Don’t get caught off guard when self-pay patients show up at your front desk not prepared to pay an outstanding balance or for the current visit. Instead, develop a clear policy on how to approach those patients to maintain collections and ensure you won’t be accused of violating a payer contract when a patient lies about insurance status.

Don’t wait for your hospital to approach you and coordinate billing for the three-day payment window. Prepare your practice by establishing a clear line of communication with your hospital and holding claims to avoid overpayments. The three-day payment rule, effective July 1, mandates lower reimbursement for providers at practices that are wholly owned or operated by a hospital when a patient is admitted within three days of receiving clinically related services from the practice (PBN 6/18/12).

If your practice is overwhelmed with mounting regulatory deadlines, claims billing, coding, staffing and other practice management duties, outsource some tasks to a local management services organization (MSO) after a vigilant vetting process.

The problem: Ancillary staff, such as nurses and medical assistants, document elements of the history of present illness (HPI). E/M Documentation Guidelines state that ancillary staff can document the review of systems and past, family and social history but are silent about whether those staff members can record the HPI. That means billing providers – physicians or non-physician practitioners who are the billing providers or are rendering incident-to services – must document the HPI.

I am often asked how to explain the difference between “medical necessity” and “medical decision-making” when speaking to a clinician. The answer, as you might expect, isn’t as clear as you would like it to be and involves insurance companies, litigation, settlements and physician judgment for specific patients.

This chart presents the upper-level denial rates for the 12 specialties that billed E/M visits the most in 2010. These denial rates, based on a Part B News analysis of 2010 Medicare claims data, factored in the total service counts and denied service counts of initial visit codes 99203-99205 combined with subsequent visit codes 99213-99215.

A physician sees a patient for asthma complaints and does an office visit (medical history, physical exam and medical decision-making). As part of the MDM, the doctor also does a spirometry test (94010) and determines nebulizer treatment (94640) would improve the patient’s condition. After the nebulizer is given, the patient receives a post-spirometry assessment for the effect of treatment on lung function. Do you bill the pre- and post-spirometry code (94640) instead of 94010?

This chart shows the denial rates for five nurse physician practitioner (NPP) specialties for E/M office visits, based on 2010 Medicare claims data. For each specialty, the denial rates of level 3, level 4 and level 5 E/M office visits is depicted, based on a combination of E/M codes billed for initial patient visits and subsequent patient visits (99203-99205 and 99213-99215).