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#18: Avoiding Coding and Billing Disasters

Discussion in 'ODwire.org TV & Radio' started by AdminWolf, Feb 13, 2013.

  1. AdminWolf

    AdminWolf Site Administrator & Tech Lead
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    Episode 18: Avoiding Coding and Billing Disasters

    As the medical model and the use of high-tech instrumentation has grown, ECPs have been increasingly subject to audits by insurance companies and the federal government.

    The fines for incorrectly coding and billing can easily run into six-figures, and in some cases can be even higher!

    In this episode of ODwire.org Radio, noted expert John Rumpakis, OD, MBA stops by to talk about how to avoid getting hit with major fines by properly coding and billing your patient encounters.

    He discusses some important coding strategies as well as disasters he's seen as a consultant.

    If you are responsible for the billing in your practice, you won't want to miss this show!

    Loading the player ...



    Feel free to ask follow-up questions of John in this thread.
     
  2. AdminWolf

    AdminWolf Site Administrator & Tech Lead
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    Thanks again to John

    Our thanks again to John for taking the time to talk.

    I was really sort of floored by one statement he made -- that he hasn't seen an audit come back with a fine of less than six-figures in a long time. Scary stuff.
     
  3. Mark Margolies

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    Electronic Records Required ?

    I personally do use electronic records but i question the statement that John Rumpakis made namely that EHR will be required in 2014. How so ? There may be lower Medicare reimbursement but that is different from saying they are required ? Who is requiring them and what will the consequences be for those who don't comply ?
     
  4. Robert Garfield

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    I'm also interested in the answers to Mark Margolies' above inquiries.
     
  5. Paul Farkas

    Paul Farkas Administrator

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    Point of information...and a word from our sponsor.

    Dr John Rumpakis will be answering question on this forum. He may be traveling today but I'm confident he will address concerns as quickly as possible.

    This very important ODwire.org Radio/Podcast was sponsored by our ODwire.org supporting members. This type of important subject are not sponsored by vendors who wish to sell product. We have to depend on our members who value receiving unbiased,uncensored information to support this project.

    Do you approve of ODwire.org Radio/Podcast subjects? Do you find the topics useful and want more of the same? If you say yes, show it by adding a gold star under your name.

    The extra benefit being a supporting member... You will be impressed by the business oriented forum topics which are must, if you have to meet a payroll.

    Take less than five minutes and pull out your credit card...
    http://www.odwire.org/forum/payments.php
     
  6. John Rumpakis

    John Rumpakis ODwire.org Supporting Member

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    My understanding is that in 2004, President Bush signed an executive order stating that all medical records must be EMR within 10 years. That is where the 2014 number came from. Additionally, President Obama has also reiterated this timeframe and stated that is his goal through the implementation of the meaningful use requirements that are part of the ACA that goes into effect on January 1 2014. The consequences that I am currently aware of are related to financial penalties placed on CMS and Medicaid billings.
     
  7. Conley Marcum

    Conley Marcum Member

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    Audits

    So, if you are not a member of any insurance panel, ie did not sign up as a preferred provider, would you ever get audited?

    I was under the impression that in 2014 if you didn't have EHR your medicare reimbursements would be decreased but it was not mandated.
     
  8. John Rumpakis

    John Rumpakis ODwire.org Supporting Member

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    If you have never been a provider for a third party payor then you would not be subject to an audit because you have always been paid directly by the patient - not with a third party's money. as far as the 2014 mandate, please see my comments above.
     
  9. Steven Nelson

    Steven Nelson ODwire.org Supporting Member

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    John, excellent interview and probably the most profound thing you said is precisely what I try to hammer into folks over and over. The record rules. They're going to audit not using a time machine, but rather the medical record and HOW you document things determines your success or failure when push comes to shove. If you didn't document, you didn't do it. If you document improperly, it doesn't MATTER what you did.
     
  10. Conley Marcum

    Conley Marcum Member

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    Audits


    I guess I should have phrase my question better. I receive 3rd party payments but I am not a participating provider for the plans.

    Thanks for your talk and input, John!
     
  11. Charles A McBride

    Charles A McBride ODwire.org Supporting Member

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    Hi John. I hope you are well. I'm not done with the podcast yet, but a question:

    Am I required to record the reason for ordering a test on the main portion of the chart or is including it in the interpretation and report sufficient? -Charlie
     
  12. Kevin J. Gross OD

    Kevin J. Gross OD ODwire.org Supporting Member

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    and, is the reason 'for further evaluation of dx xyz' or 'to compare to previous' sufficient?
     
  13. John Rumpakis

    John Rumpakis ODwire.org Supporting Member

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    Hey Charlie! Long time, my friend... Hope you are doing well also. The reason for ordering the test should be recorded in your plan, thus prior to running the test, so recording it in the I&R wouldn't be the best place. You are correct on your second question as well. For example, if you examined a patient and discovered a disk heme in the right eye, the order would read something like this. Order fundus photo of OD optic nerve for further evaluation secondary to hemorrhage noted today. Take care...
     
  14. Richard Pagan

    Richard Pagan ODwire.org Supporting Member

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    medical coding and billing is for sure a hot topic and I enjoyed the broadcast, all good advice. I think though that the elephant in the room is "vision vs medical". For ODs and MDs this is a growing problem, and is easily the largest point of contention. I wonder if you had any current opinions or other comments to share on this issue?
     
  15. #15 Feb 14, 2013
    Last edited by a moderator: Feb 15, 2013
    Bruce DeBeer

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    John, I use Officemate and ExamWriter and have a question concerning the recording of Chief Complaint.

    I'm always careful to list a chief complaint on all medically related exams as required by insurance, but I don't place it in the "Chief Complaint" box simply because I think it is stupid and redundant to list "Flashes of light" there followed by "Flashes of light seen for the past 3 days which is increasing in frequency" in the very next box. What purpose is served by stating the same thing, first in an abbreviated fashion followed by a more detailed fashion.

    Instead, I list the chief complaint in the History of Present Illness under either Vision Complaint or Ocular Symptoms depending on what the complaint is. My rationale is that a Chief Complaint is a Chief Complaint because it IS the Chief Complaint, not because it is labeled Chief Complaint. On a paper chart or an electronic chart, I feel you could have "Reason for Visit", and it would still be the Chief Complaint.

    I know that it is plainly documented that you must have a chief complaint, and I also know that many, if not most people list the chief complaint in two or three words followed by a more detailed description in the next section, but do the written rules (not opinions) say that it must be labeled as such, or can it be obvious that what you have recorded under HPI is the reason why the patient came to you? That is, their Chief Complaint.

    By the way, when the exam is printed out, if nothing is recorded under "Chief Complaint", then that label is not printed, just like "Fields", "OCT" or other labels don't print if you don't do those tests. In the above example, only "Ocular Symptoms" would print out.
     
  16. #16 Feb 14, 2013
    Last edited by a moderator: Feb 15, 2013
    David Tabak

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    Best Practices

    The lecturer state that we should have a bell curve of medical codes, yet I here over and over that "best practices" will use 99XX4 by far the most.

    The majority of my medical visits in my office do not require 2 and 3 follow up visits. When they do we, of course, code 99XX1, (99XX2 and 99XX3. If they are only coming in for medical care on a specific complaint (red eye most common) we always bill a 99XX4, assuming we treat the patient.

    What am I missing here?
     
  17. Kandi S. Moller

    Kandi S. Moller Well-Known Member

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    How do you meet more than 10 ROS for a new 99204? That's hard for an eyeball visit. You only need 2 for 99214.
     
  18. Paul Farkas

    Paul Farkas Administrator

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    Point of information...

    Although I was part of the program, I finally had the opportunity to listen to the complete 30 minutes. Dr John Rumpakis did a great job!

    You should have your staff members dedicated to billing and coding in your practice listen to the program as well.

    Keep asking questions.
     
  19. Charles A McBride

    Charles A McBride ODwire.org Supporting Member

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    I finished the podcast on the road tonight. A few questions...

    Let's say I incorrectly order a test in my plan with the phrase "Pt. needs OCT." Assume that I ordered it for the right reason and carefully documented the reason for ordering the test in the interpretation and report along with the results, reliability and how the outcome of the test might affect any decision to treat the patient, all the right stuff. If the primary aim of the auditing insurance company is to educate, educate, educate, would an auditor in this case STILL order me to replay the cost of the test?

    Some of the guidelines set by insurance contracts seem to consist of shades of gray open to interpretation. If one is audited, does the insurance auditor hold the trump card or is there some sort of an arbiter involved?

    Lastly, John, can you take moment to describe how your system to ensure proper and up-to-date coding works/what is costs etc.? Thanks much! -Charlie
     
  20. Steven Nelson

    Steven Nelson ODwire.org Supporting Member

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    I actually took some of John's advice and changed my templates in Practice Fusion to the following:

    "Order refraction" is now "order refraction to access medical condition's effect on corrected acuity"
    "Order fundus photography" is now "order fundus imaging with associated interpretation and report for documentation of medical condition and future comparison" - similar change for anterior photography.
    "RTC for re-assessment in 6 months" now reads "return for re-evaluation of medical condition in 6 months. Written report of findings forwarded to primary care physician"

    I also am now adding "as indicated on imaging" to any documented abnormality I am going to photo as in "2+ rpe dystrophy as indicated on imaging".

    It's annoying in some ways using Practice Fusion because its in SOAP format, but it does allow you to word things exactly as you like and when the record is finished, it makes a very nice narrative for referrals and reports.