American College of Physicians: Internal Medicine — Doctors for Adults ®


Tackling the top 10 billing errors

From the December 1995 ACP Observer, copyright 1995 by the American College of Physicians.

by Edward Doyle

Does your staff charge for every service and procedure you're entitled to? Are billing and coding mistakes costing you a small fortune? In short, do you get the most out of your coding?

If you're like most practitioners, the answer is probably no: You're probably making more mistakes than you realize-and as a result not getting paid what you deserve. Little mistakes such as undercoding office visits, neglecting to bill for procedures or using wrong or outdated codes can cost physicians big money, practice consultants say.

With just a little attention to detail, however, you can improve your billing system. Here are physicians' 10 most common billing and coding errors--and tips on how to avoid making them.

1. Stop choosing low levels of service for office visits.

Practice management experts say that physicians still consistently undercode their office visits for fear that choosing higher levels of service (i.e., levels four and five) will cause an audit by HCFA and other payers. As a result, many physicians prefer to keep a low profile--and avoid hefty fines--by charging for only lower-level office visits.

The strategy may work: Payers are probably less likely to look at your records if you're billing for lower levels of service. But your practice is probably losing thousands in revenue. Joseph Robertson, a practice consultant with Professional Management of Raleigh, N.C., said that many internists tend to use intermediate levels of service (for example, level three) to charge for office visits. However, level-four codes--generally acceptable for moderately sick patients with multiple problems--are more appropriate for the typical visit. Because most internists do multi-system examinations on most of their patients, "If internists frequently code office visits as level three, there is probably something wrong," Mr. Robertson said.

While physicians should not try to game the system by inappropriately upcoding office visits--the hypertensive patient you see every month does not qualify as a level-four visit--Mr. Robertson encourages internists to consider billing for higher levels of service. Remember to follow basic documentation guidelines. When billing for a level-four visit, for example, document that the patient was moderately ill and required multiple diagnoses and review of more than one system.

2. Match ICD-9 codes and procedure codes.

Many physicians simply checck off ICD-9 and CPT codes on a superbill and let their billing staff sort it out. The problem is that your staff may have no idea which CPT code goes with which ICD-9 code. They may put a diagnosis code with the wrong CPT code or may not include it on the bill at all.

Bob Weatherford, a practice consultant with Health Care Consultants of America Inc. in Augusta, Ga., said he has seen bills that list only one diagnosis to justify as many as four lab services and an EKG or chest X-ray. "If you go through the medical record you'll find that there are really four or five symptoms that are being managed," he explained, "but they don't make it into the coding." And just because your office staff doesn't recognize when a diagnosis code doesn't justify billing for a particular procedure, your payers--thanks to sophisticated computer software--probably will.

What's the solution? Mr. Weatherford suggests that physicians throw away the superbills that list commonly used ICD-9 codes. Instead, write out the diagnoses and let experienced coders find the most specific diagnosis codes. If the billing clerks have questions, they can talk to you to make sure that they got the diagnosis right and that the claim gets paid. Or if you want to continue listing ICD-9 and CPT codes on your superbill, try numbering each diagnosis and put the same number on the corresponding CPT codes. There will be no question as to which ICD-9 goes with which CPT.

3. Use the most specific and recent ICD-9 codes.

Many four-digit ICD-9 codes have been replaced with more specific five-digit codes. Where there used to be only a handful of codes for diabetes, for example, there are now hundreds--yet many physicians still use older four-digit diagnosis codes.

Until now, many payers have continued to reimburse physicians who use the older codes, but that's about to change. Debra Dorf, a practice consultant with Karen Zupko & Associates in Chicago, said that for the past year or so, Medicare carriers have been alerting physicians that these older ICD-9 codes are wrong and that they will no longer get paid when they use them. (Some carriers have said they would begin denying payment earlier this fall or in the beginning of next year.) Many Medicare carriers are also threatening to deny payments to physicians who don't use the most specific codes possible. Using a simple code that lists abdominal pain instead of the code that specifies the exact location of the pain, for example, may result in a denied claim.

4. Remember to use modifiers.

You probably know that you can't bill for an office visit and a minor procedure on the same day, but what happens when an established patient you're treating for one condition--hypertension, for example--ends up needing an unrelated minor procedure--such as a joint injection for bursitis--on the same day? You performed a full office visit and a minor procedure. Isn't there some way to get paid for both?

The answer is yes--if you use a modifier. According to Brent Garrison, a practice consultant with The Medical Management Institute in Alpharetta, Ga., physicians can charge for both an office visit and a minor procedure, as long as they do enough work to justify billing for both, document their efforts and use modifier 25, a code that tells payers they did more than just give the patient an injection. "The modifier says that you didn't know that the patient had bursitis when he or she came in, that you did more than a routine history and physical to figure out that the patient needed that joint injection," Mr. Garrison explained. Take note, however: If the patient was scheduled to receive a joint injection and that's the only service you provided, you can charge only for the procedure.

5. Bill for injections.

While you're at it, don't forget to bill for the drug you injected. According to Brenda Morrow, a practice consultant with ProStat Resource Group in Shawnee Mission, Kan., physicians often forget that they can bill for both administering injections as well as the drug or vaccine itself. To charge for the actual drug or vaccine, use J codes (the letter "J" followed by a four-digit code). Be careful, though: J codes come in units, and you may need to charge for more than one unit to fully cover an injection.

While you can't charge for both an injection (a minor procedure) and an office visit on the same day without using a modifier, Ms. Morrow noted that there are exceptions: When giving a vaccination for pneumonia, influenza or hepatitis B, physicians can bill for the office visit, the injection and the vaccine.

6. Don't confuse new patients with consultations.

When you see a patient for a consultation, make sure that you bill the visit as a consult and not as a new patient visit. According to Mr. Garrison, a level-three new patient visit pays about $62, compared to $90 for a level-three consult. To bill for a consult and not a new patient visit, the patient must have been sent to you for a consult by another physician and you must provide the referring physician with an opinion or advice. (Include a copy of the letter you give the referring physician in the record.) And even if you initiate treatment, Mr. Garrison said, you can still bill the visit as a consult.

7. Get paid for counseling patients.

Did you know that under certain conditions you can get paid for time you spend counseling patients? If physicians spend more than half of their face-to-face time counseling a patient or coordinating care--calling other physicians, making arrangements for diagnostic testing, etc.--they can bill for a higher level of service, even if they don't perform an exam or make a new diagnosis, explained Leslie Witkin, a practice consultant with Physicians First in Orlando, Fla.

Suppose that you see a patient recently diagnosed with cancer and you do nothing but counsel the patient, talk to family members and make arrangements for further treatment during the visit. You may be entitled to code the visit as a level five, provided you spend more than half of the visit--20 minutes in this case, since level-five visits are supposed to be at least 40 minutes long-counseling the patient and coordinating care.

8. Charge for home care services.

Tired of overseeing and coordinating home health care services and not getting paid for it? Then charge for your services. Every time you talk to a home health agency or nurse about changes in treatment or medication for a patient receiving home care, note when and exactly how much time you spent caring for that patient. At the end of the month, if you have spent between 30 and 59 minutes overseeing or coordinating care for that patient, you can receive roughly $60 from Medicare by using code 99375.

9. Collect those co-pays!

One of the biggest problems in collecting co-pays from patients is that staff often don't know how much to ask for. (Billing patients for a $5 or $10 co-pay isn't a good option since it costs between $5 and $8 to process the bill.) Because many health plan enrollment cards don't specify their co-pay, your staff may need some help. Create a cheat sheet that lists the co-pays for each managed care plan--and what employers participate in each plan. And to make it easier for staff to collect the 20% co-pays from Medicare patients, list the services you commonly provide and how much 20% of each comes to. Front desk staff can easily calculate co-pays before patients ever leave your office.

10. Get paid for your nurse's time.

Take advantage of the lowest level of service for office visits--code 99211--to get paid for services that your staff provides when you're not present. If a patient comes in to have his blood pressure checked and the process takes 10 or 15 minutes--for example, the patient needs to rest, both arms have to be checked, the medication has to be changed--you're entitled to bill using this code, which pays about $12. Ms. Witkin said that you probably shouldn't charge for a level-one service if the patient is in and out of the office in a matter of minutes, but she said that level-one codes are ideal for situations where your nurse does a little extra. Also consider using level-one codes when your nurse teaches patients how to use insulin or gives some other kind of detailed instruction to patients.

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