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Boost Revenue by Getting Coding Right

Ann Finn

By Lisa Eramo, MA

July 31, 2019 News, Business

It’s every physician’s worst nightmare: Receive payment for services rendered, but then a payer identifies an aberrant pattern in claims data, audits the records, decides it has overpaid the practice, and recoups those funds. That money you already allocated for overhead, staff salaries, bonuses, or new medical equipment? Gone. With one post-payment audit, you now owe thousands of dollars or more. The good news is, physicians can take steps to focus on accurate billing and avoid costly recoupments. This article explores five billing vulnerabilities and provides tips to maintain compliance.

E/M coding: Four tips to select the correct level

Payers don’t usually deny evaluation and management (E/M) codes on the front end, says Toni Elhoms, CCS, CPC, a provider coding and education consultant in Denver. It isn’t until they look at the totality of the data retrospectively—long after physicians are paid—that financial penalties ensue, she adds. “Payers are like the IRS,” says Elhoms. “You don’t want them on your back because recoupments are insidious. They come out of nowhere.”

Consider the difference in reimbursement for established patient office visits levels 2 versus 3 (i.e., CPT codes 99212 and 99213)—approximately $29. Let’s say 10 to 20 times per week over a year, a physician bills 99213 when their documentation only supports 99212. They’ll be paid initially, but likely have a $15,000-$30,000 recoupment on their hands if a payer uncovers the error during a post-payment audit.

Here are four tips to help physicians avoid denials due to incorrect E/M levels:

1. Ensure the E/M code supports the specific patient encounter.

Not every patient with asthma, for example, will justify reporting CPT code 99213, says Elhoms. Some cases may be exacerbated and/or require medication management and referrals to specialists while others may be relatively straightforward and controlled.

2. Refer to the E/M guidelines

Assigning an E/M code is not a subjective process. Instead, physicians should refer to the 1995 or ‘97 E/M guidelines that include specific requirements for time-based billing as well as billing based on the three key components: history, exam, and medical decision-making, says Elhoms. She says the most common mistake physicians make when applying these guidelines is under-documenting E/M level 4 and 5 visits for new patients. More specifically, they omit one or more systems in the requisite general multi-system exam or they omit a complete past family and social history.

3. Use copy and paste functionality with caution.

Copy and paste can save time, but it can also cause serious compliance problems, says Elhoms. That’s because when physicians automatically bring historical information from a previous encounter forward into their current note, they may inadvertently inflate the E/M level. Best practice is to validate any information copied forward to ensure it’s accurate and relevant to the current encounter—or turn off the functionality altogether, she adds.

4. Watch out for pre-populated EHR templates.

Pre-populated templates not only lead to upcoding (e.g., if certain body systems are always indicated as having been reviewed even when they’re not relevant to the current encounter), they can also lead to contradictions that raise red flags with payers, says Elhoms. For example, a physician diagnoses a patient with strep throat. If the template defaults to a normal exam for ear, nose, and throat, this could open the door for a post-payment audit. Physicians should ensure their documentation is aligned with the patient’s diagnosis even if it means manually unchecking certain boxes in the template.

NDC needed for 340B Drugs

Ann Finn

Per NYS DOH - the NDC must also be included on the carve out family planning (billed as ordered ambulatory services) claims too along with the UD modifier. The new edit 02280 will cause ordered ambulatory claims to be denied if the J-code and NDC are not billed together appropriately.

NYS Medicaid Billing Change for 340B Drugs - NDC and UD modifier now required!

Ann Finn

Reminder: Reporting of the National Drug Code is Required for all Fee-for-Service Physician-Administered Drugs

As was mentioned in the February 2019 Medicaid Updateeffective April 1, 2019, to improve claims accuracy and completeness, an accurate National Drug Code (NDC) must be reported for all physician administered drugs billed on the Institutional claim form. Drugs obtained at the 340B price, indicated by the UD modifier, will also require the NDC. There will be no exceptions to this policy.

The eMedNY billing system will enforce this requirement effective July 1, 2019. This means that starting July 1, 2019, for any physician-administered drug billed under Ambulatory Patient Groups (APG) that does not include an accurate NDC, the line will not pay. Note, all APG fee schedule drugs will still require providers to code the number of units and acquisition cost for the claim line to pay.

Questions regarding Medicaid FFS policy should be directed to the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473-2160. Billing procedure questions should be directed to the eMedNY Call Center at 800-343-9000. Questions regarding Medicaid Managed Care (MMC) policy requirements should be directed to the enrollee's MMC plan.

Fidelis to cover family planning January 1, 2019

Ann Finn

Fidelis Care is pleased to inform members about a change in how we administer family planning and reproductive health services.

Starting January 1, 2019, family planning and reproductive health services will be administered directly by Fidelis Care (New York Quality Health Care Corporation). Previously, these services were provided to members by Medicaid Fee for Service or other third party vendors.

These health services include:

  • birth control drugs and devices, including, IUDs, diaphragms and other kinds of birth control;

  • emergency contraception;

  • sterilization for men and women;

  • pregnancy testing;

  • an abortion that you and your doctor agree is needed; and

  • HIV and sexually transmitted disease (STD) testing, treatment and counseling. Screenings for cancer and other related problems are also included.

All the costs for these services are covered. You don’t have to pay anything. Your doctor or pharmacy can’t bill you for these services. No referral form is needed, and you can also keep your current doctor and pharmacy.

Kyleena IUD - New HCPCS code starting January 1, 2018

Ann Finn


Long-acting reversible contraceptive Kyleena now has a permanent HCPCS code for 2018. Beginning January 1, providers should cease using the previous temporary code Q9984 for reporting this IUD. Instead, new code J7296Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg should be reported on the claim form for reimbursement.