Proper medical billing plays an essential role in the smooth functioning of any healthcare practice. It ensures that physicians and healthcare providers are reimbursed for their services and procedures. Medical billing is a complex, tricky, and yet one of the most crucial healthcare processes. Healthcare physicians’ years of hard work and practice gets even more challenging with medical billing. Physician billing solutions are just like professional medical billing and are responsible for services performed by:
- Physicians
- Suppliers
- Other non-institutional suppliers for outpatients.
The primary purpose of physician billing services is for the physicians to get reimbursed for the services they perform. There are two kinds of billing forms used for physician billing; digital and paper version of it. There is no particular difference in both forms whatsoever except that:
- CMS-1500 – is the paper version/claim
- 837-P – is the digital/electronic version/claim
Most of the time, Medicare, Medicaid, and other insurance providers only accept electronic claims. This is where the 837-P being the digital version, comes in! “P” in 837-P stands for professional configuration. It is the electronic version of CMS-1500.
There are various tasks associated with professional billing, including:
- Scheduling the appointments
- Patient registration
- Check-ins
- Greeting the patients
- Collecting the payments
Both inpatient and outpatient healthcare services can be billed under professional billing. However, in order to bill, insurance verification is necessary. This is because claims for only selective inpatient and outpatient services can be billed.
Types of physicians:
These physicians can be any of the following:
- ER Physicians
- Pathologists or radiologists
- Surgeons or Anesthesiologists
- Primary or special care medical physicians
Proper medical billing directly affects the reimbursements and revenues of the healthcare practice; therefore, providers need to be familiar. It involves everything from documentation to submitting the claim and follow-ups. Physician billing solutions include complete medical billing and coding processes.
What is Medical Billing and Coding?
Besides providing quality patient care, medical billing and coding are two of the essential processes of healthcare practice. Revenue cycle management can help healthcare providers to maximize their revenues and reimbursements. Medical billing outsourced services companies offer specialty-based best physician services billing for the healthcare practice. There are several benefits of proper medical billing and revenue cycle management, including;
- Optimized and streamlined workflow and cash flows
- Higher clean claim rate
- Increased revenues
- More focus on the quality patient care
- Improved patient experience and satisfaction
Medical Billing:
Proper physician billing and management solutions are very beneficial for the healthcare practice. The process of complete medical billing ensures that physicians and healthcare providers are getting reimbursed for the services they rendered. The whole “going to the doctor” thing consists of three separate parties;
- The patient
- The healthcare physician or provider
- And the insurance payer
Medical billers are responsible for ensuring that the physicians are being timely reimbursed for their services. In order to bill, medical billers gather information regarding the procedure performed and convert it into a bill for the payers. This bill is known as a medical claim, and it contains the following:
- Patient’s information
- Medical history
- Insurance coverage
- Procedures or services performed by the physician
Generating a medical claim is where medical billing and medical coding overlap. Specific codes are used to translate the patient’s medical information into a medical claim.
Medical Coding:
The transformation of medical diagnosis, procedures, services, and equipment used into codes is known as medical coding. Medical coders are the ones responsible for using the correct and accurate codes for services performed. These universal alphanumeric codes are gathered using the patient’s documentation, including lab results, physician’s notes, etc. These codes report:
- Patient’s diagnosis
- The medical necessity behind procedures, treatment, supplies, or services performed on the patient.
- Procedures, treatment, services, and supplies provided by the physician to the patient
- It also reports any unusual medical condition that took place/affected during the treatment session.
Types of medical codes:
There are three commonly used medical coding systems, including:
- ICD 10 – International Classification of Diseases, 10th Edition:
ICD stands for International Classification of Diseases. ICD 10 is the 10th Edition of the ICD coding system and is published by the World Health Organization (WHO). This coding system comprises two medical code sets:
- ICD-10-CM:
- International Classification of Diseases, Tenth Revision, Clinical Modification
- ICD-10-PCS:
- International Classification of Diseases, Tenth Revision, Procedure Coding System
There is a significant difference between the two types of ICD 10 codes:
- ICD-10-CM — diagnosis code set used for all healthcare settings
- ICD-10-PCS — procedure code set used only in hospital inpatient settings
- CPT – Current Procedural Terminology codes:
Current Procedural Terminology (CPT) codes are maintained by the American Medical Association (AMA). CPT codes are one of the most commonly used code sets and are further divided into several categories.
- Category I
- These are the most commonly used codes by medical coders to report medical services and procedures. These codes are five-digit numeric codes only, ranging from 00100 to 99499.
- Category II
- This category comprises codes for performance measurement. Category II codes are supplemental tracking codes. These alphanumeric codes comprise four digits ending with an “F.” These codes are optional, meaning they are not required for proper medical coding.
- Category III
- This code set comprises temporary codes for emerging technology, procedures, and services. They are alphanumeric codes, i.e., four digits ending with a “T.”
- HCPCS – (Healthcare Common Procedure Coding System, Level II):
HCPCS stands for Healthcare Common Procedure Coding System, commonly referred to as HCPCS Level II Classification codes. This code set is specifically for healthcare providers, medical equipment suppliers, and physicians. It involves filing health plan claims for:
- Medical devices
- Supplies
- Medications
- Transportation services
- And other items or services
Physician billing guidelines for Laboratory services
According to CMS, a diagnostic laboratory test is considered a laboratory service for billing purposes, regardless of where it is performed. Location may include:
- A physician’s office, by an independent laboratory
- By a hospital laboratory for its outpatients or nonpatients
- In a rural health clinic
- In an HMO or Health Care Prepayment Plan (HCPP) for a patient who is not a member.
Like every other billing, laboratory billing is also based on specific codes. Following are some of the official guidelines for laboratory billing.
- Physicians may bill the A/B MAC (B) for the professional component of these diagnostic tests:
- Physicians ordering medically necessary diagnostic tests that are not directly related to the beneficiary’s ESRD are subject to the SNF consolidated billing requirements.
- No further development of the source of the laboratory tests is required if:
- A physician or medical group furnishes laboratory tests in an office setting, and it is appropriate for them to be performed in the physician’s office.
- Specimen collection fee for the healthcare physician is only allowed by Medicare when:
- It is the accepted and prevailing practice among physicians in the locality to make separate charges for drawing or collecting a specimen.
- It is the customary practice of the physician performing such services to bill separate charges for drawing or collecting the specimen.
- Payment for evaluation and Management (E&M) services to the patient include the physician’s fee schedule payment for:
- Reviewing results of laboratory tests
- Phoning results in the patients
- Filing the results, etc.
These are the services covered by Medicare. However, visit services entail various components and activities that may vary somewhat from patient to patient.
Errors in Physician billing solutions and coding:
When it comes to medical billing, everything from documentation to the use of codes, modifiers, and follow-ups should be accurate. There are various common errors in medical billing and coding; however, they can be reduced by outsourcing physician medical billing services. Following are the common medical billing and coding errors:
- Incomplete or inaccurate documentation:
Assigning the correct codes depends on accurate and complete documentation. Along with this, proper and complete documentation also plays a vital role in avoiding claim denials and possible audits.
- Use of incorrect codes in medical claims:
Human error or sloppy documentation can lead to the use of wrong codes in medical claims. This error can result in the claims being denied or rejected by the insurance payers, therefore, late payments.
- Use of incorrect modifier:
Overuse of modifier 22 is one of the most common errors in medical billing. This modifier signifies that the patient’s procedure typically took more time or work than required, increasing the revenues.
- Unbundling:
Using separate codes for reporting a medical procedure when a single comprehensive code exists is known as unbundling. This is an unethical practice and can result in civil liability for the healthcare providers. Centers for Medicare and Medicaid Services (CMS) clearly state that unbundling and upcoding “can expose providers to criminal and civil liability.”
- Upcoding:
It involves the healthcare provider submitting a medical claim by billing a more expensive or comprehensive medical procedure than the one performed.
- Under coding:
Under coding in medical billing includes not using codes of all the procedures performed. It results in a loss of revenue as physicians or providers are not reimbursed for all the services they perform.
- Duplicate billing:
Duplicate billing occurs when the same patient is billed for the same service or procedure multiple times when it was performed once.
Outsourcing Physician Billing Solutions and Coding:
There are several benefits of outsourcing medical billing services. Some of the benefits include:
- Reduced errors in medical claims
- A team of highly experienced professionals in medical billing
- More focus on providing safe and quality patient care
- Lesser claim denials and higher clean claim rate
- Faster payments and a higher reimbursement rate
- Improved revenue cycle
Why UControl Billing?
UControl billing is a results-oriented, medical billing outsourced services company providing medical billing solutions for physician practices.
With UControl Billing:
- Always remain HIPAA Compliant
- Improved Quality & Increase in Revenue
- Billing in 24 Hours & Timely Follow-ups
- Patient Support & Customer Services
- Competitive pricing
- Maximized reimbursements
- Reduced overall expenses
- Patient statement processing
- Mailing
- Customized Monthly financial reports
- Rules-based claim review
- Scrubbing
- Insurance follow-ups
Frequently Asked Questions (FAQs)
What are Physician medical billing services?
Physician Medical billing is the process of submitting medical claims. Moreover, it also involves follow-ups of the medical claims submitted and managing the claim denials. Ultimately, the physicians and healthcare practices can be reimbursed for their services.
What are the three types of billing systems?
There are three basic types of medical billing systems, including the following:
- A closed billing system doesn’t allow any transfers—for example, using EMRs.
- Open billing systems allow the transfer. It represents a more collaborative structure of billing, i.e., healthcare records transferred across healthcare physicians, practices, billing teams & facilities, etc. Example: using EHRs.
- Isolated billing systems are completely separate from healthcare physicians, practices, and facilities. Example: using PHRs.
What is the best software for medical billing?
Medical billing software has several benefits, including revenue cycle management, reduced errors, and increased reimbursements. Following are some of the most commonly used software for medical billing:
- DrChrono.
- CureMD
- Kareo Billing
What are Physician medical billing software and its usage?
The medical billing software is a computer application that automates the complete healthcare billing process. Healthcare practice and physicians use this software to streamline the workflow, increase reimbursements and optimize revenues. The software we use in physician billing solutions also aids in:
- Eliminating paperwork
- Claim processing
- Claim submission
- Payment processing
- Streamlined billing process
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c16.pdf
A couple of years ago, I executed the effective plan of creating a Medical billing and Coding company named U Control Billing. The company aims to bring revolutionary advancements to foster medical billing and coding revenues. As an official member of HIA-LI and MGMA, I feel honored in providing networking opportunities, problem-solving, and improving the revenue management cycle.
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