These days, physicians are terrified about overcoding — that is, billing for services they did not render or for more labor-intensive services than they provided.
These days, physicians are terrified about overcoding — that is, billing for services they did not render or for more labor-intensive services than they provided. This is not surprising considering the rise in payer audits, fines and recoupments.
However, a recent study published in the Annals of Internal Medicine found that primary care physicians may forgo considerable revenue — $210,000 annually — because they do not bill for preventive and coordination services even despite providing appropriate services to eligible Medicare patients. Experts say physicians may also leave money on the table when they underestimate medical decision-making (MDM) that affects evaluation and management (E/M) levels, or they fail to leverage code specificity that affects payment.
“(Physicians often) try to do what’s right for their patients, and they don’t focus on what they need to do for financial success,” says Kimberly Hartsfield, executive vice president, growth enablement, at VisiQuate in Santa Rosa, California. “It’s the reason so many practices get into financial trouble. There are a ton of missed opportunities.”
What are some specific opportunities to watch for? Consider the following.
Higher-lever E/M codes
Despite new E/M guidelines effective Jan. 2021, that give physicians more credit for their MDM, many physicians underestimate that work or do not understand what counts toward it, says
Lisa L. Campbell, Ph.D., CEO of Physician Practice Resources, Inc. in Midlothian, Illinois. Campbell recently audited 25 encounters for an internist and determined that all had been underbilled.
“A lot of times, physicians treat patients with multiple chronic conditions, but they don’t document a well-developed plan of care,” she says. “There’s key information missing from the medical record that could have supported a higher level.”
Victoria Moll, CPC, CPMA, COC, CRC, CPRC, owner and founder of Contempo Coding in Fleetwood, Pennsylvania, says she sees this frequently — especially when patients with a stable chronic illness suddenly have a severe exacerbation. What might ordinarily be a level three or four suddenly becomes a level five, but physicians still default to the lower level out of fear, she adds.
Physicians frequently fail to account for social determinants of health (SDOH) that were recently added to the updated MDM grid. If a patient’s social issues affect the care plan and MDM, physicians may be able to bill a higher E/M level, says Campbell. For example, consider a patient who has financial problems and can’t afford medications, or one who is homeless and may not be able to refrigerate insulin properly. When physicians document that they provided resources or altered their care plan in some way, they may be able to get additional credit that leads to a higher-level E/M code.
Moll agrees. “For some of these patients, treatment options are going to be significantly limited,” she adds. “If physicians can put some of this information in their documentation, it may meet the criteria for moderate risk of complication.”
Addressing SDOH may also improve patient outcomes, says Campbell. “If you don’t solve the social issues, you may have difficulty solving the medical issues
Underbilling occurs even when billing E/M services based on time, says Campbell. For example, physicians may fail to count the time they spend reviewing records and prior tests as well as consulting with other providers on the date of service, says Campbell.
Care coordination services
Chronic care management and transitional care management (TCM) are two services that physicians may perform but not bill because they do not understand the codes, fear being audited, or are not aware the codes exist because they are not included in the drop-down menu option in their electronic health record, says Hartsfield. However, behavioral health integration and cognitive assessment with care planning are two additional examples of care coordination services frequently underbilled.
For example, the study published in Annals of Internal Medicine found that about 22.5% of Medicare beneficiaries had a hospitalization eligible for TCM. Among these beneficiaries, 43.3% were seen in primary care after discharge, but only 9.3% had a claim for TCM.
How does this translate to revenue? If the post-discharge visits that were already provided to patients had also included a post-discharge telephone call and been billed as TCM visits instead of office visits of moderate complexity, a primary care physician could earn an additional $5.54 per Medicare patient visit.
“Primary care doctors are doing the care coordination,” says Hartsfield. “They provide a follow-up visit and arrange for home health to come in or for durable medical equipment, but they’re not necessarily billing for those codes.”
Even if the visit did not meet the criteria for billing TCM, physicians may be able to bill an appropriate E/M service, and this does not always happen, says Moll.
There are numerous preventive services that physicians may perform and not bill. Consider smoking cessation counseling. The study published in Annals of Internal Medicine found that nearly 9% of older adults smoke. Among them, nearly 61% reported receiving advice from a health care professional to quit smoking, but only 10% of the 9% had a claim for smoking cessation counseling.
Other examples of preventive services frequently underbilled are wellness visits, advance care planning, shared decision-making for lung cancer screening, obesity counseling, depression screening, and alcohol misuse counseling and screening.
“It is literally money left on the table,” says Hartsfield.
Wound care coding
Many physicians do not realize that the size, quantity, location, and complexity of lesion excisions affect payment, says Moll. So does whether the lesion is malignant or benign.
It is safe to assume that most of today’s medical practices are underbilled, says Hartsfield. However, a basic data analysis can validate that assumption. She urges physicians to look at their claims data and how those data compare with their peers. Then ask these questions: Am I performing above or below current benchmarks? Are there opportunities for additional revenue? What could I be leaving on the table?
If physicians do not have the expertise or time to dig into the data, it may be beneficial to partner with an external consultant who can audit paid claims and make recommendations.
“It’s about being thoughtful and intentional about your revenue streams,” says Hartsfield. “Having a data-driven approach is the recipe for success.”