Region V Training Project 3rd Party Billing Practices for Title X Clinics Outline October 13, 2011

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Region V Training Project

3rd Party Billing Practices for Title X Clinics


October 13, 2011

The "Affordable Care Act" is coming on-line and has significant implications for the provision of Reproductive health, in general and for Title X providers in particular. The requirements that providers will bill third party payers for services provided to covered participants means ALL Title X providers need to be prepared to do this in an efficient and effective manner.

Today’s session looks at issues around third party reimbursement and provides some ideas and suggestions to help family planning providers enhance their current practices and prepare for the future.

The following topics will be discussed today:

1. Surveying the Third Party Landscape: An assessment of possibilities.

A. Developing a business plan to increase TPR

Evaluate new program and implementation Retooling operations

Who are the prevalent insurers in your area? (See needs assessment tool.) Payment rates; what do they pay for? Under what circumstances?

Goal: - Increase third party collection by some percent B. Patient Base

-Who do you have?

-Who are the prevalent insurers for your patient base? C. Service Volume

a. May need to shift the type of patients and when you see them D. Services offered by whom?

Provide services by “billable” providers –you need to know who these are Satellite facilities- often staffed at lower level

i.e. Independent Mid-level (does this meet the criteria to be reimbursed?) E. Establishing a Contract

1) Not a good position to be an out of network provider (Problems with reimbursement)

2) Good time to work with County (local) attorney and Health officer to develop contract.

a. Means more income to the LHU (for many programs)



2. Establishing Charges: The importance of appropriate charges and

the use of CPT and ICD-9 Codes. Why Third party Payers need


A. Charges are based on what it costs to provide services. (Cost analysis helps here)

B. Once established, you want to charge the floor (not ceiling)… Medicare fees are an important standard. Look at CMS “Physician Fee Scale” for Medicare. Maximum Charge should be 125% to 150% of Medicare fee. (If you are at 140 % of Medicare fee you should be ok.)

C. You will be paid the lesser of your charge or their payment level. D. Update your fee structure. Be sure this is done on a regular basis.

Verify MCO (HMO) fees; Charge more than they pay (they make a 30-35% adjustment, on average).

E. There are ways to determine if your fees are competitive.

Charges should be consistent with other providers in the area. (Ways to check this)

Need to compare your fees to your Medicaid reimbursement rate. Your fee MUST be equal to or higher than the Medicaid rates.

CPT Codes – Set the fees for each of these (Unbundle)

A. Evaluation and Management (E/M) Services guidelines (Often seen as “Problem” codes

 These codes are preferred for office visits (including Family Planning)

 CPT 99203 is probably the most accurate for family planning providers to use for a comprehensive initial visit. (One of the examples for this code is "initial visit for 21-year-old female desiring counseling and evaluation of the

initiation of contraception.")

 Also part of the E/M section is Preventive Services codes. These have higher reimbursement (but you MUST meet the criteria)

 These can be used for new and established family planning visits. Must include:

Comprehensive history and comprehensive multi-system exam; (Ten different body areas and systems are addressed



 E/M codes, in the CPT manual, are divided into broad categories, which are further subdivided.

 Pay attention to “Office or Other Outpatient Services”, “Preventive Services”, “Consultation”, and “Prolonged Services” codes. (We will talk about some of these later)

 On an encounter form, the E/M codes should be physically placed so they are the first section to complete.

 Provider selection of E/M codes is essential to ensure clinical validity for service levels. (The providers were the only ones in the exam rooms with the patient.)

 The billing clerk/coder only verifies that the services supporting the code are documented in the chart. If not, the provider should be questioned and then the code changed or the chart corrected.

 You want to code to the highest possible (legitimate) level.

 Each CPT code has a dollar amount assigned to it by payers.

 Submitting codes that are not supported by documentation in the record may constitute fraud and abuse. That is: documenting a visit at one level and coding for another level can be considered to be fraud or abuse.

 E/M visits can only be conducted by certain people.

 Be sure to provide services by “billable” providers. (When a Nurse Practitioner walks into the room you immediately move to the next level from an RN visit.)

 Satellite facilities- often are staffed at a lower level and the agency may miss billing opportunities.

B. Counseling and coordination of care can increase reimbursement  Track how long a visit is in real clock time.

 Must be explained in the medical note what you have done to justify an increased level.

Office or Other Outpatient Consultations: CPT Codes 99241-99245  Risk reduction and behavior modification.

 Should be provided by person with special training or skill in the area.  Based on clock time that must be documented in the record.

Prolonged Service:



Physician Standby Services 99360

Other Add-ons:

After hours 99050

Sundays& Holidays 99054 (federal holiday)

Emergency Access 99058

Be sure to understand the definitions!

 Careful reading and understanding of the rules and guidelines is essential to correct E/M code assignment or validation.

 Need one volume of the “CPT Expert” coding book on site.

 May want to subscribe to a service (Find-a-code – basic $30/month) or books (Ingenix, AMA) to help for the first year.

 Need a “CPT Expert” on site.

 Careful reading and understanding of the rules and guidelines is essential to correct E/M code assignment or validation.

The guidelines are found at:

3. Optimal Billing Practices: How to maximize the Revenues you receive.

A. The ability to bill Starts at the First Contact with the patient

 Patient Telephone Call or Walk-in allows us to “set the stage”.  Private physicians office asks: “How do you intend to pay your bill

 People are more compliant in providing needed information before they see a provider.

B. Billing Practices

 Be sure to bill for ALL the services you provide at the visit.

 Educate providers not to worry about the client’s ability to pay – that is dealt with elsewhere.

 Consider “economies of scale”. It may pay for two or three agencies to combine their billing departments (computers, staff, etc.).

 Consider outsourcing. Billing vendors may be cost effective. Check references! You are still liable for everything they do in your name.

 Claims are transmitted to insurance companies with codes that reflect professional services rendered to patients.

E/M codes to document and support charges submitted

CPT codes to delineate charges and to further document services, and, ICD codes to specify the diagnoses

C. Electronic Billing of Insurance companies will be mandated.



 Identify all diagnoses, symptoms, conditions, problems, complaints, or reason for service or procedure.

 List primary condition first, then current active conditions / issues.  Utilize all five digits if possible; be as specific as possible.

 ICD-9 (coding guidelines can be found at:

 Code symptoms, signs, conditions, test results, or other reasons for the encounter.

 Code all conditions that coexist at time of service that require or affect patient care, treatment, or management.

 Create an ICD “Cheat sheet.” Or try to Google them. ICD-10 is coming!! See comparisons and changes

ICD-9 versus ICD-10

ICD-9-CM ICD-10-CM Code Totals: 13,500 Code Totals: 68,000

Chapters: 17 Chapters: 21

Primarily Numeric All Alpha Numeric


 Alphabetic Index and Tabular list

 PCS and CM

 Similar Nomenclature


 Alphabetic Index and Tabular list

 PCS and CM

 Similar Nomenclature

4. Good Collection practices: Following up on all the payments due A.Collections

The longer (older) bills are allowed to age, the less likely they are to be paid. Pay attention to Accounts Receivable as soon as possible.

Set a time to review outstanding bills to individuals and third party providers, B. Verify coverage before visit and on each occasion of a visit.

Different plans cover different things under different circumstances for different rates. C. Explanation of Benefits (EOB) codes are important.

Help us to obtain cash.

Request key (codes) from all payers with which you have a relationship. D. Follow up on all Billing



Being “out of network” provider is not an admirable position to be in. BE persistent. Question Why? Why? Why?

Not for profit is a tax status not a business plan.

Tool to determine private health insurers in your service area is an online resource with information about the Affordable Care Act. It also has information regarding public and private health insurance plans in your area. A list of private health insurers can be found using the steps below. The purpose of this online tool is for individuals to discover what health insurance options are available to them. By choosing generic responses, you will access a list of private health insurance plans offered in your service area.

1. Go to 2. Choose your state

3. Select either Family / Children or Healthy Individual (either is fine) 4. Choose “my family and I need health insurance for another reason.” 5. Choose age 19-25 or 26-64

6. Under special health care issues, do not check any box

7. Select Yes to “is it difficult for you or your family member to afford insurance?” 8. Select “Health Insurance Plans for Individuals & Families”

9. Enter a zip code for your service area

10. Enter either sex and enter a birthday of an individual between age 18 and 64. 11. Choose no to tobacco use.

12. Look under “show companies” in the left Private Insurance Plans column. You will see a list of insurance companies in your area and how many plans that insurance company offers. Although this list should not be the sole source you use to find insurers in your area, it should give you information to get started. Local employers may insure their employees using these insurance companies or other insurance





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