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Stage 2 Meaningful Use Explained


Stage 2 Meaningful UseThe meaningful use of electronic health records refers to the use of EHRs in ways that healthcare providers can measure qualitatively and quantitatively. The United States government has enacted legislation that will roll out requirements for the meaningful of EHRs in three stages, from 2011 to 2016. Stage 2 is scheduled to become effective in the near future, and will impose additional requirements for healthcare providers who wish to qualify as meaningful users.


The Health Information Technology for Economic and Clinical Health(HITECH) Act of 2009 describes the intended benefits of this act. They include an improvement in the general health of the population in the United States and in increase the security and privacy of health information for patients. The HITECH Act will also engage patients in their healthcare and reduce disparities in healthcare among patients of different economic means. It will also improve the coordination of patient care between healthcare providers.

The Obama Administration plans to use financial incentives to promote the use of EHRs. These include incentives for software developers who obtain certification for EHR software, which will ensure that this software meets specified quality standards. The incentives will also enforce open standards for EHR software to ensure that software vendors and users have the same goals.


The U.S. Department of Health and Human Services provides specific criteria for meaningful use in each of the three stages. Stage 1 was implemented from 2011 to 2012 and deals with data capture and sharing. Stage 2 will be implemented in 2014 and will deal with advanced clinical processes. Stage 3 is scheduled to be implemented in 2016 and will address improved outcomes for patients.

Stage 2 will require health information exchange to become more rigorous. It will also increase the requirements for prescribing medication through electronic means, commonly known as e-prescribing. Stage 2 will incorporate the use of lab results into the criteria for meaningful use. The transmission of patient care summaries will also be addressed in Stage 2, as will additional data that is controlled by patients.


The Centers for Medicare & Medicaid Services (CMS) describes the objectives of meaningful use for each stage, which consists of core objectives and menu objectives. Stage 2 introduces a new set of objectives, most of which are menu objectives. Many of these objectives provide exceptions that allow healthcare providers to qualify as meaningful users without meeting objectives that fall outside the scope of the provider’s clinical practice.

Eligible healthcare professionals who wish to qualify as meaningful users under Stage 2 must meet all 17 of their core objectives and three out of six menu objectives for a total of 20 objectives. Eligible hospitals are required to meet all 16 of their core objectives and three out of six menu objectives for a total of 19 objectives.

Some objectives are common to both healthcare professionals and hospitals, while others are different. For example, both groups must use computerized provider order entry to order laboratory test, medication, and radiology tests. Both groups must also record demographic information for a patient such as gender, race, ethnicity, date of birth and preferred language. Additional requirements for both groups include recording the patient's vital signs such as height, weight body mass index. They must also record the blood pressure for patients older than three years and smoking status of patients older than 13 years.

Objectives that are different between hospitals and healthcare professionals include the requirement of hospitals to provide patients the lemon aerie cause of death. Hospitals must also perform medical reconciliation when transferring a patient between settings under certain circumstances.

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Benefits Of PQRS Enrollment for Group Practices (GPs)


PQRS benefitsThe traditional fee-for-service model is quickly giving way to a new and exciting healthcare standard. The Physician Quality Reporting System (PQRS) has proven instrumental in this transition, offering the financial incentives necessary to convince medical professionals to ditch their usual approach to healthcare. Under PQRS, Eligible Professionals (EPs), are promised significant incentives in exchange for their commitment to prompt reporting of necessary information. Issues related to PQRS eligibility have left many interested parties confused since the program's adoption, with members of group practices especially curious about their standing. It is possible for group practices to take advantage of PQRS, but they must first meet a handful of stipulations. Once these conditions are achieved, approved group practices enjoy access to incentive payments similar to those available to individual EPs. 

Benefits Of PQRS Enrollment 
PQRS holds obvious benefits for isolated EPs, many of whom may otherwise struggle to get by in the current economic climate. But group practices also stand to benefit from PQRS enrollment, assuming they abide by the strict rules for reporting. For an approved group practice, the reward for satisfactory reporting is an incentive payment amounting to a selected percentage of the practice's estimated Medicare Part B Physician Fee Schedule charges. In addition to the basic monetary incentives, group practices participating in PQRS are able to improve their standard of care, while preparing for future reporting challenges in the rapidly-changing world of healthcare. 

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PQRS Enrollment Requirements For Group Practices 
In order to qualify for PQRS incentives, group practices must agree to a number of stipulations, including the posting of measured PQRS performance on the Physician Compare website and the willingness to comply with secure data submission practices. Additionally, participating group practices must already possess the needed technological specifications for the program, including the presence of Microsoft Access and Microsoft Office. 
Although group size does not determine whether a particular practice is eligible for PQRS incentives, practices are required to disclose this information while enrolling for the program. The sizing categories for PQRS include 2-24 EPs, 25-99 EPS and over 100 EPs. 

Reporting Systems For Group Practices 
While enrolling for PQRS, each group practice is required to select a preferred reporting system. Group practices tend to be better equipped for a variety of reporting systems than single EPs, so a greater measure of consideration may need to be applied to this important decision. Many group practices prefer to utilize Group Practice Reporting Option (GRPO) web interfaces, as these may also satisfy requirements for the Medicare Electronic Health Reporting Incentive Program. In order to take advantage of the web interface option, a group practice must include over 25 EPs.

Group practices lacking efficient EHR setups often opt for PQRS Registry Reporting. A new and increasingly popular option involves the Centers for Medicare and Medicaid Services (CMS) Certified Survey Vendor, which allows for reporting through the CG CAHPS survey. As with the online interface, the CMS Certified Survey Vendor option is only open to practices with 25 or more EPs. 

The pay-for-performance healthcare option is increasingly becoming the preferred approach among a variety of group practices, meaning that, in the near future, the usual fee-for-service method may no longer be the standard for healthcare billing. PQRS is currently ushering in this new age of performance-based payments, opening up the incentive program to a variety of group practices. Although participating practices must content with sometimes complicated reporting stipulations, they are rewarded with significant financial incentives and quite possibly, a better standard of patient care. 

Getting Started with PQRS

For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.

Medical Coding For Preventative Care and Diagnostic Services


preventive vs diagnostic careThe Affordable Care Act aka Obamacare ensures access to free preventative measures, allowing medical professionals to catch medical issues before they become severe, or better yet, to prevent them from developing in the first place. In order to accomplish this lofty aim, patients are encouraged to schedule regular checkups, at which preventive measures such as screenings and vaccinations may be pursued. Many of these services are offered at minimal cost or are completely covered by insurance plans. 

Although prevention and diagnosis often are lumped into the same category, they describe completely disparate types of medical care with different coverage options and payment plans. The two may occasionally experience some overlap, such as when a medical issue is highlighted during a preventative screening. Even then, medical billing procedure separates the preventative screening from any further tests used to obtain a diagnosis. 

Preventative Care 
The goal of preventative care is to maintain a reasonable baseline of health, so as to reduce the likelihood of major diseases and conditions in the future. Often, this means encouraging activities and behaviors that will result in better health outcomes. Preventative measures can also be used to detect medical issues for which, due to heredity and other factors, patients may be susceptible. Patients cannot be charged copays or coinsurance for the following preventative measures: 

  • Blood pressure screening

  • Cholesterol screening

  • Depression screening 

  • HIV screening 

  • Diet counseling 

  • Cessation intervention for tobacco users 

  • Type 2 diabetes screening 

  • Mammograms and breast cancer prevention 

A number of vaccines are also covered under the preventative care stipulations in the Affordable Care Act, including hepatitis A and B, tetanus, human papillomavirus (HPV) and diphtheria, among others. 

If other medical issues are noted during medical screenings, ensuing care may be covered under preventative coding and billing in certain situations. However, in most situations, everything that occurs after the screening will be coded as diagnostic. 

Diagnostic Services 
Preventative screenings often alert physicians to major medical problems, which, following the screening, may require further examination. Any tests or procedures conducted during this process may be deemed diagnostic for purposes of medical billing. The main exception involves preventative colonoscopy screenings; if a polyp is discovered and removed during the same visit, the entire procedure is coded as preventative. 

A great deal of confusion stems from tests that, depending on the patient's reason for scheduling an appointment, could be considered preventative or diagnostic. Mammograms are particularly apt to cause confusion; when used as a screening tool, they are deemed preventative and thus, fully covered by insurers. But for patients visiting due to lumps or pain, the screening may be coded as diagnostic. 

Coding For Preventative And Diagnostic Services 
Medical coding for preventative and diagnostic care can be complex, particularly if both types of care take place during the same visit. Preventative services should be marked with the appropriate CPT codes, with additional designation required for measures considered preventative only when pursued by Medicare members. If diagnostic services are required during a prevention-based visit, the medical coder can include the appropriate E&M diagnostic codes with the preventative encounter. The same procedure may be considered preventative or diagnostic depending on the circumstances of the visit, so it is important to thoroughly document all patient data collected during the encounter.

M-Scribe Coding Services

Due to the complicated nature of preventative and diagnostic billing, many clinics and practices choose to avoid payment issues by offering patients documents that cover the differences in medical coding procedure for preventative and diagnostic services. Patients are encouraged to read and sign these documents before receiving medical care. Even with the presence of disclaimers, some degree of confusion among patients is to be expected. 

  10 Ways to Increase Medical Billing Profitibility

For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.

Will Obamacare increase personal medical bankruptcies?


obamacareDespite its rocky rollout it’s clear now that Obamacare is succeeding in bringing medical insurance to many of America’s uninsured. According to a recent Gallup poll, the uninsured rate fell to 13.4 percent in the second quarter of 2014. It peaked at 18 percent in the 3rd quarter of 2013. This is the lowest quarterly figure since Gallup started tracking medical insurance enrollments in 2008. The Commonwealth Fund reports that as of May 1, 2014, 20 million people now have coverage under the Affordable Care Act. The largest number of enrollees, 8 million, purchased insurance directly through government run health insurance marketplaces, 6 million through Medicaid or CHIPS, 5 million from an insurer, and the remaining 1 million young adults under 26 enrolled in their parents’ plans. This is a remarkable success, especially given that 20 states are still firmly set against extending Obamacare to their Medicaid recipients.

At this point we can expect to see the uncharted shoals of Obamacare begin to emerge. For example, common wisdom is that the often comparably low monthly premium covers all, after the usual clearly stated deductibles, exclusions and coinsurance. This isn’t true, of course: the ACA isn’t National Health. It’s a pastiche woven from compromise.

Many of those freshly enrolled in Obamacare are newcomers to the medical insurance arena and are unaware of coverage pitfalls. Nowhere is this more dramatically clear than when balance billing issues arise. In balance billing, providers charge patients the full market rate for services. This often occurs because the patient, unbeknown to him or her, has been treated by a practitioner outside of the patient’s insurance network, be it PPO, HMO, or, increasingly an EPO. The New York Times last year chronicled the financial catastrophe that can befall patients and their families when balance billing comes into play. “It’s not uncommon for patients who visit an in-network hospital to learn later that they’ve been treated by out-of-network providers, resulting in thousands of dollars in charges,” notes the article, “Out of Network, Not by Choice, and Facing Huge Health Bills.”

Under Obamacare, as with traditional plans, patients referred by their in-network practitioners to a specialist who’s not in their network can end up with huge unforeseen bills. Likewise, in-hospital services are often provided by physicians unknown to patients or even unseen by them, such as anesthesiologists, radiologists, pathologists. Overwhelming bills can come from them, to.

The ACA does make some provision for balance billing in emergency services, but otherwise not, notes The Times. “It is conceivable that the problem gets worse for some people if the Affordable Care Act encourages narrower networks, which some people think it might do,” said health care law expert Professor Timothy S. Jost.

Evidence is emerging that Prof. Jost is correct. Obamacare seems to be sparking the growth of EPO’s—Exclusive Provider Organizations—into which insurance carriers are moving Obamacare enrollees. EPOs typically have fewer participating providers and offer less coverage. California’s Anthem Blue Cross is facing a potential class action suit over what The Los Angeles Times tagged as “more litigation over narrow networks in Obamacare coverage.” Anthem’s Obamacare subscribers allege they were surreptitiously moved from Blue Cross PPO’s into EPOs, and so inappropriately subjected to balance billing. Some of the Obamacare enrollees had prior PPO coverage, and believed they still did.

We’re seeing millions of new, unsophisticated medical services’ consumers coming into the marketplace through Obamacare enrollment. Most are largely unaware of medical billing nuances, such as balance billing. It’s possible over the next few years that because of this we’ll see an increase in medical bankruptcies. Studies of Obamacare’s forerunner, Massachusetts’s Romneycare, showed that medical bankruptcies in that state were largely unaffected by Romneycare. In 2007-09, medical bills “contributed to 52.9% of all bankruptcies in the state. Absolute numbers of medical bankruptcies were up by a third,” reported The American Journal of Medicine.

One out of three Americans have trouble paying their medical bills. Medical bankruptcies constitute 62% of personal bankruptcies in the US. Most medical bankrupts “were well educated, owned homes, and had middle class occupations. Three quarters had health insurance,” according to the Kaiser Family Foundation.

Unless and until the Obamacare legislation is modified to account for all aspects of balance billing, medical bankruptcies will rise if not soar.

For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.

How to Use Social Media in Healthcare to Increase Profits


social media in healthcareSocial media has been successful helping many companies engage their customers and increase revenue. Properly using these tools can have the same effect on medical practices. The key phrase is "properly using."

To properly use social media, your practice should take a few steps to better ensure successful results. These tips have proven to work for companies in all industries. Your practice should reap identical benefits if you follow these steps.

Using Social Media to Increase Practice Profits

Consider using the following tips to develop a social media program that helps increase revenue and profits for medical practices. These suggestions are offered by Oracle, an indisputable leader in digital processes and solutions.

  • Design a creative strategy to maximize social media use. Whether you choose the most popular options, such as Facebook and Twitter, or less well known, but effective social media sites, your strategy to increase revenue and control costs will work if your patients respond to your outreach. If you experience high creativity levels, you can use multimedia sites, such as Pinterest or YouTube, to deliver your message.
  • Be sure your social media setup provides for two-way communications, not just for you to dispense information. Patient feedback can be very important, so give them the opportunity to communicate with you. For example, to encourage patient feedback you could offer a brief survey with important questions, while asking for responses from your patients. These responses will reveal patient perceptions of your practice, providing valuable information about potential improvements you could make to improve it. In a way, just as companies use this technique to better understand their customers' preferences, providers use this two-way communication to learn more about their patients.
  • Control the content you use on your social media pages to ensure that you're offering the information you want. It doesn't matter whether you write the content yourself or outsource it to others. The key is to retain control of your posts so you're comfortable with the focus and text you dispense. Consider offering patients something for 'free,' such as monthly or quarterly newsletters, e-books on healthier lifestyles, or developments in your specialty that would interest your patients.
  • Set your social media goals and track the results. Decide the target results you want and measure your progress. For example, if you want to increase practice profits by five percent, create a social media strategy you believe will accomplish this goal. Measuring your results will give you evidence of the success of your strategy. Even if you don't get the results you want, by tracking your progress, you'll learn what parts of your plan work and which ones need tweaking.

When In Doubt, Get Qualified Help

If you lack the time, desire or expertise to make this a DIY project, get professional help to design and track the results of your social media strategies. While you might call on a web or freelance writing veteran, you should consider outsourcing your social media presence to a leading medical billing firm, such as M-Scribe Technologies.

Proven third party medical specialty firms understand the details of physician and practice goals and components of greater profitability, such as ways to increase practice revenue and control expenses. Additional benefits they can deliver include helping you maintain compliance with HIPAA, CMS, Affordable Care Act (ACA) and private payer regulations, while using social media effectively, always adhering to patient privacy laws.

Data indicates that at least one practice experienced up to 20 percent increased revenues, conversion rates up to 70 percent (since prospective patients perceive that they "know you") and generated new, good reviews of patient experiences. This is valuable information you'll receive when you track and measure your social media results, as they translate to bottom line increases.

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For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.

Diagnosis Coding Has Taken Center Stage in Medical Billing


Accurate Diagnosis CoHistorically physicians and payers were 'on the same page' regarding fee-for-service reimbursements. The doctor provided a service, for which the medical professional received a fee. Simple and not complicated. However, along with healthcare reform comes the need for physicians to be thorough and accurate with their diagnosis codes.

The shift to pay-for-performance (P4P) programs, originally initiated by the CMS, but increasingly adopted by private payers, demands this accuracy. Along with offering incentives to physicians for providing quality care, there are now penalties for medical professionals who may not be offering patient care of acceptable quality.

Accuracy Was Always an Issue

While accurately recording diagnosis codes has always been important, until P4P programs, many payers accepted marginally thorough supporting information to approve claims and pay providers. The new emphasis on claims clarity often proves to be challenging for physicians and billing staff, particularly for those providers not in the habit of submitting fully documented reimbursement claims.

In the past, claims with faulty diagnosis codes typically were denied. Yet, some insufficiently explained claim submissions slipped through and were approved. If payer claim reviewers were hurried into claim examinations, it was always possible that some submissions that could have had payers 'scratching their heads' were approved.

However, most of the diagnosis coding rules have changed. Accuracy, always a factor, has become the primary component of claims approval. Along with approved/rejected decisions, medical providers now face quality care issues, requiring further justification and explanation to eliminate payer confusion.

Proper Diagnosis Critical for Payment

Some physicians and billing personnel seem forgetful that Medicare Advantage plans pay, in part, as a function of the number and severity of sickness in the total population of patients. CMS calculates variable per month payments based on the levels of the 'sick' population. Some private payers are endorsing this approach, demanding that physician diagnosis coding 'fits' the matrix.

While some physicians during the fee-for-service era always went the extra mile to fully explain their diagnostic coding and process, many other providers, often because of billing staff time constraints, neglected to thoroughly document their diagnosis procedures. However, providers now risk facing claim denials with P4P programs if payer review staff is unsure that the doctor performed diagnostic services that were necessary to design a treatment plan.

Accurate and thorough coding for chronic conditions is another prime area of payer scrutiny. ICD-9 guidelines require providers to use these codes 'as often as applicable' when treating chronic conditions. P4P quality care evaluation depends on proper use of these codes. The penalty consequences of taking coding 'shortcuts' can result in lower income for the physician.

These are some of the reasons that using accurate diagnosis codes are critical for maximum claim approvals and CMS decisions that physician care qualifies as meeting quality guidelines. The strong focus on procedural diagnostic coding accuracy is here—possibly affecting your compliance and income levels.

Accurate diagnosis coding, backed up by thorough documentation regarding the necessity of diagnostic procedures, is no longer a payer ‘luxury.’ Accuracy and clarity is now a necessity for all physicians. Achieving this result typically demands some combination of the following actions.

  • Designing an almost foolproof internal procedure for billing staff or physicians to review all claim submissions for accurate diagnosis codes and supporting document clarity.
  • Have experienced coders review EHR document derived diagnostic codes before submitting claims.
  • Retaining a leading independent coding and documentation firm, such as M-Scribe Technologies, to assume the responsibility of submitting accurate, clearly explained diagnostic procedure claims for you.
  • Physicians developing the habit of fully documenting all diagnostic procedures for every patient, helping billing staff and payer reviewers to understand the reasons for the diagnosis process used.

Physicians and practices using these tips should remain in HIPAA, CMS and P4P compliance, maintain or increase revenue and create evidence of delivering quality care to all patients. Properly using diagnosis codes and supporting your diagnostic procedures with valid documentation will achieve these results. None of the potential alternative results are acceptable for either doctor or patient.

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For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.

Uncover the 'Silver Lining' Of Obamacare for Physicians


Obamacare Advantages resized 600Healthcare reform, otherwise known as Obamacare, has generated mostly negative attention from most of the broadcast, print and digital media. There are some good reasons for this less than complimentary attention.

  • Many healthcare marketplace websites have had serious bugs, preventing people from purchasing mandatory health insurance.
  • Many health insurance products are too expensive for a large number of Americans, particularly the middle class, which is getting financially squeezed by the current economy.
  • The citizenry remains generally unhappy with and/or confused about many provisions in the Affordable Care Act (ACA).
  • High deductible health plans shift too many payment burdens to patients.

These negative opinions and facts typically hide the potential benefits offered by Obamacare—particularly for medical providers. Physicians often hope that Obamacare succeeds, because it’s here whether we want it or not.

Yet, media reports have ignored the possible benefits physicians may receive. Even many medical industry publications and associations largely have ignored the possible ‘silver lining’ that comes with Obamacare.

Less Publicized Benefits

Despite all the negativism, consider the less publicized benefits of Obamacare. While there are numerous less important benefits, the following should qualify as the silver lining of healthcare reform for physicians.

  • Obamacare supplies the top component for increasing physician revenue: More patients. Particularly significant to independent providers with smaller practices, more patients provide the opportunity for physician to grow their practices.
  • The original healthcare reform debates often centered on reducing Medicare reimbursements because of unsustainable payment levels. To date, even with the implementation of the ACA, Congress has kept Medicare reimbursement amounts at former levels.
  • The shifting focus from care quantity to quality of care should motivate physicians to offer and patients to receive high quality care. Providers committed to earning the incentives that come with delivering quality care will enjoy increased income. Although targeted to doctors offering Medicare services, pay-for-performance (P4P) incentives are attracting many major private healthcare payers, who are participating in this initiative.
  • In states agreeing to expand their Medicaid programs, physicians will be reimbursed equally for Medicare AND Medicaid diagnostic and treatment services. Historically, Medicaid reimbursements were significantly lower than Medicare payments. The ACA specifies that Medicaid payments should have parity with Medicare reimbursements for identical treatment and procedures.
  • Incentives to practice in ‘underserved’ areas. The ACA provides bonuses (10 percent) to primary care physicians (PCPs) who open a practice or continue to offer service in ‘medically underserved communities.’ This bonus mirrors the Medicare provision providing incentives for practicing in underserved areas.
  • Insurance must offer coverage for pre-existing conditions. This provision also providers to grow their practices by encouraging patients to seek treatment for pre-existing conditions, often excluded from many health insurance plans before Obamacare. Since the private foundation promoting improved healthcare for Americans, The Commonwealth Fund, in a 2010 research study, found that around 60 percent of people lacking health insurance did not request medical care fearing the cost. The ability to have coverage for pre-existing conditions will have more patients seeking treatment.

These are but some components of the little publicized physician—and patient—benefits of Obamacare. Instead of focusing on the negatives of healthcare reform, physicians should evaluate the benefits and take appropriate action to maintain or increase practice income by growing their practices and qualifying for incentives offered when delivering high quality care.

Providers that use P4P as a positive motivator can eliminate most of the negative perceptions surrounding Obamacare. Instead, forward-thinking and creative providers will enjoy the often disguised positive advantages for physicians offered by the ACA. Doctors are encouraged to reap the rewards, not endure perceived penalties.


Getting Started with PQRS
For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.

How to Avoid PQRS Penalties (2% of Medicare Annual Revenue!)


tips to avoid pqrs penaltiesAlthough the physician and medical community is underwhelmed, sometimes openly hostile, to the implementation of the penalty phase of the Physician Quality Reporting System (PQRS) made a permanent regulation under The Medicare Improvement for Patients and Providers Act of 2008, penalties will take effect in 2015. Penalties will apply for non-compliance for activities during the period January 1 through December 31, 2013.

Therefore, practices should implement action plans to avoid 2015 PQRS penalties NOW. CMS believes their 2013 reporting options give eligible providers sufficient time and choices to comply with PQRS requirements.

PQRS Penalties

Medical providers who do not comply with PQRS requirements can have their Medicare and Medicaid reimbursements reduced by 1.5 percent. Since CMS reimbursements are "conservative" (polite designation) already, receiving only 98.5 percent of scheduled payments could partially cripple a practice's revenue stream.

PQRS penalties will increase to 2 percent payment reductions in 2016 for those providers that continue to operate in non-compliance. CMS, in a classic government-generated language softener, refers to these penalties as "payment modifiers," not income penalties. The resulting revenue damage, however, achieves the same negative result.

Avoiding PQRS Penalties (or "Payment Modifiers")

Yes, it's getting late; but it's not too late to avoid 2015 PQRS penalties and definitely sufficient time to avoid the heavier 2016 penalty cost potential. Since it's late 2013, most of your previous options have disappeared per the calendar. But, you still have the following options for 2013 and 2014.

  • Start using PQRS codes immediately.
  • Learn and use PQRS measure specifications for all future Medicare patients.
  • Before the end of February 2014, use a data registry and ensure that you provide PQRS-compliant care.
  • Ensure your billing staff or third-party medical billing service is using PQRS codes for Medicare reimbursable procedures, diagnosis and treatment.
  • Use the CMS "calculated administrative claims-based reporting mechanism."

While the CMS incentive program is important to increase your revenue, the penalty phase is even more vital to keeping your revenue stream healthy. Avoiding PQRS penalties, by taking these precautions, will serve the same--or more important--purpose.

Medical providers are busy. Billing staffs are busy. However, CMS offers multiple measures for compliant PQRS reporting. If your practice encompasses many Medicare or Medicaid patients, you need not incur PQRS penalties.

Adopting some measures as soon as possible--today is good--will avoid revenue-damaging penalties. Among the options to avoid PQRS penalties you can take are the following actions.

  • Initiate claims-based reporting, as defined by CMS procedures (using "G" codes).
  • Use registry-based reporting with CMS approved registries.
  • Implement electronic health records (EHR) reporting.

These reporting systems will help you avoid PQRS penalties, as you will have evidence that you have used CMS approved reporting systems. Using proper PQRS codes and CMS reporting methods help you avoid damaging penalties that will reduce your income.

Preparing and taking avoidance actions now is imperative. Be aware that CMS changed its definitions of individual and group medical practices. Originally, group practices included those with 25 or more eligible providers. Now practices that include only 2 or more eligible providers qualify as "group practices." If your practice includes as few as 2 physician and non-physician providers or as many as 99, you have a CMS-defined group practice.

Don't wait any longer, if your practice accepts Medicare or Medicaid insurance. While the incentives for complying with PQRS are beneficial, the potential penalties are damaging. Avoiding these penalties is well worth the compliance and submitting claims that satisfy PQRS regulations.

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M-Scribe helps practices in chosing speciality specfic measures, registry and in submission to CMS.

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For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.

Removing the Common 'Mystery' of Code Modifiers


physician payment doubtSome practice medical billing personnel, even those with experience, exhibit misunderstanding of code modifiers when submitting claims. If you research some payer statistics, you'll find numerous examples of medical providers re-submitting previously denied claims using the identical modifiers that generated original payer confusion. Payers typically again deny these claims.

Modifier Misuse Results

While most medical billers understand the purpose of modifiers, to further clarify the physician action during patient encounters, sometimes coders repeatedly misuse modifiers, increasing payer confusion. Inaccurate claim submissions increase reimbursement delays or generate claim denials, achieving two negative results.

  • Decrease income to the physician, and
  • Increase billing costs, as staff time is wasted by re-submitting unreimbursed claims.

Denied Claims Re-Submission Issues

Re-submitting denied claims by using the same modifiers that caused the original payer decision is an exercise in futility. Coders failing to use different modifiers or including additional documentation for clarity have little hope for a positive payer reimbursement decision.

Although difficult to justify, this billing action is an all-too-common procedure. Payers often become equally mystified by claims re-submissions that offer no additional documentation or clarity, leaving payers no alternative but to further delay or deny these claims once again.

If your billing staff submitted the original claim with no modifier, re-submitting with the appropriate modifier helps the payer reverse denial decisions. However, using a potentially ambiguous modifier without clarification often heightens payer confusion, a common reason for the original claim denial.

This lack of accuracy and level of detail can escalate from claim denials, reducing practice income, to costly payer audits, investigations and, sometimes, fines. Frequently submitting claims without modifiers or containing the wrong modifiers generates payer red flags that can cause even more costly actions, increasing the effect of lost income opportunities.

Consider Examples of Modifier Use and Misuse

Modifier 25 is one of the commonly misused modifiers. Targeted to encourage payment for care evaluation and management (E&M) services performed the same day physicians provided an additional procedure for the same patient, coders sometimes append this modifier to the procedure claim in lieu of using the proper E&M code.

Modifier 24 misuse is another example worth noting. Intended for use when a physician provides an E&M service during a post-operative period, but the service is unrelated to the original procedure. Attempts to ‘unbundle’ this service from the original claim when the E&M service obviously relates to the original surgical procedure create payer denials, since they already reimbursed for the procedure. This modifier should only be used for unrelated services, e.g., addiction counseling, not for post-operative evaluations of patient recovery from surgery.

Properly using Modifier 59 allows providers to successfully unbundle claims, when justified. This modifier alerts payers that physicians performed procedures outside normally bundled services. A proper use example is when treating different injuries at sites other than stated in the original claim.

Removing the ‘Modifier Mystery’

The benefits of avoiding claim delays and denials need no further evidence. For reasons that should be equally obvious, removing the ‘cloud of mystery’ created by misuse of modifiers should be a top medical provider priority. These tips should help achieve this goal.

  • Review claims before submission. If it confuses the medical provider, the odds are the claim will also confuse payer staff. Provide sufficient documentation that clarifies use of modifiers if you’d like to get paid.
  • Be careful when ‘unbundling’ claims. Payers have become more diligent in examining claims for unwarranted unbundling. The increasing incidence of provider attempts to use modifiers to increase payments that are outside payer definitions of unrelated services originally reimbursed has caused payers to closely examine these claims. Successfully unbundling claims requires more clarity to generate payer approval.
  • Train billing staff in the proper use of modifiers. The cost of education and training will be more than offset in decreasing claim denials and increasing income.
  • Use a top medical billing firm. Leading billing and documentation organizations, like M-Scribe Technologies, use experienced coders who fully understand the proper use of modifiers to increase physician income.
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Modifier codes for Medical Billing: Considerations and Examples


Medical coding modifiersIt promises to be another whirlwind year for medical billing and coding, the ongoing conversion to EHR compliances and PQRS for incentives and potential penalties makes it very hard for billers and coders to comply with all the rules and regulations. Though ICD-10 has been pushed for another year, and despite the added functionality ICD-10 codes lend to diagnoses and billing, modifier codes will still be used, as claims will still need to be modified. Fortunately modifiers work equally well with ICD-9 and ICD-10 codes and are remaining unchanged. Even so, change may affect them. It seems a good time to review their structure and utility, and the possible impact new practice systems may have on their usage.

A modifier is a two digit code by which a reporting physician indicates that a performed service or procedure has been altered by some specific circumstance, though without a change to the basic procedure and its defining CPT code. Modifiers can be used with any CPT code. Properly used, modifiers make claims reporting easier: their considered use eliminates the necessity of separating procedure listings to describe modifying circumstances, and accurately applied, lowers the risk of claims rejection by the patient’s insurer. Practices should incorporate modifier code usage in any review of their coding and claims submission procedures.

Modifiers are a critical component of coding and using them incorrectly can result in lost revenue and audits. Knowing your modifiers and their proper usage can reduce the risk of lost income and improve audit compliance.

When to Use Modifiers

Modifiers are used under the following circumstances:

  • When a procedure is performed more than once on the same day.
  • When more than one procedure is performed on the same day
  • When a procedure is a non-covered service
  • When more than one assistant surgeon completes a procedure
  • Provision of a procedure in a specific location, such as an HPSA area, teaching facility, rural area
  • When necessary to differentiate between the professional and technical portions of a procedure done in a hospital setting.
  • When multiple providers share or split work on the same surgical procedure
  • To reflect increase, reduction or discontinuation of a procedure
  • To reflect participation of the provider in a government-funded incentive program, such as PQRI or Electronic Prescribing
  • When a patient falls within a global period from a previous procedure

New Practice Management Systems and Modifiers

Many practices are changing to newer medical billing practice management systems and software to support their conversion to ICD-10, and as part of their EHR conversions. Easily overlooked amid meeting the many challenges these present are the relatively few and unchanging modifier codes. A new system may impose new requirements on the use of modifiers, such as only allowing numeric modifiers, or limiting the number of modifiers for a procedure. It may require different sequencing, e.g., convention has long dictated the listing of modifiers affecting reimbursement go before those that are informational. Will this sequencing be supported within a new claims management system?

Although CMS itself has no modifier code rules, carriers often do, publishing their own guidelines so practices will be able to conform to their claims submissions requirements. If you find these guidelines unavailable, you should contact your payer in writing well ahead of any planned changes to a new practice management system.

Researching changes to modifier code usage in advance may well save you time, money and frustration later on.

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For more information about M-Scribe Coding and Billing Services please contact 888-727-4234.
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