Fundamentals in Healthcare Law Webinar Series - June 15, 2022

1. Fundamentals in Healthcare Law Curriculum
2021 – 2022 WEBINAR SERIES
PA R S O N S B E H L E . C O M
N AT I O N A L E X P E R T I S E . R E G I O N A L L AW F I R M .
Medical Billing and Revenue
Wednesday, June 15, 2022

2. 2

3. 3
Legal Disclaimer
This webinar is based on available information as of June 15, 2022,
but everyone must understand that this webinar is not a substitute for
legal advice. This presentation is not intended and will not serve as a
substitute for legal counsel on these issues.

4. 4
Presenter
• J. Kevin West
208.562.4908
kwest@parsonsbehle.com

5. 5
At its most basic level, generating revenue by healthcare providers
results from--
1. Providing a service to a patient, and
2. Submitting a claim for reimbursement to the payer

6. 6
Medical Claims for Reimbursement
For revenue to be realized, everything depends on whether--
1. Claims are properly coded and billed,
2. Medical records support what is billed, and
3. Billing staff are competent and well trained.

7. 7
Medical Billing & Coding
• “Medical billing and coding translate a patient encounter into the
language used by healthcare providers for claims submission and
reimbursement”

8. 1. a. What is Medical Coding?

9. 9
Diagnosis Coding
• ICD-10 Diagnosis Codes
Diagnosis codes describe the patient’s condition
ICD-10 Manual is maintained by the World Health Organization (WHO)
The manual contains over 70,000 unique codes

10. 10
Procedure Coding
• Current Procedural Terminology (CPT)
Procedure codes (mostly 5 digit numerical codes—e.g. 99202) describe
what the provider did during the encounter
The CPT Manual is maintained by the AMA
The manual updated annually
Contains tens of thousands of codes

11. 11
CPT Procedure Coding
• CPT codes fall into 3 categories:
◦ Category 1 Common procedure codes (5 digit numerical)
◦ Category 2 Supplemental tracking codes (5 digit alpha-numeric)
◦ Category 3 Temporary codes (5 digit alph-numeric)
• Category 1 codes fall into 6 areas:
• Evaluation and Management: 99201 – 99499
• Anesthesia: 00100 – 01999; 99100 – 99140
• Surgery: 10021 – 69990
• Radiology: 70010 – 79999
• Pathology and Laboratory: 80047 – 89398
• Medicine: 90281 – 99199; 99500 – 99607

12. 12
Procedure Coding
• Healthcare Common Procedure Coding System (HCPCS)
HCPCS codes (alpha-numeric codes, e.g. L1971) describe durable
medical equipment (DME), prescription drugs, etc...
These codes describe items/products provided vs. procedures performed
The HCPCS Manual is published and maintained by CMS

13. 13
• Modifiers
Add specificity to medical codes
May be numeric or alphabetic
Modifiers specify location, duration, # of units, coverage issues,
procedure logic, etc...
Common modifiers: -25, -59, -GA, -KX

14. 1.b. What is Medical Billing?

15. 15
Medical Billing
1. Front-end billing
Patient registration
Insurance coverage verification
Prior authorization
Collection of co-pays

16. 16
Medical Billing
2. Back-end billing
 Populating the CMS 1500 claim form used by Medicare and many other
payers for submission of claims for reimbursement
 Populated by information from superbill, medical record and/or EHR
software
 The claim is transmitted (typically electronically) to payers, usually
through a clearinghouse

17. 17

18. 18
Adjudication of Claims
• The process of accepting/rejecting and paying claims by payers
• Electronic Remittance Advice (ERA) typically sent to the provider
• Explanation of Benefits (EOB) sent by payer/provider to patients
• Reconciliation on patient ledger as between what payer and patient
have paid

19. 19
2. Does the Medical Record Support What Was
Billed?
• Three key issues:
◦ Does the chart note clearly describe what procedure/service was performed?
◦ Does the chart note describe why the procedure/service was performed (medical necessity)?
◦ Does the chart note state who performed the procedure/service (and their credentials)?
• Medical necessity is established by SOAP criteria
Chief complaint
History
Exam findings

20. 20
Medical Record Documentation Requirements
• Local Coverage Determinations (LCDs)
• Local Coverage Articles (LCAs)
• Commercial insurance: Medical coverage policies
• State Medicaid coverage policies

21. 21
Top 10 Documentation Errors
1. Failure to review and proofread electronic chart notes before finalizing
2. Failure to properly sign and date the note
3. Failure to amend the note properly
4. Failure to include patient medications—existing and new Rxs
5. Failure to document the patient’s response to treatment
6. Inconsistencies between history, exam and treatment sections of note
7. Failure to properly document the chief complaint (i.e. just repeating what the
patient says)
8. Failure to document informed consent, non-compliance, no-shows etc.
9. Lack of operative notes for minor procedures
10. Lack of orders (when required)

22. 22
3. Who Does the Billing?
• Internal vs external billers (pros and cons)
• Qualifications, training (CPC certification)
• Use of billing software

23. 23
The Impact of EHR on Coding and Billing
• Upsides
Data collection efficiency
Transmission/communication across user platforms
Ease of storage
Template guidance
• Downsides
Poor quality records (verbose, repetitive, inconsistent, irrelevant
verbiage)
Poorly design for certain specialties
Time consuming; diverts attention from the patient

25. 25
Fraud and Abuse Concerns
• Upcoding
• Downcoding
• Unbundling (misunderstanding of corrective coding initiative)
• Lack of medical necessity
• Lack of documentation
• Improper coding choices

26. 26
Fraud and Abuse Concerns
• Billing for experimental and investigational services
• Balance billing
• Self-referrals
• Kickbacks
• Fee splitting
• Billing by unlicensed/unqualified/uncredentialed personnel

27. 27
Coding and Billing Audits
• Medicare
• Medicaid
• Commercial Insurance

28. 28
Collections
• Revenue loss concerns
• Fraud and abuse concerns
• Liability concerns

29. Boutique, Cash Only & Direct
Primary Care Practices

30. 30
Boutique and Cash Only Practices
• Opting out of Medicare is usually required
• Revenue concerns (can you make it without being a participating
provider?)
• Straddling the fence concerns—billing insurance for some patients
and at the same time doing cash only for others is a problem

31. 31
“Direct Primary Care”
• Usually an option only for general/family practice doctors
• Flat monthly or annual “subscription” fee
• “Menu” of services covered by the subscription; other services are
an extra charge and/or are referred out
• Some employers are offering this as a fringe benefit to employees as
part of/in addition to their benefit plans

32. Questions?

33. 33
Thank You
• J. Kevin West
208.562.4908
kwest@parsonsbehle.com