new person is doing things
correctly. The experienced worker will check over each item and bring any mistakes back to the new person and show them what they’ve done incorrectly. We find this is a great tool. Learning from visually looking at your mistakes is the best experience you can give someone.

As you can see the training process (at least in our office) is very intense and very disruptive to normal work flow. It takes two people to do the job of less than one really. The process is slow but if you want the person to be effective you need to take the time in the beginning to make sure they are
trained properly. When we bring on a new person it is usually several months before they are up to speed and the person involved in their training can go back to their regular duties.

If you want your employees to be good quality employees then you need to take the time to train them. You can’t expect them to give you excellent quality if you haven’t taught them how to do that. We find that mistakes take a lot more time to correct on the back end than they do to avoid them up front. If you take the time to properly train the person, it will pay off in the end.

Proper Use of the 59 Modifier

Many people do not really understand modifiers and when they need to be used. A modifier should never be used just to get higher reimbursement. It shouldn’t be just added on to get a code paid. Modifiers should be used when they are required to describe more accurately the procedure performed or service rendered.
The definition of the 59 modifier per the CPT manual is as follows:

Modifier -59: “Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries)not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. Unfortunately many times it is used to prevent a service from being bundled or added in with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system.

It should also only be used if there is no other more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed then that modifier should be used over the 59 modifier.

When using the 59 modifier to indicate a distinct and separate service, documentation should be in the patient’s medical file to substantiate the use of the 59 modifier. The insurance carrier may request medical records to deem if the 59 modifier is being appropriately used. If a provider is going to bill using the 59 modifier they need to make sure they are documenting the services provided in the patient’s file, showing that the services were distinct and separate.

Use of the 59 modifier does not require that there is a different and separate diagnosis code for each of the services billed. Also, just having different diagnosis codes for each service does not support the use of the 59 modifier.

An example of appropriate use of the 59 modifier might be if a physical therapist performed both 97140 and 97530 in the same visit. Normally these procedures are considered inclusive. If the 59 modifier is appended to either code they will be allowed separately. However, the 59 modifier should only be added if the two procedures are performed in distinctly separate 15 minute intervals. If the therapist does the codes simultaneously then the 59 modifier should not be used.

Another example would be if the patient is having a nerve conduction study with cpt codes 95900 and 95903 being billed. If the two procedures are done on separate nerves then the 59 modifier should be used to indicate that. If the codes were performed on the same nerve then the 59 modifier should not be used.

Billers should never add the 59 modifier to a claim even if they know that billing the services without the modifier will result in bundling or a denial. The 59 modifier should only be added by the provider or by a coder who has access to the patient’s chart. If you are the biller and you believe that the 59 modifier would be appropriate but it was not indicated, you should go back to the provider to see if it was omitted by mistake. Don’t just add the modifier to the claim.

“Stop the Bleeding!” – Ways to prevent unnecessary loss of income during these hard times

For most Americans, whether or not the government has officially declared these times as a recession or a depression, things are a little tougher than they were 10 years ago. This includes doctors. Many patients think that all doctors are living good and aren’t hurting like “the rest of us” but that isn’t true. Doctors are feeling the pinch now too. After all there are a lot of expenses in running a medical office, especially with all of the changes going on with EMR and ICD 10.

They have the normal expenses of office space rent, taxes, receptionist(s), nurse(s), physician help (NP’s or PA’s), insurance, office supplies, utilities, computers, software, and the list goes on. In addition to that many are faced with needing to buy new software to be compliant with the EMR laws and training expenses to prepare their staff for the switch to ICD 10. Most patients really don’t have any idea how much a doctor has to pay just to keep their office open.

Now more than ever medical providers need to “stop the bleeding” by plugging the holes in their office that are causing them to lose money. One of those holes for many providers are denials. I read a statistic a while back that said that 47% of denied claims are never appealed. To me, that number is staggering. Sure there are claims that are denied correctly, the services may not be covered, or the patient may have met a maximum and the patient is responsible for the charges. But I don’t believe it
can be that many. And unfortunately, I’ve been in enough medical offices to know that many have office staff that are just not dealing with the denials.

I have found there are a couple of different reasons why denials in an office can go neglected. One of them is due to lack of time. Many offices are chaotic. They not only have the regular patient load, which in and of itself is enough to keep them running all day, but they have the add on patients who just have to be seen immediately. In addition, they’ve got the phones ringing, someone has called in sick so they are short handed, and they’ve got pharmaceutical reps coming in. You get the picture. They barely have time to get the billing out, possibly record the payments that have come in, but handling denials? Maybe they will get to those tomorrow. Unfortunately tomorrow never (or at least not usually) comes.

The staff isn’t purposely ignoring the denials. They truly think they will get to them. The problem is that many insurance carriers have time limits on when a claim can be appealed. Most allow 60 or 90 days from the date the claim was processed to file an appeal. Also, if the denial means that a different insurance needs to be billed the timely filing limits on that carrier may be reached if the denial isn’t handled quickly. If the denial means that the patient needs to be billed, the odds of getting
payment are greater the closer it is to the date the services were provided. The doctor usually isn’t even aware there is a problem. Many times, neither the doctor nor the staff have any idea how much money the office is losing due to these denials not being handled.

Another reason that denials go unresolved is if the staff in the doctors office doesn’t know how to handle them. It’s not always that they don’t have a good comprehension of medical billing, but they don’t always know what needs to be done in the case of certain denials. It may be a denial they are unfamiliar with or haven’t run across before. Or it may be an insurance carrier that they haven’t dealt with much. If they don’t know how to handle it then it may go unresolved.

In some cases, doctors hire people to do their billing that don’t have a good comprehension of medical billing. In this case not only do the denials go untouched, but there are a larger number of denials than there are in an office with an experienced biller. It is unfortunate, but some providers don’t understand the importance of the billing.

No matter the reason that the denials are not being handled, the important thing is that the doctor do something to change it. There are a couple of things that can be done. First, see if there is anything that can be done on the initial billing to prevent any of the denials that are being received. If a doctor is receiving a lot of denials for terminated insurance plans then the staff needs to do a better job of verifying the insurance with the patient at the time of their visit. Maybe they are not asking
the patient when they come in if there are any changes in their insurance information. Many patients forget to inform their doctor when they change policies. Having the receptionist ask will cut down on these denials.

Another thing that can be done is to develop a system for handling each denial. Having a system will eliminate the need for the staff to determine what needs to be done each time a denial is received. For example, if the doctor receives a denial for timely filing the staff should know exactly what to do. First, check to see if the claim was originally submitted in a timely manner. If it was, a claim should be reprinted along with proof of the original submission. If the claim was submitted electronically
that proof may be an electronic report verifying the first submission. If it was a paper claim, it may be a patient ledger printed out from the practice management system.

In addition to the claim and the proof, an appeal form should be attached. It’s best to design a generic one for the insurance carriers that don’t have their own adjustment forms. This will cut down on time since the staff can just simply grab the generic form and attach it to the claim and the proof instead of writing up new one each time one is needed. For the carriers that have required adjustment forms, they should be kept handy for quick and easy access.

Having a system in place for each denial will greatly reduce the amount of time needed to file the adjustment request or submit an appeal. It will also make the process easier for the staff so it won’t be such a dreaded task. Reducing the number of denials received and having a system for handling those denials will help the staff be able to deal with them in a more timely fashion.

In this economy a doctor must do all they can to ensure that they collect all of their receivables. Their growing expenses coupled with the declining reimbursement rates from insurance carriers make it a necessity to reduce the amount of money lost to unpaid or denied claims. Making sure that denials are being handled is one way they can “stop the bleeding”.

Copyright 2011 – Michele Redmond

Physical Therapy Book Next

OK, the vacation is over. Back to work. (What vacation?) Time to start work on the half completed “PT, OT & ST Billing Made Easy”. Michele has been working in her spare time on our next book on physical therapy over the last few months and now she will concentrate her efforts on this project. I’m working on a new marketing book and marketing program we plan on announcing this fall.

Denials, Appeals & Adjustments – New Book Now Available

Michele and I are really happy to announce that yesterday we released our newest ebook “Denials, Appeals & Adjustments”. We both felt that this was the hardest book of the 13 books we offer that we have ever written. I thought our book on contracts was hard, but this one really stressed us out. There was so much to cover and so much to explain.

Last week Michele, my husband Paul, Mick’s 3 girls and I all drove to Md for “Summerfest 2011”. It is an annual youth group event with participants from several churches that we all enjoy. We took our computer with us and worked in between sessions at the hotel pool on denials, trying to complete the last of the list. We worked in our room and we wrote notes as we drove back and forth to the church. This week Monday & Tuesday were particularly hectic after being gone from the office for 3 days last week and still trying to complete the last of the book. You can’t imagine the relief at finally completing it yesterday.

A special thanks to all of you who purchased the ebook last night. We hope it helps you better understand what to do about denied medical claims and answers all your questions.