Ivana Saninocencio, the founder and CEO of Dracut, Mass.-based Prime Billing Solutions, has worked in the medical billing and coding field for over 10 years. Having worked with multiple different medical specialties in 22 different states, she drew on her experience to share five tips for billers and coders.
1. Check benefits and eligibility
Before the patient is seen in the practice, check eligibility and benefits. If you aren't checking these two things, it can result in your claims being denied or underpaid. Most patients aren't aware that their insurance is no longer active, or they aren't sure whether or not they require a prior authorization from their insurance before the doctor can perform their procedures. You also need to verify if the doctor is credentialed and in network with this insurance. Checking benefits will also let you know if the patient has a copay, deductible or coinsurance. Most insurance plans require prior authorization for any kind of surgical procedures. Find the code that you will be using for this procedure, and let the representative who is checking benefits know what procedure code you will be using. They will advise whether or not this code is billable under patient's insurance plan.
2. Use very specific ICD-10 and CPT codes
Make sure that you are precise on the diagnosis and procedure you are looking up. Pay very close attention to details of the doctor's procedures and diagnoses, as upcoding and downcoding will play a significant role in how much the insurance will reimburse you. For example, billing diagnosis code F11.20 (opioid dependence) on a claim with procedure code 80307 (drug screening) will reimburse you about $30 less than specifying the exact opioid the patient is using: Z79.51 (long term [current] use of inhaled steroids).
3. Use the correct modifiers
Modifiers are two-digit codes that are added to the procedure code to indicate if a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. It can also indicate which side of the body a procedure was performed on. For example, modifier RT means "right side" and LT means "left side." Medicare is very strict on modifiers and will deny a claim if the proper modifier is not used.
4. Use a good billing software and clearinghouse
Most of the time, your billing software will be different than your clearinghouse, so make sure they are compatible. You can do so by choosing a web-based medical billing software, which offers the convenience of fully integrated medical clearinghouse services. Be sure the billing clearinghouse is contracted with the majority of the insurance carriers that you use most often. You should also choose a billing software and clearinghouse that offers a free trial so you can test their customer service skills. Find one that offers a free and unlimited customer service and technical support. It is also very important that your software is able to submit claims electronically and receive electronic remittance advices.
5. Collect patient payments at the time of service
Once the patient leaves your office, the chances of them paying their portion of the claim bill decreases by 40 percent. Be sure that when you check benefits and eligibility before the time of service, you ask what the patient's copayment, coinsurance, and deductible is. If they have a past due balance, be sure that they are paying a portion of that before they schedule their next appointment or surgical procedure.