Medical Billing Articles

Billing & Revenue Cycle Problems in Pain Management July 30, 2021

Pain Management

Maintaining a profitable practice means ensuring a healthy revenue cycle for any pain management practice. However, pain management practices still encounter hardships due to their complexities in billing and coding. It can be challenging to manage the processes when it involves stakeholders and obtaining payment relies on consistent interactions. Keeping departmental and payer communications open can help keep accurate information sorted and categorized throughout the process. The following are the most common billing and revenue cycle issues in Pain Management Practices:

  1. A manual process on claims denial management
  • Using a manual process for managing denials can slow down your cash flow. At the same time, it can still lead to more inaccuracies and errors.
  • According to Michelle Tohill, Director of Revenue Cycle Management at Bonafide Management System, healthcare providers should switch to automated systems to avoid denials. In addition, staying on top of diagnostic codes and different insurance policies can be exhausting. However, many software providers will automatically update requirements and coding procedures.
  • She also added that there are still many software providers who are constantly updating codes and requirements. In this way, your billing staff can double-check claims. Making sure they meet the demands and saving research time.
  • Furthermore, your staff needs to be aware of future happenings to get reimbursements, less time figuring things out, and detect necessary parties.
  • Automating claim denial management in medical billing can help providers identify errors before submitting claims.
  • There may still be difficulties toward submitting claims and associated labors in managing denials, stated Brendan FitzGerald, HIMSS Analytics Director of Research. Surprisingly, software providers have not automated the denial management process through a vendor-provided solution.
  • If managing denials are a lot, productivity might be slow through a manual process.
  • Denial management is still a question, whether it is outsourcing or in-house. The HIMSS study found that 44% of healthcare professionals preferred outsourcing such as revenue cycle management, clearinghouses, or EHRs, while 18% implemented an automated system in-house.
  • Medical billing teams from denial management draw data over healthcare industries and handle multiple payer rules and codes.

  1. Coding Errors

Incorrect codes will lead to deferred, denied, or half-paid claims. Pain management practices continue to struggle with the complexities of codes for pain management coding procedures. These are the top coding issues:

  • Inaccurate coding on clinical coverage
  • Improper procedural codes
  • Out-of-date codes

These can bring about mistakes that become costly to your pain management practice. On the other hand, money is not always an issue. It can also lead to legal consequences like:

  • Imprisonment – for penalties and false claims submitted per file
  • Clinical Maltreatment – If there’s proof of deliberate distortion throughout quite a while and across countless patients. 

 Even though these may seem alarming, the most well-known result of billing issues is that insurance agencies will not reimburse your cases.

  1. Prior Authorization Delays

Prior Authorization (PA) setbacks can deprive physicians of time in catering to patients and increase their expenditures. Some medical insurance companies require prior authorizations (PA) before providing pain management procedures. It serves as a significant barrier for physicians to deliver quality care. PA helps with:

  • Monitoring healthcare costs
  • Proper approval from patients plan
  • Providing payers with a secure prescription for medicine and drugs

Despite this, the process can slow down the delivery of needed services and care for patients. To improve PA performance, physicians adopt the usage of Pain Management EMR Software. Electronic Prior Authorization integrates directly with your electronic medical records (EMRs). Healthcare professionals can use it to obtain prior authorization in real-time. Additionally, it eliminates the need for time-consuming paper forms, faxes, and telephone calls.

  1. No proper staff training

Unskilled staff in the healthcare industry might cause revenue cycle management issues. In relation, they might not bill or capture patient data correctly. Proper staff training is necessary to capture patient’s demographic information on the front end. Also, on how to translate that data to successful insurance claims after that. With that, patient schedules and registrations must also be accurate to avoid problems in revenue. Conducting staff training might be time-consuming, but it is worthwhile. It can increase cash flow well after, although it might also be costly. Moreover, your pain management practice will boost these areas:

  • Enhance job proficiency
  • Boost staff self-esteem
  • Employees will stay longer to your business

If you also think of outsourcing your revenue cycle management, talk to a Pain Management Billing specialist. Working with them can save you time and resources.

  1. Failure to follow up on Accounts Receivable (A/R)

A/R follow-up process can be a handful at most times. The team assigned for this is to consistently handle interactions with patients, healthcare providers, and insurance agencies. There are also processes that your team needs to complete:

  • Verification,
  • Charge entry
  • Payment posting

Medical billing specialists regulate the precise diagnosis and exact procedure codes based on the treatment plan. If your A/R team has issues regarding this, your practice might be at stake. Your practice cannot establish good revenue without a proper A/R process. Without it, it can lead to high collections of A/R, and backlogs will occur. The worse thing is that insurance companies will deny claims if your A/R team fails these processes. If you want to increase your profitability, you can read these 8 Tips in Pain Management Practice.

Tap Into Our Expertise

These are just some of the common problems associated with pain management practices. Think about outsourcing your revenue cycle management to trained and experienced medical billers and coders. Having people take charge of your medical practice problems and provide solutions is always a great idea to boost revenue.

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!

5 Signs You Need to Call a Medical Billing Specialist July 1, 2021

Medical Billing Specialist

There are still doctors who think outsourcing their medical billing process would deprive them of a healthy cash flow. However, most doctors swear by their outsourced billing services and wouldn’t consider bringing it in-house ever again. No matter where you fall on the spectrum, there might still be leaks in your revenue cycle. Here are five signs that you need to tap into the expertise of an experienced medical billing specialist.

1. Revenue Stream Slowing

You might not notice your revenue stream reducing when you’re focused on the day-to-day duties of patient care. First and foremost, assess how well your in-house billing department is operating, how much it costs, and if you’re paid on time. Then, start adding up what you spend on phone bills, internet, information systems, physical space, support staff salary, and billing supplies to get a handle on your billing expenses. When comparing the cost of a third-party medical billing specialist, this figure will come in handy.

2. Recruiting and staffing challenges

Because the process of filing claims and following up on them can be time-consuming, independent practices often find it difficult to maintain staff while being cost-effective. Any practice will suffer from high personnel turnover, leaving the billing department particularly vulnerable. The revenue cycle, on the other hand, will not run properly without up-to-date and constant staffing. If you’re having trouble finding and keeping the right billing employees, outsourcing might be the way to go.

3. Services rendered without payment and late payments

Payment problems can cause the revenue cycle to wind down quickly. Medical billing has evolved into a complex science, and most practices deal with multiple payers regularly, making it easier for unpaid bills to slip through the cracks. An outsourced billing system can help by taking care of the time-consuming and inconvenient task of following up on outstanding claims and notifying patients about their costs.

4. A high number of rejected claims 

A rejected claim must be reviewed, altered, and sent again immediately by your billing or office staff. The procedure can take up a considerable amount of their time and decrease the insurer’s productivity, not to mention making a new claim submission a second time. As a result, your billing process is not as efficient as possible if you notice an increase in rejected claims. With the help of a medical billing specialist, you will get fewer rejections and better service.

5. The billing and coding process is not up-to-date.

You may be overlooking inefficiencies in your practice if your billing staff cannot keep up with changing rules and trends. Errors in medical billing are costly and all-too-common. A third-party medical billing specialist will retain a high level of competence while also providing you with efficiency reports, which will give you vital, real-time feedback.

Benefits of Outsourcing your Billing Process

Working with experienced medical billing specialists has many benefits. Here the top 3 benefits of outsourcing your medical billing process:

  • Healthy Revenue Cycle

Medical billing companies are experts in the field. Entrusting your revenue cycle management to renowned specialists will be the best choice you can make for your practice.

  • Committed and licensed professionals

You’ll need the assistance of a devoted and licensed staff, and you won’t necessarily need to go through the training and hiring process. The experts will advise you to keep track of all of your claims. Their primary focus will most likely be on maintaining and improving the status of one’s practice.

  • Maintaining regulatory compliance

Medical billing companies are always up-to-date in changes in regulatory compliance and coding procedures. 

  • Save money

You can save a ton by outsourcing because you won’t have to spend as much money on overhead costs, hardware, and software. Management software can cost up to $200 per month per physician, and it isn’t inexpensive. Those concerns do not present once you have decided to outsource maintenance, and the cost of the equipment appears to be around $500.

  • More time with patients

Who doesn’t want more time and energy to devote to their patients? When you outsource medical billing services, you free up time and resources to focus on your key strengths, such as healthcare. Once your medical billing professionals take care of your billing and insurance processing, you’ll have hours on your hands.

Tap Into Our Expertise

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding services. 

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How to Achieve Clean Claims at First Submission July 1, 2021


What does a clean claim mean?

A clean claim is “free of any errors.” It is critical to submitting these the first time to ensure a smooth procedure. You can determine your clean claim percentage by the average rate of paid claims on the first submission. It’s best to keep this percentage high when running a lucrative surgery facility with limited resources and time constraints. So, how exactly can you secure a high percentage of clean claims while also establishing a consistent process? Here are seven steps that will help ensure clean claims submissions rate over 95%:

1) Be accurate and timely on patient information

Always ensure that patient information on claims is accurate and up to date. Patient demographic information, policy information, and medical information are all things to double-check. Detailed and up-date documentation allows your coders to give the most relevant procedure and diagnostic code(s) to support your claims. It will enable your practice to receive reimbursement for the service on time. Not only should the particular diagnosis and data about the surgery or treatment be included, but so should the patient’s medical history.

2) Verify patient eligibility as soon as possible

Providing patient eligibility verification at least two days before the DOS (Date of Service) will result in more accurate claim submission and fewer claim rejections. This eligibility verification approach also aids healthcare practices in maintaining a healthy cash flow by reducing write-offs and improving patient care. You must check all co-pays, deductibles, policy effective dates, in-network/out-of-network benefits, and other requirements during this step.

3)  Perform quality checks 

In the medical billing process, quality checks are critical in ensuring the submission of clean claims. Before submitting a claim, check it for demographic, coding, and submission issues. You need to double-check demographic inaccuracies, medical coding problems, and errors that arise throughout the submission process. Establish a system that gathers pre-authorization data on the front end and allows your billing staff to correctly measure denials for “no-authorization” so that the physician receives fast feedback. 

4) Submit prior authorization at least five days before DOS

To minimize prior authorization-related denials, submit it at least five days before the DOS. Use the best system to capture pre-authorization information on the front end accurately and allow your billing team to track “no-authorization” denials in real-time. It guarantees that the healthcare provider receives prompt input. The type of operation, which procedures require prior authorization, and whether the patient plan covers the treatment are all items that you must verify in this phase.

5) Know carrier-specific coding guidelines  

Claims may be rejected if their program doesn’t recognize a modifier. As a result, it’s essential to know what payers will and won’t cover. Using the correct modifier and adding the modifier to the correct method is among the details you should double-check.

Verify CPT and ICD compatibility, as well as the submission mechanism (paper or electronic). To ensure coding compatibility, create carrier-specific Local Coverage Determination (LCD) rules. Medical practices could also automate the claims cleaning process by developing rules engine software systems or outsourcing. You must know the answers to the following questions: 

  • What modifiers are accepted by the payers? 
  • Should you use a –50 modifier or a mixture of –RT and –LT for a bilateral procedure? 

6) Be up-to-date on new medical coding regulations

Some of the most significant difficulties affecting medical reimbursements are insurance claim denials and claim rejections. Medical coding guidelines and standards are also too complicated for healthcare providers to keep up with.

Outsourcing the claim submission process to the best medical billing firms can keep you up to date on all medical coding changes and ensure that your claims are accurately classified before submission. Claim denials are frequently the result of faulty coding or late claims filing. Claim scrubbing, in this case, swiftly detects and corrects coding problems before submission.

Healthcare practices can also leverage the automation process known as electronic claim submission to handle claims faster by installing the best medical billing software. This stage requires the verification of ICD and CPT compatibility and the kind of submission mechanism (paper-based or electronic claim filing) to ensure coding compliance.

7) Develop an effective denials management review process.

Most doctors are eager for documentation feedback, especially if their work is causing denials and hurting the practice’s bottom line. You can minimize clinical documentation difficulties by holding regular in-service events that keep physicians up to date on payer changes or new documentation needs.

Identifying all payer requirements in detail, from documentation and pre-authorization to allowable claims and proper formatting, and then applying that information to build a clean claims submission process can mean the difference between quick payments and late payments, or even non-payment some cases.

Tap Into Our Expertise

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

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Key to Successful Billing Oral Sleep Appliances to Medical Insurance June 2, 2021

Oral Sleep Appliances

As more dentists move into procedures to aid sleep, questions about how to bill oral appliances to medical insurance are becoming more prevalent. Oral appliances for obstructive sleep apnea (OSA) have no specific dental codes, and it’s almost unheard of for dental plans to pay for these products. However, medical insurers often reimburse them. Here are some effective tips for dental practices in billing medical insurance. 

OSA Billing for High Deductibles and Policy Limitations

It is between the patient and their insurance provider if the patient has a high deductible. For certain patients, having the oral appliance add to their deductible is also a plus. If the health company has a continuous positive airway pressure therapy (CPAP) clause or a Policy Limitation, an oral appliance case would be quickly disqualified from billing to medical insurance.

Policy Limitations

Other insurance companies only cover OSA appliance therapy every three years. So, if a patient had treatment and the insurer paid for it a year ago, the insurance would not pay for another oral appliance treatment until the time requirement is met. In this scenario, the patient will have to wait for their appliance or pay cash. If they don’t want to wait for the insurance time limit, they can use financing like CareCredit to get the appliance now.

Your dental office is not responsible for the coverage provided by the patient’s medical policy. It is your duty to manage the patient and assist them in improving their general health and quality of life. Begin billing medical insurance as a service you offer to your patients in order to reduce their patient section.

CPAP Requirements

If the patient’s medical insurance includes the use of a CPAP, the patient must use it for at least 30 days before exploring other options. This treatment is much more difficult, requiring the patient to jump through additional hurdles.

The Key Is Proper Documentation 

Proper and accurate documentation is crucial to successfully bill medical insurance for OSA. The minimum requirements are as follows:

  1. Sleep test results

A copy of the sleep test is a necessary part of your documentation.  A polysomnogram (PSG) or a home sleep test (HST) are two types of sleep tests. Some insurance companies have limitations on the types of tests they would cover. For instance, before Medicare can pay for PSG, it now requires that home sleep tests be used first. A number of sleep test machines are also available.

Some diagnostic devices are not FDA cleared. For this reason, a few payers refuse to accept them as diagnostics. As a guideline, you can use the same sleep test findings that the board-certified sleep specialist used to interpret them. As a consequence, the findings of your sleep test will fit the perception. To be eligible for treatment, certain payers recommend that a patient have a certain AHI. As a consequence, it’s important that the patient’s AHI be clearly stated in your sleep test reports. These will be repeated in the clinical notes, which we will go through in more detail later.

  1. Diagnosis from a board-certified sleep specialist

To cure sleep apnea, a patient must first be diagnosed. Only a board-certified sleep specialist may make this diagnosis. The sleep specialist will score the outcomes of the sleep test to decide the seriousness of the patient’s apnea.

It makes no difference if the sleep test was conducted in a lab or at home. An interpretation is a term for the scoring and diagnosis process. The board-certified sleep specialist interprets the results, confirms the diagnosis, and then documents the extent of the patient’s sleep apnea, as well as treatment guidelines. Diagnoses never actually expire, but only a few insurance providers have a time limit or expiration date from the date of interpretation, as long as it is before the treatment.

  1. The dentist’s clinical chart notes

The Subjective, Objective, Assessment, and Plan (SOAP) notes can be a source of anxiety or irritation in offices. In a SOAP note, you’re describing the patient’s symptoms, the diagnostic details you’ve gathered (which would include the sleep test as well as the severity interpretation), and the treatment recommendation you’ve made. You’ll also make notes about the patient’s comfort, updating home instructions, and the delivered titration position of the appliance.

In general, dentists perform intra- and extra-oral exams as part of their sleep appliance assessment. You want to make sure a patient is a successful candidate before treating them. Prior to care, you should perform a comprehensive examination of the jaw, including a range of motion and muscle palpation, and ensure that any jaw or tooth conditions your patient has been reported. A patient might complain after six months that your oral appliance has harmed their jaw joint or teeth. You would be able to prove that the patient had certain previous problems by having good documentation.

  1. CPAP affidavit

Not all payers require a CPAP affidavit, but enough of them do that we recommend you collect one on every patient. This affidavit does not prevent them from later getting treated with a CPAP machine. The affidavit simply states that they have been given both treatment options, and they are choosing the oral appliance for whatever reason they give.  They will sign the affidavit and include any detail about why they feel a CPAP wouldn’t work for them. Again, reiterate this to your patient, this does not prevent them from getting a CPAP at a later date. It simply states they choose the oral appliance at this time.

  1. Presenting Medical Billing To The Patient

Now you know exactly what documentation you’ll need to bill an oral appliance to medical insurers. From here, you’ll need a copy of the patient’s medical insurance card, as well as full benefits, to check to see if the patient is covered.

You’ll learn if they have a remaining deductible to meet and if they have any plan exclusions during the verification of benefits (VOB). if they have a history of using continuous positive airway pressure (CPAP) or if there are any other explanations why the device might not be covered. You won’t know the allowable at this stage since they don’t release a fee schedule unless you’re a participating provider.

Don’t let possible roadblocks stand in the way while you learn more about the method of billing medical insurance for oral appliances. Don’t be afraid to give medical billing to your patients as a payment option. Keep in mind that the ultimate aim is to lower the patient portion while increasing case acceptance.

Tap Into Our Expertise

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing. Let us help you during these dire times.

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Effective Coding Habits for Sleep Medicine June 2, 2021

Coding Habits for Sleep Medicine

Sleep medicine is a growing field that is very daunting to coders and physicians as it’s a subspecialty of neurology. It comes with highly complex technicalities in the guidelines and procedure code descriptions. Fortunately, code selection is simple when codes are grouped and compared by elements. Doctors, medical providers, and medical coders can be uncertain of how to code sleep studies and other services for patients with sleep disorders. This article will outline effective coding habits for sleep medicine practices to ensure the best reimbursement possible while providing accurate documentation in patient records. 

Different Types of Code Sets for Sleep Medicine.

The CPT® code range 95803-95783, as well as the HCPCS Level II code range G0398-G0399, comprise sleep medicine procedure codes. Miscellaneous sleep diagnostic testing, home sleep study tests, sleep studies, and polysomnography are the different types of code sets.

Miscellaneous Sleep Diagnostic Testing Codes

Two different types of sleep diagnostic tests can be used.

  • 1st Test 

95805  –   Multiple sleep latency or wakefulness monitoring, recording, examination, and interpretation of physiological sleep measurements during multiple trials are used to determine sleepiness.

Multiple sleep latency monitoring consists of four or five brief naps arranged a few hours apart in the office environment. During these nap sessions, the patient’s brain waves, muscle function, and eye movements are all tracked and documented. This information can be used to identify narcolepsy and prolonged daytime sleepiness, as well as evaluate the effectiveness of breathing disorder therapies. Modifier 52 Reduced services should be added if there are less than four nap opportunities reported.

  • 2nd Test

95803  – Testing, documenting, analyzing, interpreting, and reporting on actigraphy (minimum of 72 hours to 14 consecutive days of recording)

Patients should be given an actigraph device to put on their wrist in the home setting for this test. Over three to 14 days, the actigraph device records sleep and movement. When the unit is returned to the provider’s office, the data can be accessed to a computer and analyzed using advanced software to aid in the evaluation and monitoring of sleep disturbances including circadian rhythm disorders and sleep-disordered breathing.

Home Sleep Studies Codes

Since they are conducted at the patient’s home, home sleep studies are less expensive than in-office/hospital sleep studies. Overnight, a piece of special equipment monitors breathing, oxygen levels, and breathing effort. To diagnose sleep disorders, this data is extracted from the device and interpreted using specialized software.

There are three HCPCS Level II codes for documenting home sleep study studies, with the number of channels used during recording being the distinguishing factor:

  1. G0400

Unattended home sleep test (HST) with type IV portable monitor; minimum of three channels Both in-office/hospital sleep studies are coded in the CPT® code range 95806-95783. These are either sleep studies or specialized polysomnography.

  1. G0399

Unattended home sleep test (HST) with type III portable monitor; at least four channels: two respiratory movement/airflow, one ECG/heart rate, and one oxygen saturation.

  1. G0398

Unattended home sleep study test (HST) with type II portable monitor; at least 7 channels: EEG, EOG, ECG/heart rate, EMG, airflow, respiratory effort, and oxygen saturation

Sleep Studies (Non-polysomnographic) Codes

Sleep studies that are not polysomnographic can be attended to or left unattended. An attended, non-polysomnographic sleep study has only one code which is:

  • 95807

A technologist is present during the sleep analysis, which includes a simultaneous recording of breathing, respiratory effort, ECG or heart rate, and oxygen saturation.

The code is chosen based on the parameters used during the recording. Modifier 52 should be included if the total recording time is less than six hours. Three CPT codes exist to report unattended, non-polysomnographic sleep studies which are:

  • 95806

Simultaneous monitoring of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) during an unattended sleep study.

  • 95801

Simultaneous monitoring of minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) during an unattended sleep study.

  • 95800

Simultaneous monitoring of minimum heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time during an unattended sleep study.

Polysomnography Codes

Polysomnography is a form of sleep study that records brain waves, blood oxygen levels, heart rate, breathing, eye movements, and leg movements in an office or hospital setting. It may be used for diagnostic, therapeutic, or “split” purposes.

Diagnostic Polysomnography

To disclose strictly diagnostic polysomnography, use one of three codes:

  1. 95782 Sleep staging with four or five additional sleep parameters for children under the age of six, with a technologist present.
  1. 95808  Sleep staging with 1-3 additional sleep parameters for anyone of any age, supervised by a technologist
  1. 95810 Sleep staging with four or five additional sleep parameters for children aged six and up, with a technologist present.

The number of parameters used during recording and, in the case of 95810 and 95782, the patient’s age are used to determine the code. If the total recording time is less than six hours, add modifiers 52 to 95808 and 95810. If the cumulative recording time is less than seven hours, add modifier 52 to 95782.

Therapeutic and Split Polysomnography Codes

For patients with a history of sleep apnea, therapeutic polysomnography is used. The test aims to figure out what titration levels of therapies like continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) are adequate for treating the patient’s apnea. On the other hand, split polysomnography is a part of the research that is diagnostic. If the patient is discovered to have sleep apnea during recording, CPAP or BiPAP titration is started to assess therapeutic levels for the patient.

Therapeutic and split polysomnography are reported using two codes, which are chosen solely based on the patient’s age:

95811   Sleep staging with 4 or more extra sleep parameters at the age of 6 years or older, with the initiation of continuous positive airway pressure therapy or bi-level ventilation under the supervision of a technologist.

If the total recording time is less than six hours, add modifier 52.

95783    Sleep staging with four or more additional sleep criteria, as well as the implementation of continuous positive airway pressure therapy or bi-level ventilation, with a technologist present. If the cumulative recording time is less than seven hours, add modifier 52.

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At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

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Podiatry Billing Tips to Boost Reimbursement April 30, 2021

Podiatry coding and billing are challenging because treatments and procedures involving the foot are unique due to medical necessity requirements and restrictions on certain conditions. To get the most out of your reimbursement, you need to have complete documentation. Also, you need to know insurance coverage and complicated codes. Here are five tips for boosting your reimbursement:

Appeal for denials

When the insurer has decided not to cover a claim, a claim may be denied, and it will not be paid. Check the explanation of benefits (EOB) sent by the health insurance company to know the exact reason for denial before appealing. Address the reason for denial when appealing. Check the carrier’s written policy for exceptions, as well. Following the submission of the appeal, the practice staff can either contact the insurance provider to confirm receipt of the appeal, or check the submission online and follow up within 30 days. Following appeal submission, the practice staff can either contact the insurance provider to confirm receipt of the appeal or check it online and follow up in 30 days.

Verify insurance properly

The method of reviewing the patient’s plan with the insurance provider and confirming the eligibility of his or her insurance claims is known as health insurance verification. In podiatry billing, the first step is to verify insurance coverage. Until beginning care, check and validate the patient’s insurance eligibility and benefits to minimize denials and improve cash flow. Patients must be aware of their payment obligations at the time of appointment scheduling, which aids in their decision-making and helps the practice prevent last-minute cancellations due to ineligibility.

Verify all information, including the patient’s name, date of birth, address, insurance ID number, deductible, and insurance phone number, in addition to confirming the patient’s insurance coverage.

3. Claims Involving Complicating Conditions

On the first submission of a claim for podiatry claims involving complicated conditions, coders must document the name of the physician who diagnosed the condition and the approximate date the beneficiary was last seen by the indicated physician (when active care is required). Carefully record the diagnosis and the severity of the diagnosis.

4.  Accurate codes matter

Coding in the field of podiatry is quite complex. In medical claims, you need to use the most suitable code to record podiatry procedures. It is vital to use the correct CPT, HCPCS, and ICD-10 codes for all medical statements, whether you link it to pressure ulcers, illnesses, fractures, active wound care management, or debridement.

Use the following medical codes in billing for foot care:


  • 11055 – Skin lesion Trimming
  • 11056 – Skin lesion Trimming (two to four)
  • 11057 – Skin lesion Trimming (more than four)
  • 11719 – Non-dystrophic nails trim
  • 11720 – Nail Debridement (till 5)
  • 11721 – Debridement (more than six)
  • 11730 – Partial or complete nail plate avulsion
  • 11732 – Additional partial or complete nail plate avulsion


  • G0127 – Dystrophic nails trimming, any number
  • G0245 – Initial physician assessment and treatment of a diabetic patient with diabetic sensory neuropathy resulting in lops, which may include: (1) a lops diagnosis, (2) a patient history, and (3) a physical examination that includes at least the following components: (a) visual examination of the forefoot, hindfoot, and toe web spaces; (b) assessment of a protective sensation; (c) assessment of foot structure and biomechanics; (d) assessment of vascular status and skin integrity; and (e) assessment and footwear recommendation; and (4) patient education


  • B35.3 – Tineapedis
  • B07.0 – Plantar wart
  • E11.621 – Type 2 diabetes mellitus with foot ulcer
  • E13.4 – Other specified diabetes mellitus with neurological complications
  • S83.9 – Sprain of unspecified site of knee
  • S93.3 – Subluxation and dislocation of the foot

Coders must keep up with changing coding standards and guidelines, as any mistakes in codes submitted will result in claim rejection or payment delays.

5. Choose the right modifier.

It would be necessary to apply appropriate modifiers to a claim form that contains such procedure codes to distinguish between the codes that were paid on the date of operation. Class A (Q7), Class B (Q8), and Class C (Q9) results are denoted by “Q” Modifiers (Q7, Q8, and Q9) in podiatry.

The following are some of the most common modifiers used in podiatry billing:

  • GX Notice of liability issued, voluntary under payer policy
  • GZ Item or service expected to be denied as not reasonable and necessary
  • Q7 One Class A finding
  • Q8 Two Class B findings
  • Q9 One class B and 2 class C findings

You can modify the procedure codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127 with the “Q” modifier. When submitting claims with the Q7, Q8, or Q9 modifiers, indicate the findings related to the patient’s condition.

  • Class A Findings: Non-traumatic amputation of the foot or integral skeletal portion thereof.
  • Class B Findings: Absent posterior tibial pulse, advanced trophic changes, and absent dorsalis pedis pulse.
  • Class C Findings: Claudication, temperature changes, edema, paresthesias, and burning.

The use of correct modifiers often aids in the collections, reducing errors, and avoiding revenue decline. When hiring an outsourced podiatry billing company to handle such paperwork, make sure they specialize in podiatry and experts in the medical billing industry.

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At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing. Save your money by outsourcing to a professional billing service.

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Podiatry Coding Tips to Improve Your Bottom Line April 16, 2021

Doctor looking at Podiatry Coding

People who have been dealing with medical coding for a long time know the frustrations of its complexity. A simple coding error can lead to increased claim rejection rates and decreased reimbursement rates. Doctors in Podiatric Medicine are not strangers to the intricacies of coding. They have to strictly use the appropriate modifiers, protocol codes, and patient diagnosis codes. Here are several tips that can help you avoid podiatry coding mistakes:

Review podiatry coding updates

The healthcare industry has undergone significant transformation in recent years, and podiatry is no exemption. Every year, there are coding improvements for all specialties, and coders must be aware of these changes to receive adequate compensation from payers. Furthermore, it has been noted that the podiatry coding standards have changed, and practices that are ignorant of these changes incur losses.

The Medicare Physician Fee Schedule requires billing and coding workers to be mindful of various fees and regulatory updates. Knowing these rules will help practices minimize the amount of paperwork they have to deal with when it comes to Medicare billing.

Use the correct modifiers

Correct modifiers allow for accurate payment of all podiatry procedures, including bunionectomy procedures. We highly recommend checking Correct Coding Initiative (CCI) edits, which can be found on the CMS website or in podiatry-related websites like the American Podiatric Medical Association (APMA) Coding Information Center.

When coding Evaluation and Management (E/M) modifiers, coders are often confused. The -24, -25 and -57 modifiers are three basic assessment and management (E/M) modifiers. For E/M programs, these modifiers must be used. Assert declination would occur if these modifiers are used for other utilities.

Specific E/M codes are paid rather than being combined for a single payment. If the E/M service is “important and separately identifiable” from the treatment a podiatrist is doing on the same day, use modifier 25. If medical attention was not needed, do not use this modifier.

 Be careful in “Unbundling” 

Unbundling, also known as fragmentation. refers to reducing the billing and base process of each component that can result in a higher payment than billing the entire comprehensive code. However,  take note that unbundling for the sake of obtaining a higher payment can be considered fraudulent billing.

Use the appropriate modifier to unbundle services properly

There are many legally unbundled cases. When two codes are performed at two different anatomical locations, they can be bundled together but are paid separately.

For example, billing for an arthroplasty code and a bunion code. If you’re not using any modifiers, group them. When performing these procedures on a lesser digit, using the right modifier would cause a bunion procedure as well as an arthroplasty procedure to be properly compensated. Another example is paying for several “single” procedures where there is a code for the same treatment that is classified as “multiple.”

Double-check for any downcoding

Another common blunder is downcoding. Upcoding entails paying for a higher quality of operation or different services than would normally be necessary. On the other hand, downcoding doesn’t have any useful purpose.

The idea is that if you obtain and bill a lower-level code (usually an E/M service), you’ll “go under the radar,” lowering your chances of being audited by insurance agencies. An insurance provider may be worried that, although you are costing the insurance company less money, your billing can still be considered fraudulent.

You could be cheating yourself out of legal money if you downcode. Changes in relative value units (RVUs), sequestration, and fines for not engaging in the Merit-Based Incentive Payment System (MIPS)/Medicare Access and CHIP Reauthorization Act (MACRA) scheme all appear to be eroding the reimbursements. Downcoding means you’re losing more money. Get paid for what you do and keep a copy of the chart note on hand to support your billing.

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Tips to Improve Profitability in Pain Management Practices March 31, 2021

Pain management is a specialty in flux. Not only are more chronic pain sufferers seeking out treatment, but the release of a recent Center for Disease Control report, which found more people die from prescription drug overdoses than heroin and cocaine combined, has created a backlash over opioid prescriptions and a call for alternative treatments. Here are 8 tips for a pain management center to increase profitability:

Increase Patient Referrals

Increasing the number of patients in a pain management practice is the first step toward increased profitability. Most patients are referred to a pain management practice by a primary care provider, so increasing referrals by primary care providers is one way to raise the patient volume. To generate more patients, you need to take a look at your clinical model and your relationship with multiple primary care providers. Conduct assessments and provide changes to your given services to create a unique story that will encourage referring physicians to frequently send their patients to you with a pain condition.  

Hire a physician liaison. 

 A physician liaison plays an important role in managing and building relationships with primary care providers for your practice. Someone must actively inform and interact with primary care doctors that the services they need are available in your practice. They can potentially get you 50-75 new referrals each month. A four-year degree in an allied health area such as functional or behavioral health is required for this role. They should have a friendly demeanor and be at ease approaching and engaging with people. 

Communicate with primary care providers

To ensure a consistent and continued patient referral flow, maintaining constant communication with primary care doctors is crucial. It includes providing timely reports and reminders to prescribing doctors, primary providers, and specialists. Associations with prescribing doctors are viewed as collaborations. They are familiar with their patients’ histories and needs, while pain management practices have insight, support, and service in an environment where many primary care doctors lack knowledge and experience.

Offer cutting-edge treatments. 

Primary care providers would refer more patients to you if you offer all pain management procedures like radiofrequency ablation and spinal cord stimulator implants. According to the co-founder of Universal Pain Management, Francis Riegler, MD, the spinal cord stimulator devices are only available to only three medical device manufacturers and the market is extremely competitive. Practices should inquire with other vendors around their vicinity to get the best price. 

Incorporate anesthesia.

Incorporating anesthesia into your procedures can increase your revenue than with conscious sedation or no sedation. However, it should always be done with medical necessity. Base it on a patient-by-patient case and adhere to the strict protocols on regulatory requirements. 

Maximize the use of space. 

Use every inch of space of your practice wisely. You can convert your large conference room into two additional procedure rooms. You can also transfer your follow-up consultations to telehealth, too. 

Automate tasks

You can set up an automated system for your scheduling, inquiries, refill requests, and more. You’d be able to reduce no-shows too with patient portals and patient apps where your patients can schedule or cancel their appointments 24/7. A patient self-service check-in kiosk will lessen the administrative burden of your staff by expediting the check-in processes. 

Always Double-check

Having complete and correct patient information and correct coding are critical to profitability. Train your staff to always double-check all data to ensure proper reimbursement. Also, take time to evaluate contracts with payors to make sure the practice received the agreed-upon reimbursement for procedures and treatments. 

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Measuring Pain Practice Accounts Receivable For Better Billing Performance March 19, 2021

pain practice accounts

How to Measure Accounts Receivable

You can use the following methods in measuring the quality of the accounts receivables of your Pain Management Practice:

1. Day’s Sales Outstanding (DSO)

The day’s sales outstanding (DSO) ratio is a simple way to assess the quality of accounts receivables. It’s determined by dividing average accounts receivables by revenue and multiplying by 365. The DSO ratio indicates how long it takes practice to turn its receivables into cash on average. It is often easier to use than the accounts receivable-to-sales ratio and the accounts receivable turnover ratio because it is in an intuitive unit of calculation (days).

2. Accounts Receivable Turnover Ratio

Analyzing a practice’s accounts receivables turnover ratio is another way to assess the quality of its receivables. It’s calculated by dividing a period’s sales by the average accounts receivables balance during that period.

The accounts receivable turnover ratio is a metric that measures how quickly a company can convert its receivables into cash. A high ratio usually indicates that a practice’s accounts receivables are of higher quality, as it reveals that receivables are being converted to cash more quickly.

Because a company can receive cash from its accounts receivables faster, a shorter DSO indicates that the accounts receivables quality is higher. While a high DSO ratio (more than 90 days) can indicate that receivables will become “stale” and may not be collected, it also indicates the poor quality of practice earnings.

3. Accounts Receivable-to-Sales Ratio

The accounts receivable-to-sales ratio is a simple way to assess the quality of your receivables. The ratio is calculated by dividing accounts receivable at a given point in time by sales over time. It shows what percentage of a practice’s sales are still owed to them. With a few tweaks, it’s the inverse of the accounts receivable turnover ratio. It’s the exact opposite of the accounts receivable turnover ratio, but with a few tweaks.

Since it is not guaranteed that all accounts receivable can be collected, a high accounts receivable-to-sales ratio may indicate a riskier practice with a poor quality of accounts receivable.

What Period Should be Analyzed for the Formulas?

While opinions differ on this, we think it is prudent to use a period that is appropriate for your specialty and practice and then study this measure over time to determine its pattern for your work. We suggest a time limit of the last 90 days. Divide your  Current A/R Balance with the quotient of Total Billed Charges over the past 90 days. 

How to Determine if the Result is Good or Bad?

The lower the A/R Days, the better it is. This means you’ll have fewer billed payments awaiting billing and adjudication. The A/R Days benchmark varies by specialty and can be influenced by practice-specific factors like treatment mix, payer mix, and internal policies. Consider the following scenarios:

Insurance providers can take longer to assess and pay claims for a specialty practice that conducts complex procedures with high average payout rates, such as Interventional Pain, resulting in a longer average period to adjudicate and pay the practice’s claims and a higher A/R Days measure.

Since pain practices are subject to denials due to inadequate prior authorization, medical necessity, or other obstacles, these factors cause claims adjudication delays, resulting in higher average A/R Days. Pain practices need to be aggressive about collecting time-of-service payments from patients at the front desk because these balances can take time to collect which can cause A/R Days to rise.

What other Factors Need to be Considered in Evaluating A/R Days?

The A/R balance of practice often includes both debit and credit balances, which means that although the majority of the balances are debited to be paid to the practice, others are credits showing possible overpayments that may be refunded. Significant credit balances in the total A/R balance will outweigh large debit balances, resulting in a deceptive A/R Days metric. Specialty practices that have higher than average credit balances can take this into account when calculating A/R Days. The argument is that when determining whether your A/R day’s number is positive or bad, you must understand the content and essence of the statements that make up your A/R Balances.

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Changes in CPT Codes in 2021 March 1, 2021

cpt codes for 2021

The 2021 Current Procedural Terminology (CPT®) code set was released earlier last fall by the American Medical Association (AMA). There are 329 editorial changes, including 206 new codes, 54 deletions, 69 revisions, along with the “first massive revamp of office codes and guidelines and other outpatient assessment and management (E/M) services in more than 25 years.” Changes became effective earlier this year, last January 1, 2021. Here are some highlights about the changes that you should know:

E/M Services

The office and outpatient E/M Services have the biggest changes. According to the AMA, these modifications include:

  • History and physical exams are no longer an element for code selection.
  • Letting physicians choose the best patient care by permitting code level selection according to the medical decision-making (MDM) or total time.
  • Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

The new CPT standards retain 5 coding levels for established patients and decrease the number of levels to 4 for new patients’ office/outpatient E/M visits. The AMA RVS Update Committee (RUC) also amended the values for the office/outpatient E/M visit codes, which will raise Medicare and possibly other payers’ payments for these services.

According to AMA President Susan R. Bailey, M.D., health care organizations need to understand and be ready to use the revisions to get the full benefit of the burden relief from the E/M office visit changes. She also adds that the AMA will help physicians and health care organizations with the transition and offers resources to understand the operational, infrastructural, and administrative workflow adjustments that will result from the pending transition.

The 2021 code set also represents the continuing pandemic of COVID-19 that devastated the globe in 2020. In the 2021 CPT code set, the following SARS-CoV-2 based CPT codes were accepted and officially issued, although some have been in use since earlier this year.

  • 87635: Added to report infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique. (Effective March 13, 2020.)
  • 86318: Revised to report immunoassay for infectious agent antibody(ies) and to be a parent to 86328. (Effective April 10, 2020.)
  • 86328: Added to report single-step antibody testing for severe acute respiratory syndrome coronavirus 2. (Effective April 10, 2020.)
  • 86769: Added as a child code to report multiple-step antibody testing for severe acute respiratory syndrome coronavirus 2. (Effective April 10, 2020.)
  • 0202U: Added to report the BioFire® Respiratory Panel 2.1 (RP2.1) test. (Effective May 20, 2020.)
  • 87426: Added to report infectious agent antigen detection by immunoassay technique of SARS-CoV and SARS-CoV-2.
    • PLA codes 0223U and 0224U: Added for detection of SARS-CoV-2.
  • 86408-86409: Added for reporting coronavirus 2 (SARS-CoV-2) neutralizing antibody screen and titer. (Effective Aug. 10, 2020.)
    • PLA codes 0225U and 0226U: Added for detection of SARS-CoV-2. (Effective Aug. 10, 2020.)
  • 99072: Added for the additional supplies and clinical staff time required to mitigate transmission of respiratory infectious disease while providing evaluation, treatment, or procedural services during a public health emergency, as defined by law. 
  • 86413: Added for reporting quantitative antibody detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
  • 87636: Added for reporting combined respiratory virus multiplex testing for either SARS-CoV-2 with Influenza A&B.
    • PLA codes 0240U and 0241U: Added for detection of SARS-CoV-2, Influenza A, and Influenza B.
  • 87637: Added for reporting combined respiratory virus multiplex testing for either SARS-CoV-2 with Influenza A&B and RSV.
    • PLA code 0241U: Added for detection of RSV.
  • 87811: Added for antigen detection of SARS-CoV-2 by direct optical (i.e., visual) observation.  
  • 87301, 87802, and their subsidiary codes: Revised immunology guidelines.
  • Accepted addition of code 87428 for reporting multiplex viral pathogen panel using antigen immunoassay technique for SARS-CoV-2 testing along with influenza A and influenza B.
  • 91300, 91301: Added to report Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccines.
    • 0001A, 0002A, 0011A, 0012A: Added to report the immunization administration of these vaccines

Prolonged Services

A few new codes, including direct and indirect medical interaction given in varied settings beyond normal assessment and management services, have been applied to the bill for prolonged services.

  • Direct Patient Contact – Outpatient

Codes 99354-99357 are utilized where long-term treatment requiring direct patient interaction is given by a physician or other trained healthcare provider and is provided in either the inpatient, observation or outpatient area (not including office or other outpatient E/M services) beyond the normal service.

99354-99355 is used to document on a given date the average amount of face-to-face time spent by a doctor or other trained healthcare provider delivering extended outpatient service. 

The first hour of prolonged service is recorded using 99354. And if the time spent is not constant, it can be used only once per date, per venue. If prolonged service is given for more than one hour, 99355 is used to record every additional 30 minutes after the first hour.

Prolonged service with a cumulative length of fewer than 30 minutes on a specified date is not recorded separately. Prolonged service of fewer than 15 minutes after the first hour or less than 15 minutes after the last 30 minutes is often not separately recorded.

  • Direct Patient Contact – Inpatient

Codes 99356-99357 are used to document the cumulative amount of time spent in the hospital or nursing home by a physician or other trained health care provider offering prolonged treatment to a patient at the bedside and on the floor or unit of the patient.

The first hour of extended service is recorded using 99356. And if the time spent is not constant, it can be used only once per date, per venue. If extended service is given for more than one hour, 99357 is used to record every additional 30 minutes after the first hour.

Prolonged service with a cumulative length of fewer than 30 minutes on a specified date is not recorded separately. Furthermore, prolonged service of fewer than 15 minutes after the first hour or less than 15 minutes after the last 30 minutes is not separately recorded.

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