Resist the temptation to underbill: Here’s how
A recent study published in the Annals of Internal Medicine found that primary care physicians may be leaving a lot of money on the table—$210,000 annually—because they unintentionally fail to bill for various preventive and coordination services they actually provide. This includes chronic care management, transitional care management, smoking cessation counseling, and more. However, underbilling may be a more pervasive problem particularly when it comes to determining the medical decision making (MDM) that affects evaluation and management (E/M) levels.
Underbilling: Why it’s problematic for today’s medical practices
When there are chronic patterns of underbilling, medical practices don’t collect all of the reimbursement to which they’re entitled. Over time, this medical coding trend can lead to significant financial difficulties as operating costs begin to exceed revenue.
Underbilling can also be a violation of fraud and abuse rules and even establish false utilization patterns that could flag physicians as outliers and subsequent targets for payer investigations and/or audits. Underbilling can also affect the amount patients owe and how soon they meet their deductible. All of this affects the patient financial experience.
The good news is that medical practices can take proactive steps to identify potential areas of underbilling, audit claims, and provide education to avoid common medical coding mistakes.
Service categories to audit for potential underbilling
Following are four types of services physicians could unknowingly underbill and what they can do to ensure revenue integrity.
1. E/M services. To ensure accurate medical coding, physicians must fully understand the MDM portion of the E/M service they provide. What’s most important? Documenting a well-developed plan of care for each chronic condition, including stable chronic illnesses with sudden severe exacerbations. Physicians must also address and document any social determinants of health (SDOH) that affect the care plan and MDM. For example, SDOH could include problems related to education and literacy, employment and unemployment, physical environment, housing and economic circumstances, social environment, upbringing, psychosocial circumstances, and primary support group. It could also include occupational exposure to risk factors. Finally, if billing E/M services based on time, physicians must count all of the time they spend reviewing records and prior tests or consulting with other providers on the date of service. That’s because the time it takes to complete these tasks can potentially justify a higher-level E/M service.
2. Care coordination. Care coordination services include chronic care management, transitional care management, behavioral health integration, cognitive assessments with care planning, and more. In some cases, physicians may not even be aware that CPT codes exist for these services. For example, the study referenced above found that nearly a quarter of Medicare beneficiaries (22.5%) had a hospitalization eligible for transitional care management. Among them, about 43% were seen in primary care after discharge, but only 9% had a claim for transitional care management.
3. Preventive services. Examples include smoking cessation counseling, wellness visits, advance care planning, shared decision making for lung cancer screening, obesity counseling, depression screening, alcohol misuse counseling and screening, and more. The study published in the Annals of Internal Medicine found that nearly 9% of older adults smoke. Among them, nearly 61% reported receiving advice from a healthcare professional to quit smoking, but only 10% of the 9% had a claim for smoking cessation counseling. This pattern of underbilling suggests there may be significant untapped revenue opportunity.
4. Wound care coding. When physicians don’t accurately capture the size, quantity, location, and complexity of the lesion excision, they could underbill their services without even realizing it.
Looking ahead
Physicians who want to understand whether underbilling is a problem in their medical practice should ask these questions: How does your medical coding data compare to that of your peers? Do you perform above or below current benchmarks? Is it possible that you’re leaving money on the table? Are you underestimating the work you perform, is it a modifier issue, or is it something else entirely? You could also work with a medical coding consultant or partner with your outsource coding vendor to better understand problems and implement best practice recommendations. Learn how edgeMED can help at www.edgemed.com and be sure to visit the Healthy Snacks Blog for more expert insights, best practices and industry trends.
