Providers Need Billing Services More Than Ever

We are often asked if medical billing is a good field to enter and how the new Affordable Health Care Act is affecting this field.  While the Affordable Health Care Act has definitely influenced the field of medical billing, it has not decreased the need for educated medical billers.  The key word in that last sentence is educated.  Doctors need experienced, informed people handling their billing.

There have been so many changes in the past few years that it can be very difficult to keep up with all these changes.  Unless your focus is on insurance billing, it is very easy to miss changes that directly affect payments and cash flow.

Here are several examples of current changes that are going to greatly affect providers when the staff is not aware of these announcement flyers that have been sent to the offices.

1.  Last spring our local Blue Cross/Blue Shield sent out a flyer stating that they were requiring taxonomy codes to be included on all insurance claims or the claims would be denied.  Now, no other insurance carriers to our knowledge require taxonomy codes on the insurance claims, but as of July 2014, our local Blue Cross did.  If you didn’t read that flyer and prepare insurance payments from Blue Cross stopped in July.  Those unprepared offices then had to find their taxonomy codes, enter them on the claims in the correct box and resubmit all claims.  We know of many offices that had an interruption in their cash flow as a result of this change.

2.  Just recently our local Blue Cross found yet another way to slow down the claims processing for providers by sending out another flyer that states that in December 2014 (next month) all insurance claims must have the name and date of birth of the policyholder as well as the patient.  This is huge as many offices collect only the patient information, not paying that much attention to the policyholder.  Any claims where the patient is not the policyholder will now be denied.  We are expecting this to also disrupt many provider’s cash flow.

3.  PQRS – As much as we have read and written about PQRS, it will still come as a shock to many offices when an additional 2% is deducted from their Medicare payments next year.  We will hear “Why are they deducting my money again?”  Many providers still do not understand what PQRS.  As a billing service we are educating our providers so that they can decide if they want to avoid the penalty and how they can do that.

4.   With the Affordable Care Act it is now more important than ever that providers are verifying benefits prior to the patient being seen.  Many of these ACA plans have very high out of pocket expenses.  Gone are the days where the provider can simply rely on the amount they receive from the insurance carrier and not worry so much about collecting the patient’s portion (although that was never a good idea – we do know many offices that had that mentality).   It is important that the person doing the billing is on top of ALL billing, including patient billing.

5.  With or without the Affordable Care Act it is also now more important than ever that the providers office is handling denials effectively and working the aging report regularly.  Many offices that do in house billing fall short in this area.  With all of the other changes it is important that providers are collecting on all that they are entitled to.

This is why billing services are still a very good business opportunity.  As we have always said, it is no “get rich quick” scheme.  It is hard work but it is a needed field.  It is also so important to keep up with changes.  Whether they are big or small they affect the income.  It is increasingly difficult for a small provider to keep up with the expenses of a medical practice.  They must find better ways to keep the income steady and maximize their receivables.  Larger practices must make sure that money is not slipping through the cracks since they have so many higher expenses.  Outsourcing to a billing service can be a smart move for both the small and larger offices.

Denial Tip #2 Handle Denials Quickly

We find that many providers’ offices and even billing services tend to put denials aside to take care of them later.  This is a bad idea and can actually end up costing the provider money.  The best time to handle a denial is as soon as the denial is received.

Some insurance carriers have time limits on when denials must be handled.  For example, one of our local insurance carriers only allows sixty days from the date of the denial for a denial to be handled.  If an appeal needs to be submitted, or information must be corrected, it must be done within sixty days or it will not be accepted.  Often when the denial is put aside more time passes than intended.  This can lead to missing the time limit on handling the denial.  Maybe there is still time to file the appeal or submit the information, but there is no time for research or gathering the information needed for the appeal or correction.

Another reason it is not a good idea is that the claim is still showing as outstanding in the practice management system.  This means it is still showing up on aging reports and may result in unnecessary work being done.  If the denial is set to the side with no notations made in the system, the person working the aging report may not realize that the claim was denied and call to check on the status.  This would be a waste of time since the claim was denied and the information on the denial was obtained.

Here at Solutions Medical Billing, we take the information of any denied claims and put it right in our work folders for that individual provider.  When the claims and payments are entered for that provider the denials are worked as well right then.  If a denial is set aside or put in a drawer it is much too easy to let it fall through the cracks.

Much money is lost by providers every year on denied insurance claims.  Handling denials quickly will help reduce the amount of money that is lost.

PQRS for Optometry

OK last time we broke down PQRS for mental health and we got lots of feedback stating how helpful it was.  So now we are going to break it down for Optometry providers.

Just a quick recap for those who still don’t know what PQRS is:  PQRS or Physician Quality Reporting System is a system used by physicians to report performance measures to Medicare.  Prior to 2015 PQRS was simply an incentive program (known as PQRI).  But in 2015 it will become a penalty program.  Physicians who do not report performance measures using PQRS will be faced with a 1.5% penalty in 2015 and a 2% penalty in 2016.  Even though the penalty program doesn’t start until 2015 the penalty is based on reporting done in 2014 so in order to avoid the penalty providers must be reporting performance measures now.

The PQRS program is for Fee-For-Service Medicare patients.  It does not include patients who are enrolled in Medicare Advantage Plans, or Part C Medicare.  So let’s break this down and make it as simple as we can.  (Don’t forget, it is a government program.  They don’t usually make anything easy.)

Let’s break the whole process down into 3 steps:

1.    Identify the measure you will use to report
2.    Link the chosen measure to the appropriate reporting code
3.    Report them to Medicare

  1. Identify the measure you will use – CMS has over 300 reporting measures but (thankfully) most are not relevant for optometry. There are 14 measures that appear appropriate for optometry with 7 of those 14 being specific to eye care. Here are the 14 appropriate measures:
  1. 12   Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
  2. 14   Age Related Macular Degeneration (AMD): Dilated Macular Examination
  3. 18   Diabetic Retinopathy: Documentation of Presence or Absence of Macular

Edema and Level of Severity of Retinopathy

  1. 19   Diabetic Retinopathy: Communication with the Physician Managing On

going Diabetes Care

  1. 110 Preventive Care and Screening: Influenza Immunization
  2. 111 Pneumonia Vaccination Status for Older Adults
  3. 117 Diabetes: Eye Exam
  4. 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and


  1. 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant


  1. 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure

(IOP) by 15% OR Documentation of a Plan of Care

  1. 173 Preventive Care and Screening: Unhealthy Alcohol Use – Screening
  2. 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation


  1. 236 Controlling High Blood Pressure
  2. 317 Preventive Care and Screening: Screening for High Blood Pressure and

follow –up documented

  • Remember, the performance measure must be reported using the appropriate g-code or CPT-II code, but the actual results do not get reported.
  1. Link the chosen measure to the appropriate reporting code – Find the appropriate G-Code or CPT II code to report the measure. Make sure the procedure code that is being billed is appropriate for the measure being reported. See the table from CMS below:

(* Please note that this information is always changing. Please check the CMS website to make sure that you are using the most up to date codes.)

Click here to download chart of the measures and appropriate codes.

  1. Report the measures to Medicare – Measures can be reported to Medicare in one of four different ways:
  2. Claims based reporting – codes are included on the claim for the services
  3. Registry based reporting – measures are reported to large Medicare approved organizations that report the data to Medicare
  4. EHR based reporting – measures are reported through the EHR system
  5. Group practice reporting – measures are reported through a group practice

The most common reporting method is claims based reporting. Claims based reporting is done by adding a G-Code or a CPT II code to the claim. Once the appropriate code is selected it is billed on the same claim as the services. The code must be entered with either a $0.00 or a $0.01 charge. (Nothing is paid on the code. Some systems will not allow it to be entered with a $0.00 charge so a $0.01 charge must be used. It will depend upon the system being used to create the claim.)

So now that we have covered the steps of PQRS, let’s go through a couple of examples:

Example 1: Doctor sees a glaucoma patient who is 18 years of age or older.   The doctor should perform an optic nerve evaluation at least yearly and would measure the intraocular pressure at least yearly.   When the IOP is not controlled, a provider would typically develop a plan to reduce the IOP to an acceptable level. The doctor could code a 2027F and a 3284F for a controlled glaucoma patient or 2027F, 0517F and 3285F together for an uncontrolled glaucoma patient.

Example 2: Doctor sees a diabetic patient, with or without diabetic retinopathy, between 18 and 75 years. The PQRS code 2022F would indicate a dilated eye examination was performed (assuming that the provider would typically dilate all diabetic patients yearly). Also, when diabetic retinopathy (with or without macular edema) is found, the doctor would use 2021F to indicate a dilated macular or fundus examination was performed.

If the doctor sent a report to the patient’s primary care doctor he would also use 5010F to indicate a report was sent along with G8397 to again indicate the dilated macular or fundus examination was performed. ** This can only be done if the patient was 18 and older.