Understanding the processes of medical coding, billing and insurance claims leads to fewer underpaid and denied claims. Two AMA experts walk through the basics of educating physicians about proper coding, one of eight key steps of revenue-cycle management.
“Federal regulations and insurance companies set the rules for submitting a claim to reimburse a medical practice. Unfortunately, many claims are denied or result in partial payment. These claims require additional effort to avoid lost revenue,” wrote Taylor Johnson, the AMA’s manager for physician practice development, and Michael Tutty, PhD, MHA, the Association’s group vice president of professional satisfaction and practice sustainability. The article appears on the Medical Group Management Association’s (MGMA) website.
At least 32% of outpatient commercial claims and 11% of traditional Medicare claims go unpaid at 90 days. Coding and billing errors contribute to these problems. An MGMA poll revealed that 22% of claim denials are attributed to coding issues, payer requirement inconsistencies and medical necessity requirements.
“Practices that empower physicians to increase their knowledge of the claims cycle can decrease the long-term workload and improve the practice’s overall productivity and profitability,” wrote Johnson and Tutty.
Learn more about revenue-cycle management and other essentials to start, sustain or grow your operations with the recently updated “AMA STEPS Forward® Private Practice Playbook.” A separate toolkit can help you streamline and automate your private practice’s revenue cycle.
Establish a “baseline” level of education
To avoid denied or unpaid claims, physicians need to have a basic level of understanding of the claims process so they can engage with their administrative team, the authors advised.
Practices should design an education plan for doctors to achieve this goal. The plan should address:
- The use of evaluation and management (E/M) codes.
- Commonly used procedures and drug codes such as bundled procedures or medications.
- Common modifiers used for E/M, procedure and drug codes;
- Prior authorization procedures, and
- Payer policies on modifier usage and customary codes.
“Educating the physician on bundling and unbundling codes can prevent reimbursement questions from physicians and better understanding of compliant coding,” wrote Johnson and Tutty. Coders, billers, and auditors should offer feedback to providers on findings from denied or partially paid claims.
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Making the most of the EHR
Leveraging mapping solutions of EHRs can also improve the billing and coding cycle. “The practice administrator should know physician EHR workflows so that the solutions implemented will benefit the physicians,” advised Johnson and Tutty.
The article identified several EHR solutions, one of which is procedure mapping. This involves attaching a specific procedure to an EHR order. If done correctly, “the CPT code will automatically populate the superbill. This removes an additional manual charge entry step for the physician or billing department,” explained the authors.
Other strategies include order sets, a time-saving feature that enables practices to set up specific orders for a particular condition, and shortcuts such as smart phrases and physician “favorites” for diagnoses, procedures or drug codes.
A query process streamlines communication between doctors and administrative personnel to ensure accurate billing and coding of a claim. This can prevent denial or partial payment.
It takes astute clinical judgment as well as a commitment to collaboration and solving challenging problems to succeed in independent settings that are often fluid, and the AMA offers the resources and support physicians need to both start and sustain success in private practice.
Dive deeper:
- 8 keys to improve revenue cycle management in your practice
- Why private practices need a stronger handle on the revenue cycle
Educating doctors on workflow
Practices should create visual examples of several types of claims workflows to give doctors a “big picture” of the claims process.
The “claim control and follow-up workflow” for instance instructs physicians on how to identify any unsubmitted or denied status claims while running a report on the claims dashboard, and the steps for investigating and correcting all claims in this category.
“Workflows may differ for each practice, and the flow chart should be updated to reflect the specific workflow for your organization,” the authors advised.
Communication is an important part of this educational process. This involves giving physicians regular feedback on claims status and providing contacts if they have questions about billing or the patient’s chart.
Use your practice-management software or revenue-cycle management system to generate claims reports for each physician and the practice, wrote Johnson and Tutty. “Reports that include information on paid and denied claims will give the physician insight into what works and what doesn’t,” they added.
Find out more about the AMA Private Practice Physicians Section, which seeks to preserve the freedom, independence and integrity of private practice.
