Practice Self-Assessment: Guidelines for Evaluating Your Billing and Coding Practices
February 1, 2009

Although many physician practices constantly strive to improve clinical services in order to offer the highest level of care to patients, some of the more mundane and non-care related functions of the practice are many times neglected unless something happens to immediately demand attention (e.g., the “RAC”). As a result, some inefficiencies may develop within the practice and opportunities to create additional income may be “left on the table.”

Items of particular concern for private practitioners should be your billing and coding practices. You can be sure that you will be notified if you are billing for services that are not covered or if you are “over-coding” procedures, but you will never receive a phone call to let you know that you could have charged for an additional procedure that you have already provided or that you actually documented a more complex procedure than what you have coded for.

Some ways that you may be able to fine tune your coding procedures include:

Avoid automatic use of “middle of the road” levels of severity (e.g., 99202, 99203, 99242, 99243, etc.) in order to simplify your coding and documentation. A few dollars foregone here and there in order to make things simple could easily add up to more than you think.

Keep updated on Current Procedure Terminology (CPT) codes and know which procedures within your specialty can be billed in conjunction with related procedures. You may provide treatment without knowing that you have actually provided two or more services according to the latest CPT guidance.

Also in regard to billing, it is important that you review your contracts with the insurance payers that you accept. Despite the fact that as a private practitioner you most likely have less bargaining power than larger medical groups, you may find that the payment schedule that a particular insurance payer has assigned to you is far out of date and well below market rates. Even if your payment schedule is up to date, you still may have some amount of bargaining power depending on the facts and circumstances of your situation.

A couple of simple ways to “audit” your own insurance payer contracts are:

Keep a list of your top 20 procedures and the corresponding reimbursement from each insurance payer. Are you being compensated fairly?

Periodically review a couple of your Explanation of Benefits statements from each payer to determine if they are paying you what they owe you.

Compare the amount that you have billed for each procedure to the amount that you have been reimbursed. If you’ve received 100% of the amount that you have billed for, you actually may have been able to bill for more and may need to increase your fees.

Keep in mind that if you are unable to come to a mutually acceptable payment schedule with a particular insurance payer, you may want to consider if it is in your best interests to continue your relationship with that payer.

If you need help in evaluating your coding and billing practices, you can always consult an outside professional firm that specializes in physician coding and billing services. You may find that the one-time cost of paying for an objective analysis of your practice has an immediate pay back in the form of increased billings and collections.

If you have any specific questions regarding this article or if you would like to suggest a topic for upcoming articles, feel free to call or email Jeffry Moffatt at 317.275.7405 or jmoffatt@blueandco.com.