Increase reimbursement, reduce take-backs with these 4 steps

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Ray Painter, MD

Mark Painter

In general, urologists are doing quite well financially. The laws of supply and demand have finally caught up with the profession, as we had predicted years ago. However, you could do better. How can urologists increase their income? In this article, we share with you steps you can take to increase your income, and, at the same time, significantly decrease the chances of take-backs.

In previous articles and seminars, we have discussed the “Wheel of Fortune,” a graphic that depicts the 20 steps performed between the time a patient makes an appointment and the final money is deposited in the bank. If all steps are performed accurately, you are paid the maximum amount you should be paid, legally and ethically, according to your contracts. If the first 15 steps are performed accurately and in a timely fashion, you are paid within the first 2 weeks after the service is provided.

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Of the 20 steps in the Wheel of Fortune, four are the primary focus of the urologist or advanced practice provider and should be performed by the clinician: documentation, identification of all services provided, determination of the circumstances/reason all the procedures are performed, and accurate communication to your billing staff in a timely manner. If you follow our instructions, the extra time it takes to do your job when you are in the process is minimal, and the pay-off in the long run is better reimbursement, fewer requests for documentation changes, and a total savings of time due to fewer questions from billing staff.

Documentation. Document clearly what services were provided and why. Update the patient record with each visit. The documentation should clearly support all services performed and note any special circumstances during the service that required additional effort. If extra work was required, the note should support the clinical reasons for the efforts required.

If more than one service was provided or more than one problem was addressed, the note will need to provide a clear picture of the patient’s condition, the circumstances for the visit, and service/procedures provided. Your documentation should allow any other provider to understand the care provided to the patient and the reasons the patient required each medical intervention.

Documentation should also stand alone or clearly reference other documents, tests, or images used in making your diagnosis(es) and treatment decisions. Spending a few extra minutes documenting clearly and accurately helps to ensure accurate initial coding, supports appeals and medical record requests, and protects from medicolegal issues. It is the foundation of the clinical practice and the revenue cycle management Wheel of Fortune.

Identification of all services provided. Identification should be made by checking each procedure on a short list or favorites list depending on your systems, which may include selecting a code-specific template or marking a superbill that you have prepared ahead of time. This task should take less than 15 seconds. Using a sample of 400-plus urologists, 80% of urology revenue is represented by 47 CPT codes and 40 ICD-10 codes. Your short list and your understanding of your high-volume/high-dollar services and procedures and common ICD-10 codes will allow you to make quick work of this.

The short list should be prepared as follows:

• Ask the billing staff to retrieve the 50 to 60 most common services performed and your top 40 ICD-10 codes by place of service. This list can then be shortened for each location (hospital, hospital #2, ambulatory surgery center, office, etc.)

• Plan a 1-hour (more or less) meeting with your billing staff initially and at the beginning of each year to review that list of services.

• Confirm that the codes being billed represent the services you have provided. (You may be shocked at some of the things you have billed.)

• Refine, review, and learn the codes on the lists and any special requirements for any codes.

• Determine whether this is going to be available to you on paper, electronically, via EMR, etc., for each place of service.

The final list should contain about 80% of all services you will provide. Do not sweat the small stuff or one-offs for this list. All you have to do is check off the services provided at each encounter.

Don’t reinvent the wheel; use the short list to identify your services each time you perform a surgery. For those few procedures that are not on the list, plan to seek assistance.

Next: Determination of the circumstances/reason all the procedures performedDetermination of the circumstances/reason all the procedures performed. Even though the reason for most of your procedures and services is routine medical practice, you need to document what services you provided and why you provided that service that day.

It’s sort of like taking your car to a mechanic. The car has multiple problems and is still under warranty. The mechanic’s job is to determine what’s covered by warranty and what can be charged extra.

Consider multiple procedures reported on the same date, for example. When you are paid for providing the primary procedure, the “global” payment for that procedure includes all related procedures and services for that date. The computer has been programmed not to pay you for any related procedure or service. If the secondary procedure was performed to facilitate or is a necessary part of the primary procedure, you should not ask to be paid.

However, if the procedure was unrelated, performed at a different encounter, performed on another organ, etc., then it should be paid and, in most cases, can’t be paid if the appropriate modifier is not attached. The problem lies in the fact that sometimes the secondary procedure is related to the primary procedure and other times it was performed for a different reason. At times, the appropriate modifier should be applied and additional payment requested; other times it should not.

Herein lies the problem. If you do not convey the reason the procedure was performed to your staff, they may misinterpret. A biller’s job is to collect money for the services that are billed. A good biller will determine if special reporting, such as a modifier, is required. The tools available and the time available to the biller are limited. If the biller cannot support a modifier or is not required to review documentation, you risk billing fraudulently or the biller will be required to contact you for clarification. Medicare is obsessed with not overpaying you for any service performed.

Once you understand these concepts, you will be able improve your communication, documentation, and your income. It will also cut down on time spent answering questions and improve the efficiency of the billing staff, allowing them to focus on the hard stuff.

Accurate communication to your billing staff in a timely manner. Using the short list as described above, you have identified services provided and should be able to quickly provide the information to your billing support team.

Delay in communication is another problem for most practices. Dumping charges or waiting weeks or months to submit charges increases errors, slows your revenue stream, and sidetracks your billing staff. Communicating with a short list on your high-volume routine work is easy and should be completed within 48 hours of providing a service.

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Next, you need to develop communication with your staff as to how you convey the circumstances for those services outside the norm. You could use emojis, shorthand, or different letters to convey different things. Or, if you’re knowledgeable, you could add the appropriate modifier when required. You can learn this by adding to your knowledge in increments with some additional time. You did not become a urologist overnight; build your knowledge by investing time in increments.

Remember, your part in the Wheel of Fortune is the foundation of the wheel, but it is not the only part of the process required. Billing is a team sport. Lean on your team. Ask for feedback. And get help where and when you need it.

In summary, you do not have to be a certified coder, take the time to look up specific codes, or become an expert on modifiers to provide the functions you need to provide as a member of the team. However, if you do your job and appropriately document, identify the services provided using the recommended shortcuts, determine the circumstances for each procedure, and communicate accurately to your billing staff, you will save yourself time, improve your take-home pay without working any harder, and significantly lower your risk of take-backs.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.