Clinic EM Records

Overview

Codebusters coding teams support large multi-specialty physician-based coding environments for large health systems and physician owned group practices.

Accurate claim submittals are fundamental to meeting compliance requirements and financial needs.

  • Immediate access to hundreds of fully vetted physician-based coders
  • Zero start-up cost to build and train the Coding Team
  • Per record and hourly billing options
  • Multi-specialty coding team support
  • 100% accuracy guaranteed
  • Continuous auditing and transparent reporting
  • Proprietary workforce management platform
  • Outsource one or more departments, or use as a backup staffing support
  • Reduce claim denials, improve AR

 

Professional Services Coding

Codebusters provides coding and auditing services to physicians in small or large groups, Independent Practice Associations (IPAs), and multi-specialty organizations. We work closely with you to understand your unique relationship to payers and affiliates, and help identify potential compliance risks. Coding and auditing can be performed onsite or remotely, and we can provide training to your staff onsite and/or via video chat.

Codebusters’ professional services include expertise across a broad range of specialties. We work closely with our clients to ensure that they understand the documentation requirements for billing their specific practices and capture all appropriate charges.

Doctor looking at a medical record

Practitioner Reimbursement Challenges

The compliance issues surrounding billing within different sites of service and physician arrangements can be quite complex. Additionally, Evaluation and Management Services (E/M) coding requirements vary within medical specialties, especially as it relates to medical decision-making, and creates the need for coders with direct experience in a given practice specialty. Coders must possess strong knowledge of surgical and E/M CPT coding, modifier usage, and ICD-10 coding as it relates to medical necessity rules. Coding staff should also be well-versed with physician payment systems, such as RBRVS and the included Medicare Global Surgery Package (GSP).

Physicians working out of clinics often maintain multiple relationships (i.e. being based out of a clinic, but working at a number of hospitals or specialty clinics). Establishing strong information flow mechanisms between the site of service and the medical clinic are crucial for appropriate access to documentation regarding coding and billing.

Professional vs Technical Component

For nearly every service provided on an outpatient basis (less than 24 hours), there are two components. There is a claim filed by the physician or Nonphysician Practitioner (NPP) providing services to the patient (the professional component). If the services are provided in a hospital-based clinic, the hospital facility will usually file a claim with the insurer (the technical component). A physician providing services in a non-hospital-based clinic is paid the full amount of the professional component.

Professional Service Fee Auditing:

Codebusters approaches each professional services audit with the customer’s needs at the forefront. Auditors can perform audits and training feedback onsite or remotely. We help physicians and NPPs (independent or part of a larger group, IPA, or hospital chain) abide by complex coding and billing guidelines so they receive full compensation. Each audit is designed around clearly-defined parameters and existing compliance efforts. As part of the planning stage, we consider current and past compliance initiatives, the highest areas of risk, and budgetary restrictions. Understanding the complex nature of physician relationships and contractual agreements is critical to establish the appropriate coding and billing systems to apply. Our audit teams help practitioners alleviate uncertainty with regard to proper Medicare and other payer billing through documentation training, workflow analysis, proactive auditing, and correcting patterns of errors.

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Compliance

The compliance concerns for physician coding and billing depend largely on the site of service and the practice specialty. Primary areas of focus are proper diagnosis coding and establishing the medical necessity of procedures performed, correct E/M level, and appropriate qualifying modifiers. E/M codes should be validated against the documentation to support the level of service provided by the physician or nonphysician practitioner. The application of 1995 or 1997 E/M Documentation Guidelines must also be reviewed for consistency and financial effectiveness. Special focus should be spent on E/M codes for day-of-discharge management services, consultations, critical care services, psychotherapy, and individual psychiatric testing for inpatients. The OIG has long investigated the use of E/M codes by physicians, typically looking for aberrant patterns skewed toward high volumes of high service levels. Consultation coding is also a major area of focus by the OIG. For physicians at teaching hospitals, documentation should be evaluated to verify that it supports the supervision of residents.

Focus Areas:

  • E/M level coding
  • Frequency of E/M levels relative to benchmark for specialty
  • Proper documentation relative to coding and billing for consultation services
  • Preventive medicine codes versus use of regular therapeutic office visit codes
  • Coding of all applicable services and diagnoses
  • Correlation of diagnosis codes to procedures based on medical necessity guidelines
  • Use of waivers for services that the payer deems not medically necessary
  • Modifiers -54 and -55 for Medicare’s GSP
  • Modifiers -76 and -77 repeat procedures
  • Modifier -25 when billing both E/M level and surgical procedure
  • NPP coding and billing for incident-to services
  • Review of supervisory status (direct vs indirect) for billing relative to NPPs
  • Documentation of case management services that rely on accurate reporting time
  • Complete and proper documentation and coding for services provided outside of clinic
  • Checking for incidence of potentially bundled codes and the proper use of -59 modifier relative to CMS’s CCI
  • Accuracy of claim forms relative to full inclusion of diagnosis codes and procedure codes