Compliant and accurate coding backed by comprehensive clinical documentation is crucial for ensuring physicians receive the highest level of reimbursement to which they are entitled. Inaccurate coding can delay payments, negatively impacting cash flow as insurance carriers withhold reimbursement until claims are corrected or appropriate supporting documents are received. For providers who primarily provide care for older patients, the process is even more complex due to stringent Medicare regulations and idiosyncrasies specific to each care environment that impact the coding and documentation required for reimbursement. Caring for older patients typically involves managing multiple complex diagnoses that must be evaluated at each visit. During those same visits, physicians often need to address additional issues ranging from basic considerations such as flu shots to more complex chronic conditions such as renal disease or diabetes. This can lead to a number of coding issues, including failure to use appropriate code combinations and lack of specificity in the code ultimately selected. In this article, we have listed medical billing challenges in Geriatrics with respect to various place of service.
Ambulatory Setting
- Many tests or procedures may be performed in the clinic, and Medicare is likely to ‘bundle’ and reduce payment unless medical necessity is met. Coders must utilize documentation guidelines for coding and meet typical auditing standards.
- In many cases, failure to use the correct bundle can result in denial of payment. In other instances, using individual rather than bundled codes can reduce reimbursement rates, as the latter typically reflects higher severity. More often than not, these coding issues can be resolved with improved clinical documentation.
- When a coder seeks additional information to determine whether a higher-level code is warranted, it delays billing and slows the overall revenue cycle. Conversely, if documentation is insufficient to support a higher-severity code, the claim is likely to be denied or care billed at a lower reimbursement level. It can also impact whether or not the payer considers the care medically necessary.
- Things gets more challenging for those practices and facilities that have not yet made the leap to electronic documentation and coding systems. Paper-based documentation and coding systems are highly prone to human error that can wreak havoc on the bottom line.
Home Healthcare
- Human error and incomplete or insufficient documentation are the primary culprits behind coding and billing problems within the home health sector. That standardized data-gathering tool drives the plan of care for the patient, the coding and sequencing, and thus the reimbursement. The challenge is the skill of each clinician, which can impact the assessment of the environment, severity of illness, ability to communicate.
- The first is a requirement for documentation of a face-to-face encounter with a physician or a nurse practitioner prior to admission of a Medicare beneficiary to home care. This applies to patients referred by hospitalists as well as by physicians from all inpatient settings, such as rehab facilities and skilled nursing facilities (SNFs). The real issue is documenting the encounter, the date, and the reason for the visit.
- Another challenge is, physicians to personally sign and date all orders for a patient’s care before a claim can be filed with Medicare for reimbursement. In the past, when undated documents were received from physicians, intermediaries had been permitted to date stamp them to show when they were received by the home health provider. This will cause additional workflow for physicians because we must return paperwork back to their office for dating.
SNFs, ALFs, and Hospice
- Related to documentation issues, another challenge for many physician practices is accurately coding for place of service. The challenge has assumed new prominence as patients are moved more quickly from higher-cost inpatient settings to specialty settings, including rehabilitation facilities, SNFs, and assisted living facilities (ALFs).
- The most significant challenge in these settings lies in understanding how Medicare reimburses for care provided. Like ambulatory care, which codes and bills based on diagnosis and treatment, there are edits for SNFs that establish limitations on services based on a diagnosis in combination with a procedure or a service code.
- Those limitations can be for daily services, across a month, or a limitation or guideline that’s recommended for a certain type of service, such as physical therapy or occupational therapy, for an annual benefit period. So, understanding the benefits their patients can receive is important.
- Attempting to bill for services that fall outside the established limitations or guidelines will result in denial or delayed payment while the claim is corrected. What makes coding and billing for care in this setting even more challenging is that those delays impact not only the physician submitting the claim, but can also impact any other physician or provider who is part of that patient’s care team.
- Physician services rendered to hospice patients produce yet another challenge in terms of coding and billing. Expenses for most services provided for hospice care are bundled and paid under a consolidated billing system. Hospice enrollment requires a physician to certify that a patient has a terminal condition supported by a medically appropriate and necessary plan for palliative care. The problem is that not all conditions or services are related to the hospice care plan; therefore, in these situations, a physician deserves additional reimbursement. Physicians and support staff need to have solid working relationships with the (hospice agency and/or ALF) as well as have coders expert enough to recognize this is a hospice situation and apply the appropriate modifier.
Medical billing for Geriatrics is a challenging task requiring experts at all stages of revenue cycle management. Hiring such billing and coding experts for your practice may not be financially feasible due to unavailability of Geriatrics coders and billers. Medisys Data Solutions can assist you in Geriatrics billing for your practice. Our Geriatrics billers and coders will submit your claims accurately and assist you in receiving accurate insurance reimbursements. To know more about our Geriatrics billing and coding services, contact us at info@medisysdata.com/ 302-261-9187
