The goal of the ACR practice management team is to provide hands-on training for members to help rheumatology practices maximize reimbursements and minimize claim denials or rejections, Ms. Chung says.
Resolving Coding Questions & Denials
Coding and billing issues represent the most common questions that practice managers, billers and even physicians ask the ACR, and many of these questions seek answers to why a claim was denied.
To help members, Ms. Tillman speaks directly with practice managers and takes a stepwise approach to investigate all coding questions and denied claims. She starts by finding out what service was provided, then reviews the medical policy to verify all the covered services and check for any frequency limitations. She also makes sure all services can be billed on the same claim and sends a copy of the policy to verify that the practice is following all the guidelines before submitting a claim.
Medical codes are an integral part of revenue cycle management, making it important to understand the adjustments and modifications to ensure proper reimbursement, reduce denials and deliver quality patient care. For example, the CMS’ revisions to the HCPCS drug codes for methylprednisolone and methotrexate had a ripple effect with coding and billing drug wastage in rheumatology practices.
“Sometimes, a very simple coding error can result in a denial that can be corrected and resubmitted for payment,” Ms. Tillman explains. For example, she says, if a provider is using a multi-dose vial to administer a drug, they will be reimbursed for only the amount administered to the patient and not for any discarded amounts of the drug.
E/M Coding Changes in Practice
This year, Ms. Tillman and Ms. Chung are still seeing an uptick in questions from practice managers about how to accurately code the updated E/M services. Although the E/M coding update was implemented in 2021, there are still many questions on the coding guidelines on medical decision making and time as it relates to clinical documentation.
“Although these changes were made to make coding easier, adapting to these changes continues to present challenges due to payer policies denials,” Ms. Chung notes.
For example, providers are no longer subjected to the three key components of E/M for both new and established patients, but they can make their code selection based on the medical decision-making level or time spent on that date of service. If time is chosen, time must be documented specifically and include total time of care provided for that day. Additionally, time can now include both face-to-face and non-face-to-face time, such as reviewing a patient’s test results in preparation for their clinical visit, as long as the non-face-to-face time is provided on the date of service, Ms. Tillman explains. In addition, the history and examination component of E/M is no longer required for visits using codes 99202–99215; instead, each service should include “a medically appropriate history and/or examination” and be documented in the patient’s medical record, Ms. Chung adds.
