Author: admin

Why Are Medical Coding & Billing Due Diligence Important?

There are numerous reasons why you would want to engage in thorough medical coding and billing due diligence before a practice merger or acquisition. However, the most important is to ensure compliant and accurate documentation, as well as timely and accurate coding and billing.

By checking into this history, you can determine a lot about the financial well-being of a practice, including how it affects the overall value. Additionally, non-compliant billing and coding can increase the liability risk for a medical practice. If you are taking control of that practice, that liability carried onto you. Thus, it is important to know what you are dealing with from the very beginning by doing a thorough job of due diligence.

Coding Due Diligence Benefits

It’s important to realize that the benefits of coding due diligence go far beyond just checking for liability issues. For example, you can enjoy greater visibility in coding patterns and have a more complete basis for your purchasing decision.

Working with Symbion Coding Inc to obtain this type of report also ensures diagnoses and procedures described in the patient’s health records are appropriately coded. In turn, this allows you to identify whether the risk lies with the physician, coders, or some combination thereof.

Working with Symbion for Coding Due Diligence

At Symbion, we are here to make the due diligence portion of your acquisition or merger easy. Our experts can help detect a variety of elements including:

• Whether E/M documentation meets all appropriate guidelines or not
• Any possible missed opportunities for HCC codes for Medicare Risk Adjustment
• Determining if diagnosis and procedure coding guidelines are followed
• If file documentation routinely supports medical necessity
• Whether medical records are being copied and/or pasted versus individually prepared for each unique patient

And that is just the start of what we’re usually able to uncover. By having these details, you can make a better determination and wiser decisions during your business transaction.

Receive a Complete and Detailed Report from Symbion

So, what does Symbion provide with our medical coding and billing due diligence service? First, we offer a quick turnaround time to help you get the information you need when it is most important. Second, the report we offer is fully confidential and we also routinely work with attorneys to ensure attorney-client privilege. In the end, you will receive a report that not only shows errors, but also identifies possible root causes, opportunities for documentation improvement, analysis of results with potential impact, and recommendations to address the identified issues.

As most practitioners and nurses would agree, health records are the most critical document used within the medical care setting. After all, they are the primary vehicle for recording and communicating health information and ensuring continuity of care.

There are numerous pieces of information within a health record that are used for various purposes. For example, notes and information within these documents are used to evaluate adequacy and appropriateness of care. They also provide clinical data for research and show quality of care. On the financial side, these records can support reimbursement from insurance providers and make keeping the healthcare center profitable a reality.

In short, documenting the patient’s condition completely and accurately is a paramount part of the healthcare process. That is why it is so important to review your document program and have a plan for making needed changes for better accuracy.

What is a Clinical Documentation Improvement (CDI) Program?

So, what exactly is a clinical documentation improvement (CDI) program? Essentially, it is the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. The overall goal is to ensure the patient’s true severity of illness is documented and reported appropriately.

While that might all sound like a mouthful, what it all comes down to is having a process of reviewing your documentation to make sure your entire medical team is reporting healthcare data accurately and completely at all times. This is something that needs to be done often to ensure all protocols are followed and that your patients are getting the best care possible. It is also something that should be checked to discover any bad habits or problems that arise with specific staff member reporting.

Reasons for Clinics to Implement a CDI Program

Hospitals have been doing inpatient CDI programs for years and regularly make changes to their documentation protocols. The unfortunate part is that most individual clinics and doctor’s offices don’t have the same level of funding to be able to do this on a regular basis, nor does the staff usually have time in the day due to other responsibilities.

Think about this for a moment. What time during the day does an office manager or receptionist have to go through existing medical records and review them for complete and total accuracy? What about a medical biller or coder? Generally, their day is busy with just trying to keep up with the normal duties of their position. Thus, it can be a good idea to work with a third-party to implement a thorough CDI program.

Clinical Documentation and the Changing Healthcare Environment

The healthcare environment is rapidly changing, and it can be more critical than ever to ensure all patient health records are accurate and complete. In order to receive payment for health services rendered, the quality of records submitted can make a big difference in amount and speed of pay.

Payment systems utilizing ACOs and bundled payments incentivize efficient care, but also require physicians to document specifically, clearly, and accurately. In addition, the Physician Quality Reporting System (PQRS) also offers better benefits for having better health record documentation.

Plus, many health payers now use some version of value-based reimbursement that links financial reimbursement to patient severity of illness. This means that it is more vital than ever to capture and record accurate diagnoses.

What Can Individual Medical Practices Do?

When it comes to ensuring your individual medical practice has the most accurate health records possible, one option to consider is to hire a third-party to implement a CDI program. On a small scale, your organization can hire a medical coder with specific CDI experience to help review existing records and implement better protocols for new records.

Likewise, you can also opt to work with a third-party coding and billing partner, such as Symbion Coding (www.symbioncoding.com). We offer clinical documentation improvement advice and review within the services that we already offer, which can give your practices a two-fold approach to improved reimbursement and accuracy.

Both are excellent options that lead to one final and successful result: a better healthcare records system that ensures your patients are getting the best care possible and that your practice is receiving the appropriate reimbursement for the treatment provided.

Conclusion: Benefits of Having a CDI Program

What this all comes down to is that every medical practice should have a CDI program in some form. Whether this is an individual party who is trained to handle chart review tasks or a third-party organization with a wealth of experience analyzing records in bulk really comes down to your individual clinic needs.

However, the end result is still the same of better-quality documentation within the medical record. Better data and accurate reimbursement for the practice. And an overall reduced compliance risk associated with improper billing. For most practices, these benefits alone far outweigh the cost of hiring third-party help and make the CDI process incredibly worthwhile.

Jean Delva
Founder & CEO of Symbion Coding, Inc.

Over the last few years in particular, insurance plans with high deductibles have become very popular – which means that patients are responsible for larger percentages of their own healthcare costs than ever before.

At the same time, many people are under the (unfortunately mistaken) impression than unpaid medical bills in a credit report will NOT cause any damage to their credit score over the long-term – meaning that they may not feel the urgency to pay in some situations.

Thankfully, improving patient collection in your practice to this point is not nearly as difficult as you may be fearing. You just have to take a few key steps today that will pay huge dividends (both figuratively and literally) tomorrow.

Improving Patient Collection: Steps to Take Before the Patient Appointment

After a patient books an appointment but before that day actually arrives, you should always verify all insurance information on-hand to make sure that the patient in question has the appropriate coverage. At a bare minimum, check to see that they have a deductible and if the answer to that is yes, ensure that the deductible has been met. There is software out there that can help your medical practice and your staff members do this automatically, all so that you can save a great deal of time in the process.

Likewise, have someone reach out to and communicate with the patient if there is any copay or deductible (or past due balance) before the appointment. Make sure they understand the situation and do what you can to help them take care of it in a sympathetic way, all before their appointment happens.

What to Do During a Patient’s Appointment

Once the patient’s appointment day is here, try to collect their copay, deductible or past due balance before the patient sees the provider (if possible). It is natural to meet a bit of resistance to that point, so be sure to frame your communications in a way that puts their mind at ease.
For example: rather than asking patients if they want to pay today, ask them HOW they want to pay today. Let them know about any special payment arrangements that they can make and generally just make sure that they understand all of the various options available to them.

Likewise, make sure that someone in your office can actually accept a credit card to facilitate the payment (if applicable). Really, what you are doing is trying to take care of potential issues now to create the most hassle-free payment experience possible for people. Not only will this help take care of any perceived issues with this appointment, but the positive experience will also help make people more inclined to pay again in the future.

Billing Considerations for After the Appointment and Beyond

It goes without saying that, at times, you may not be able to collect patient medical bills before or even on the day of an appointment. This is especially common these days, given the economic uncertainty brought on by the ongoing COVID-19 pandemic. Everyone has a different and unique situation, and you can never be too sure of what challenges someone may face. But at the same time, that does not mean that you do not have steps available to you after they have left your office.

First, be sure to follow up with the patient about any past due balance as soon as you can after the appointment – even as soon as the next day is okay in a lot of situations. Generally speaking, it may be more practical for medical practices to send statements to patient homes as a first option. This statement should include as much relevant information as possible including when the service was provided, what specifically was done during the service, the portion of the bill being paid by insurance, and more. If the patient receives the statement but still does not pay, that is when you will want to reach out by giving them a call.

Again, you are trying to put their mind at ease and remind them of what they are actually paying for. A lot of times people will be much more open to the idea of making this type of late payment if they understand what you are trying to collect for.

If possible, offer an option to pay bills online as this can absolutely help increase collection. Someone may not like the idea of giving a credit card number over the phone, and that’s understandable – but let them know that you have a secure online payment portal that they can take advantage of at their convenience.

Likewise, if you are able to, offer a payment plan for larger amounts to help all parties involved. Not only do patients not have to worry about suddenly coming up with a huge amount of cash at once, but you also get to collect on the bill itself – albeit in small portions. Oftentimes, this compromise can make all the difference in the world. All of this will not just improve your relationships with your patients – it will help support your revenue cycle as well.

At Symbion, we pride ourselves on acting as a partner to medical practices like yours – and one that wants to help you optimize your collection and achieve the most accurate, timely reimbursement possible. So if you’d like to find out more information about these and other simple strategies that you can use to improve patient collection in your medical practice, or if you’d just like to discuss your own needs with someone in a little more detail, please don’t delay – give us a call today at (800) 672-8149 or visit us at www.symbioncoding.com.

There is no doubt that the COVID-19 pandemic has changed the medical community as a whole. Where most people used to just make an appointment and show up at the office, many are now opting for telephone encounters to help prevent virus spread.

For practitioners, this is a much more convenient way to offer patient centered care. Instead of trying to see a set number of people within the walls of the office each day, doctors can now treat more patients in a much more convenient format.

Here is what you need to know about telephone encounters including what they are and why they need to be documented correctly.

What Are Telephone Encounters?

Simply put, telephone encounters are clinical exchanges that occur via telephone between providers, nurses, and patients. Telephone encounters can be very useful for numerous reasons, including:

• Increased Clinic Access: Patients who might not otherwise be able to make it into the clinic physically now have access to care.
• Reduced Unnecessary Burden on Patients: Travel time and other obstacles are now reduced or completely eliminated.
• Reduced Unnecessary Hospital Visits and/or Readmission: By having easier access to primary care physicians, less patients are physically visiting emergency medical centers.
• Improved Continuity of Care: Subsequent visits to follow up for specific conditions is much easier.
• Maximize Physician and Nurse Time: Calls usually only last a few minutes, which allows for treatment or more patients within a day.

In short, there are many reasons why a practitioner would consider adding telephone encounters to their schedule that are beneficial to the overall clinic (This article does not examine the amount pay by health plans to medical practices).

Not All Phone Calls Are Telephone Encounters

However, it is important to realize that not all phone calls are telephone encounters. Knowing the difference is important, as it can mean the difference between having bills approved by insurance companies or outright denials.
The real benchmark is whether or not the call includes information that can be communicated by non-licensed staff. This includes communication of normal results, billing inquiries, or other generic phone calls. Additionally phone consults that result in an in-person appointment less than twenty-four hours later would not be considered a telemedicine visit.

Criteria for Telephone Encounters

To ensure practitioners are using the telemedicine system appropriately, there are a few guidelines that determine whether an event is truly a telephone encounter. At least one piece of criteria must be met to be considered an eligible telephone encounter:

• Medical Decision Making: The call includes medical decision making and/or care coordination that results in the involvement of a physician, nurse, or pharmacist, such as treatment plans or changes in prescription medication.
• Substitute for In-Person Clinic Visits: To be a telephone encounter, the call must be deemed an alternative for a physical visit to the clinic.
• Refills of Medications: The call includes refills of medications that would have otherwise required an in-person clinic or emergency room visit.
• Follow-Up Visit: The conversation serves as a follow-up to a previous in-person visit.
• Educational Visit: The call or involves a form of patient education such as counseling, informed consent, or motivational interviewing.

Furthermore, it is important to note that only established patients are eligible for legitimate telephone encounters.

Documentation of Telephone Encounters

When it comes to medical billing and coding, there is a specific amount of documentation that needs to be done correctly. All telephone encounters should be documented to the medical record in the same manner as an in-person clinic visit. A few of the most common documentation requirements include:

• Notation of Initiation: It should be well documented that the patient, parent, or guardian initiates the phone call.
• Notation of Consent: Documentation that the patient consents to the telephone call.
• Notation of Reason: Include notes on the reason or chief complaint requiring the telephone call.
• Medical History: Document relevant medical history, background, and/or results for the patient.
• Assessment: The practitioner’s assessment of the patient with full and detailed notes.
• Treatment Plan: The provider’s plan for treatment of the patient, including all relevant medications or other instructions.

It is also important to include detailed information to show the medical necessity on the total time spent with the patient. While it might be tempting for some patients to discuss their grandchildren’s soccer game or some other personal topic, this filler conversation should not be included in the documentation.

Wrap Up: Protecting Your Practice During Telephone Encounters

It continues to look like telephone encounters are going to stay popular long after the COVID-19 pandemic fades. That is why it is so important to learn these guidelines now and apply them within your practice. Failure to do so can lead to denials and delay of payment, which nobody wants to deal with. Instead, train your team now to help make the billing and coding process easier in the future.

Over the past few years, there has been an alarming increase in cyberattacks targeting the healthcare system that represents one of the most pressing challenges to come along in this industry in quite some time. Between the prominence of ransomware, malware and phishing attempts that can be used to compromise protected health information (PHI), to the value of this confidential information on the black market, it’s easy to see why even smaller providers are being impacted in such large numbers.

Even something as seemingly simple as losing a mobile device (or having one stolen) is no longer a “minor inconvenience”, if that device had access to a network filled with private health information of patients. At that point, that could be a backdoor onto the network and a potential source of a cyberattack – pointing to a situation that must be addressed at all costs.

Thankfully, creating a more secure environment and safeguarding patient information is less the result of any one major move and is more about a series of smaller ones. When taken together, they offer up the best chance at making sure all private information stays that way for as long as possible.

The Reasons Why Smaller Medical Providers are More at Risk

It is absolutely true that even the largest healthcare providers are prone to experiencing a cyberattack, the number one reason why smaller medical practices are actually more at risk comes down to a lack of resources.

A lot of smaller practices simply do not have the human resources necessary to create a secure environment. They lack an IT team or even an employee with the skills needed to monitor systems and close security vulnerabilities. Even if they do, they probably do not have access to the type of financial resources they would need to replace older, vulnerable equipment with newer, more secure alternatives.

Many smaller medical practices in particular suffer from a lack of cybersecurity awareness. You cannot expect your average healthcare employee to successfully defend against a phishing email if they don’t know what one looks like in the first place.

Safeguarding the Records: What You Need to Know

Thankfully, there are a few straightforward best practices that you can follow to help make sure your own environment and network are as protected as possible moving forward. These include things such as:

• Creating a cybersecurity policy that involves the use of encryption on all mobile devices in the event that they are lost or stolen. This way, even if the physical device itself should fall into the wrong hands, that person won’t be able to access any of the information contained on it – or use it as a backdoor opportunity to infiltrate your network.
• Always make sure that both your computers and the software you install on them are updated whenever possible. Oftentimes people do not realize that software and operating system updates do more than just tweak the user interface or add new features. They patch security vulnerabilities that could potentially be exploited by someone who knows what they are doing.
• Create different Wi-Fi networks for your staff and for patients. That way, even if the patient network is compromised due to the presence of insecure devices, you do not have to worry about that spilling onto your primary practice network.

Along the same lines, you will also want to make sure that all user passwords are changed on a regular basis and that strong passwords are already used. A password manager will be a key part of this by allowing employees to free up their brain power rather than forcing them to remember a long list of passwords. Most password managers will also automatically generate stronger, non-repetitive and unpredictable passwords as well.

It is also important to use multi-factor authentication whenever possible, which requires a password and an additional input before someone can gain access to an account. This can be a PIN from a phone, some form of fingerprint verification, facial recognition, or something else. Regardless, it is far more secure than just a password alone.

At the same time, always make sure that any vendor you use to store and process information (like your coding and billing company, for example) has safety measures put in place to protect that data. No matter what steps you take, if your vendor is not secure and compliant, you are not either.

The Importance of Staff Training

Finally, understand that investing in staff training is and will always be one of the keys to staying safe in the modern era. Never forget that most data breaches happen due to social engineering – meaning that people who lack cyberattack awareness training are being taken advantage of on a regular basis.
You should hold training sessions for your employees at least once a year with a particular focus on the types of behaviors that cause violations and breaches in the first place.

Symbion Coding: A HIPAA Trusted Partner

At Symbion Coding, we are a secure and HIPAA compliant coding and billing vendor. In addition to offering a true multi-layered approach to protection that keep your PHI safe and secure at all times, we also work directly with our partners to make sure that they feel safe throughout the entire process. We sign and abide by a business associate agreement whenever we engage with a new client, which helps make sure that we always act as a true partner to your practice in every sense of the term.

If you are looking for a coding and billing vendor that is HIPAA compliant with the knowledge and expertise in revenue cycle, please give us a call at (800) 672-8249 or visit us at www.symbioncoding.com today.

DOCUMENTATION TIPS

Medical record documentation of patient diagnoses that is clear, concise, and described to the highest level of specificity facilitates:

• Quality patient care with better outcomes
• Accurate diagnosis code assignment
• Appropriate and timely health care provider payment for service rendered

History versus active

• Please do not use “history” to describe a current or chronic condition that is still present
• If a condition is in remission, please describe the condition as in remission instead of using the word “history”

Consistency
Be watchful when using template that might introduce contradictory and/or conflicting information in the progress note. Many templates may default to “normal” value for review of systems (ROS) or in the physical exam which may conflict with information in the HPI or in the assessment. For example, a patient with severe major depression and PHQ-9 score of 23, but ROS states “patient denies depression” can be problematic to support the diagnosis for severe major depression.

Provide a clear picture of patient’s health status

Providers should document all conditions that impacted the patient’s care on the date of service. Also, all co-morbid conditions that currently exist should be documented and address in the plan. It is a good idea to include a specific treatment plan for each diagnosis such as status (stable, worsened, improved) medication changes, dietary recommendations, scheduling of diagnostic testing, etc.

By applying the above tips can help your practice achieve better outcomes for your patients and more accurate reimbursement for your value-risk contracts. At Symbion Coding, we believe in helping medical practices, MSO, ACO achieve accurate reimbursement. Please give us a call at (800) 672-8149 or we can meet in person at a place and time that is convenient for you.

ABOUT SYMBION CODING INC

Founded in 2015, Symbion Coding is a dynamic group of coding and HIM experts, working to create solutions to help medical practices, ACO and MSO achieve optimal risk score accuracy. We focus primarily on helping healthcare providers with value-risk contracts to achieve better financial results in today’s healthcare new payment models.

If you had to make a list of some of the major pain points associated with most medical practices, resubmitting claims would undoubtedly be right at the top.

Not only does this mean that a medical practice has to wait longer periods of time to collect money that they’re owed, but you also have to consider the costs associated to rework that claim in the first place – costs that add up in a frustrating and often surprising way.

This has always been problematic, but it is an especially difficult situation to find yourself in given everything that is currently going on in the world. During a period of time when practices need to remain more productive and more competitive than ever, you cannot afford to spend so much time working and reworking claims that do not have to be this difficult. You also certainly do not want to extend your ability to get paid for the work that you have already done any longer than you absolutely have to.

Thankfully, there are a number of straightforward steps that you can take to reduce denials in your own practice and often prevent them altogether. You just have to keep a few key things in mind.

What You Need to Know to Prevent Denials: Breaking Things Down

By far, one of the most important things to do to prevent denials from happening at all involves the acknowledgement that billing absolutely begins with the front desk.

Your front desk employees need to be checking someone’s eligibility as soon as you can – ideally two to three days before an appointment. They should verify that the provided demographic information is accurate and that they have every other relevant bit of data they need to submit the claim in the first place. Likewise, you should be educating your staff members on coding and the impact of clinical documentation on the revenue cycle. The providers themselves especially need to be educated. All of these things will make a big, big impact moving forward.

In addition to taking steps to prevent denials that occur because of coding errors, you can also make use of an external person to provide the aforementioned education to your employees. Think about it like this: the costs associated with hiring that external educator are often far lower than the loss of revenue due to a provider’s lack of knowledge. Even if you go through comprehensive training sessions twice a year with a special emphasis on the most common diagnoses and procedures used in the medical practice, you could still increase your reimbursement in the long run.

Track Denials for Better Outcomes Moving Forward

Another one of the best ways to reduce denial rates in your medical practice involves coming to a better understanding of why they may be happening in the first place. Far too often, medical practices know that denials are happening, but they are not really sure why. They are certainly not aware that, more often than not, they are falling victim to the same few mistakes that are happening over and over again. If they would just make some slight adjustments to their workflows here or there, the lion’s share of their problems would be over. But some medical practice may not have the knowledge or the resources to do that, so this frustrating cycle repeats itself indefinitely.

To get to that point, you will need to determine the root causes that you are dealing with. Oftentimes, this involves issues at the front desk (like incorrect demographic information), billing errors (like CCI edits or incorrect modifiers), coding problems (like a ICD-10-CM code for female being used on a male patient) and more.

Once you have a better understanding of why those denials are occurring, be sure to share the results with providers and office staff members so that they are aware of what is going on. Implement new processes to avoid making similar mistakes and definitely continue to monitor things in the future.

Based on that, you will definitely want to conduct internal audits on a regular basis as sometimes this can be the most efficient way to find revenue cycle gaps that would have otherwise gone undiscovered. Do not be afraid to seek independent outside help if you need to or if you happen to be busy on other projects. Symbion Coding, Inc., for example, charges a reasonable fee to provide audit services that come complete with a recommendation on how to close those revenue cycle gaps once and for all.

In the end, while the above steps may be a significant amount of effort above what you are used to, you need to consider the raw value that they will bring to the table. Not only will you spend less time re-working claims that never should have been denied in the first place, but you’ll also speed up the frequency at which you get paid and increase revenue to your practice as well. All of this frees up more time in your day to focus on those matters that really need you, thus paving the way for an even more successful medical practice in the future.

If you’d like to find out even more information about how to reduce and eliminate claim denials as much as possible in your medical practice, or if you’d just like to discuss your own needs with someone in a bit more detail, please don’t delay – contact Symbion Coding, Inc. today at (800) 672-8149 or visit our website: www.symbioncoding.com