Is this a good time to get into Medical Billing?

Alice asked me to jot down my thoughts for this month’s newsletter and I thought “I don’t have time to jot down my thoughts!  I’m swamped.”   But then I stopped to think “Why am I so swamped?”  And that gives me the topic for my thoughts.  Over the twenty years we have been in business we have heard one question above all others:  “Is this a good time to get into Medical Billing?”  The answer has always been “Yes!” but now I say it with even more enthusiasm.

Lately we have been receiving more calls than ever inquiring about our services or asking for help.  Providers are being hit from all directions and they need help making sure they are not losing money.  PQRS, EHR, Meaningful Use, low reimbursements, higher out of pocket costs, and the list goes on.  It is more crucial than ever that providers make sure that the person handling their billing is doing a good job.  Gone are the days when providers could afford to lose a little here and there (not that I ever understood those days anyway!).  In order for a provider to stay afloat they need to make sure they are collecting all that they are entitled to.  So when anyone asks us “Is this a good time to get into Medical Billing?” we say “Absolutely!”

The next question we get asked is “What do I need to do to get started?”  That question cannot be answered in one sentence.  It really depends on your background.  Do you have any experience in medical billing?  Are you looking for a career or do you want to start your own business?  Do you have any experience in owning a business?  The answers to those questions will determine your next step.  Most people we come across have little or no experience in medical billing.  If you have no experience you really need to learn medical billing even if you plan on starting a billing business and hiring others to do the work.  You need to understand billing to know that they are doing everything right.

There are a lot of places that will tell you they will teach you all you need to know.  The problem is many of them are extremely outdated and can be outrageously priced.  Many are taught by people who have never done billing or who haven’t done billing in forever and they don’t really teach actual day to day billing. The billing field changes literally daily so it is so important that you are learning current billing and that whatever method you choose is up to date.  Alice and I have written several books on medical billing but our books are for specific parts of the business and just can’t teach you what you need to know to actually do medical billing.  So in 2013 we teamed up with Merry Schiff to create reasonably priced, current online medical billing classes.  You can read more about them at:  A Step Above Medical Billing Study Course..  So if you are considering a career in medical billing, Yes this is a Great time to get into it!

PQRS Gets More Complicated as 48 Measures are Retired

Many of us have been struggling to understand the PQRS system and meet the requirements to avoid penalties imposed by Medicare. To make it just a little more complicated as of January 1, 2015 forty-eight of the 300 + measures were retired.   Since the beginning of the year some providers have found that claims are being rejected do to invalid PQRS codes that they were using successfully last year. Mental health providers in particular were affected when measure #106 for Adult Major Depressive Disorder and two of the most common PQRS codes that they were using for reporting were retired.

PQRS, Physician Quality Reporting System, was initially created as an incentive program (PQRI, Physician Quality Reporting Incentive) but then was transitioned to a penalty program. As of January 1st 2015 any eligible professionals who are not reporting PQRS measures on at least 50% of eligible cases will be faced with a 1.5% penalty in 2015 and a 2% penalty in 2016. Even though the penalty program didn’t start until 2015 the penalty is based on reporting done in 2014.

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.

Most providers are already performing the screenings and have been for years but now they must report this information to CMS using PQRS. Many providers and billing staff are still trying to figure out how this reporting is done. There are four different methods of reporting.

A common method is reporting the PQRS codes directly on the medical claims. The measure that the provider is going to use is chosen, such as depression screening, and the appropriate corresponding PQRS code is added to the claim. The second method is through Registry Submissions where basically a service submits the data on behalf of the provider. The codes can also be reported through a Data Submissions Vendor or through EHR Direct.

Providers who are reporting measures that have been retired will receive denials that the PQRS codes reported are invalid. One of the deleted measures was a measure 106, the measure for Adult Major Depressive Disorder or MDD. This measure was a commonly used one by mental health providers. There are over 300 measures, but very few apply to mental health. Providers reporting using measure 106 were left wondering what to use.

There is another measure for depression that can be used. Measure 134 is for Preventative care and screening: screening for clinical depression and follow-up plan. It is often overlooked because of the heading “Preventative care and screening.” It is important that the provider read all of the information regarding reporting under measure 134 to make sure that it is an appropriate measure for the screening that is being performed.

Once the measure that will be used has been determined, the appropriate PQRS code that describes the screening can be chosen. The Specifications Manual from CMS lists all appropriate codes for each measure along with a description of the code. These codes must then be reported by one of the four methods mentioned above.

For example, if a provider is reporting screening for clinical depression under PQRS measure 134, there are six different CPT Category II codes that can be used to report the measure. The code that is used would depend upon the outcome of the screening. If the patient tested positive for clinical depression and a document plan was documented in the patient’s chart, then CPT Category II code G8431 would be reported.

It is important that providers are reporting PQRS with current valid PQRS codes and measures. If the measures and/or codes that are being reported were retired then the reporting will not be counted. If the provider is billing electronically then the codes will most likely be rejected at the clearinghouse level stating that the codes are invalid. Providers should be checking their electronic reports in order to ensure that these denials are caught. Of course they should be checking their reports for many other reasons as well.

For claims submitted on paper the rejections should come on the explanation of benefits statement. The billing staff needs to recognize that the code was rejected so that they are aware that the codes are not actually reporting the PQRS measure since the measure was retired. Providers may think that they are reporting on more than 50% of eligible cases but find that they are still facing a penalty since the codes and measures they reported on were no longer active.

To verify that the codes being used for reporting are active, they should be checked on the most current PQRS information provided by CMS. The Specifications Manual for 2015 can be accessed at the CMS website at under “Resources for 2015 PQRS Measures.”

CMS has also established a help desk to answer any questions regarding PQRS. The Qualitynet Help Desk is available for calls from 7 am to 7 pm CST Monday through Friday and can be reached at: Phone: 1-866-288-8912 TTY: 1-877-715-6222. Questions can also be emailed to

In order to avoid the penalty eligible professionals must ensure that at least 50% of eligible instances are reported to CMS using PQRS measures. PQRS measures only need to be reported on Medicare patients. Simply reporting the codes is not enough. As with CPT codes, practitioners must also make sure that their documentation reflects the PQRS code reported. If at least 50% of eligible cases are reported in 2015 the provider will not be penalized.

Many people feel that PQRS just puts added paperwork on the practitioner and their staff. It does take a little additional effort on behalf of the practitioner but some feel that it will act as a brief reminder to the provider to perform these essential tasks that they should be performing regularly. If the necessary time is taken to figure out what needs to be done it really doesn’t take that much extra effort to implement it. However, there are some providers who are just willing to take the penalty or will choose to no longer treat Medicare patients.