Exceptional Coders | Innovative Technology

Claim denials can be crippling for providers. And they’re especially irksome when they’re caused by avoidable coding errors. Managing E/M coding modifiers and incident-to services properly are two areas that providers can greatly improve in order to avoid denials and obtain maximum revenue.

Medical coding problems arise in part when they result in payers spotting abnormalities in the claims information. This prompts an audit and discovery of overpayments, and the payer then takes steps to get that money returned. The provider suffers because they’ve used that money for payroll or equipment, and now their cash flow is disrupted. Repeated instances of such recoupments can result in significant dollar drain and additional future reimbursement scrutiny. 

The Centers for Medicare & Medicaid Services recently announced updates for ICD-10-CM coding. Managing and keeping abreast of these codes are a complex undertaking, as there will be 72,184 codes in FY 2020. Healthcare organizations should strongly consider utilizing outside coding assistance to effectively understand the changes and benefits of the changes to ICD-10-CM.

The quality of coding, of course, largely determines how practitioners submit bills and the amount they’re paid. A dermatologist practice (or other provider) therefore must have confidence in the accuracy and timeliness of their coding. There are changes in the works for dermatology coding, as with all coding, and doctors and staff should proactively understand these changes and make the necessary adjustments in their coding procedures. There is no time like the start of summer with the increased risk of UV rays for this renewed attention to dermatology.

As healthcare finance leaders converge in Orlando next week for the annual Healthcare Financial Management Association (HFMA) Annual Conference, this recent HealthLeaders article highlights how to find the hidden dollars in your hospital (without reducing labor).

The United States Attorney’s Office District of Massachusetts recently announced that CareWell Urgent Care Centers has agreed to pay $2 million to resolve allegations they violated the False Claims Act by submitting claims to Medicare, MassHealth, GIC, and Rhode Island Medicaid that falsely inflated the level of E/M services performed and by failing to properly identify the providers of E/M services.

A recent survey of 100 healthcare leaders within finance, revenue cycle, reimbursement, and health information management at hospitals and acute-care facilities sought to report on the areas of most-needed improvement within revenue cycle management. The results of the survey, by BESLER who partnered with HIMSS, found a significant majority of respondents -- 84% noted coding and clinical documentation as two areas of high or medium revenue cycle risk. Nearly half noted these two areas as their greatest vulnerability. Why are these two areas causing such concern among leaders and resulting in depleted revenues?

Mid-revenue cycle management is concerned with the phase of the process between the point where a patient accesses care and the care provider’s business office. Typically processes during this time include documentation, coding, CDI, and compliance. A recent Markets and Markets report  expected sustained growth in this market. It projects a compound annual growth rate (CAGR) of 7.9 percent and a market size of $4.5 billion by 2023.

By optimizing revenue healthcare, organizations can put themselves in a position to survive and thrive in the modern marketplace of shrinking margins, consumer engagement, and higher cost pressures. This is true whether you are affiliated with billing companies, hospitals, physician practices, or payers. One of the most important ways to optimize revenue is by ensuring accuracy and efficiency in medical coding and documentation.

As the share of Medicare beneficiaries enrolled in Medicare Advantage has steadily grown to over 19 million beneficiaries according to a U.S. Attorney, federal prosecutors intervening in a newly unsealed whistleblower lawsuit in California is yet another example of the government's willingness to protect the integrity of the Medicare Advantage program through the courts.