Month: July 2018

Revenue Cycle Management

Clear up EOB Confusion

Remember: An EOB is not a bill.

Working in the healthcare field, you know that acronyms are a part of your daily life. From the Health Insurance Portability and Accountability Act (HIPAA); to local coverage determinations (LCDs); to relative value units (RVUs) — as a coder, you are constantly bombarded by acronyms.

It’s common for one such acronym, explanation of benefits (EOB), to cause confusion among patients. Read on to learn more about EOBs, as well as remittance advice (RA).

Delve Into How EOBs Work

Insurance companies send EOBs to patients two to three weeks after their initial appointment.

“EOBs are insurers way of explaining their reimbursement, based on the CPT® codes and ICD-10 codes submitted,” says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey. “EOBs usually list the service provided was approved or not approved, the amount a provider charged, the amount approved by the insurer, the amount paid by the insurer, the amount you may be billed, then a code that indicates how the claim was paid, denied, or partially paid based on the patient’s policy. This is explained in detail on the EOB.”

Don’t miss: Although patients often mistake an EOB for a bill, an EOB is not a bill.

“Most patients do not understand EOBs or the definition of the acronym ‘explanation of benefits,’ which means what the insurer will pay based on your particular policy,” Brink says.

Check out this example from Brink: A participating provider charges $200 for a service. Medicare’s approved amount for this service is $160. Medicare pays 80 percent of $160-$128. The 20 percent difference, $32, is the patient’s responsibility to pay. If the patient has a Medigap insurance plan, then that $32 is usually paid by insurer depending on the insurance plan. The $40 difference from what the par provider charged and the Medicare approved amount must be written off by the par provider since it is part of the par contract with Medicare. Biller and coders must understand this and adjudicate the remittance advise, which is sent to the provider, correctly.

Note: An EOB is sent to the patient and an RA is sent to the provider. The patient needs to understand the EOB since he is responsible for the 20 percent.

Helpful tip: When asked how practices can help ease the confusion patients often have about EOBs, Brink says practices should explain to patients what the EOB will tell them and try to help them interpret it.

Practices could let their patients bring in EOBs and explain them. Practices could post this on their websites as a helpful service they provide, Brink adds.

Some practices offer education classes for patients to teach them about EOBs, and the patients like these classes, Brink says. “I see this in bigger practices who have the personnel to do this, for instance, education sessions, such as breakfast seminars.”

Practices Should Utilize RAs to Ensure Maximum Reimbursement

While an EOB is sent to the patient, a RA is sent to the provider who billed the service, according to Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

“Both types of statements provide an explanation of benefits, however,” Witt says. “The content of the RA and the EOB is nearly identical with the exception of a few minor items.”

Both RAs and EOBs contain the following information, according to Witt:

  • Information regarding the patient
  • The service provider
  • Any adjustments made to the claim
  • The type of procedure performed
  • The date the procedure was performed
  • The cost of the procedure
  • An explanation if the payment was denied

“Additional information regarding the patient’s benefits is often included as well, including the particulars of the plan, such as co-payments and deductibles,” Witt adds.

The major difference between RAs and EOBs is that an EOB contains a disclaimer stating the EOB is not a bill, according to Witt.

Example: For example, at the top of an EOB for Cigna, you will find the statement: “THIS IS NOT A BILL. Your health care professional may bill you directly for any amount you owe.”

Practices should utilize their RAs to streamline their processes.

“All billing staff should spend time studying the reasons cited for adjustments or denials from the RA they received,” Witt says. “Each RA message should be tracked to ensure that any patterns of inappropriate adjustments (incorrect use of a modifier, bundling issue, reduction for secondary procedure, etc.) or denials (code not covered, code bundled, demographics incorrect, not medically necessary, etc.) are addressed to ensure maximum reimbursement.”

Billers should also use RAs to compare what was paid to the published fee schedule from the insurer, Witt adds.

-originally posted from TCI Supercoder June 26, 2018

Revenue Cycle Management

4 Common Myths on Reporting Heart Failure Dx Codes

ICD-10 can be tricky to master with the sheer number of diagnoses to choose from, sequencing rules, and special notes. However, you don’t have to sacrifice precious dollars in your cardiology practice.

Bust these four myths to streamline your heart failure claims.

Male anatomy of human organs in x-ray view

Myth 1: Acute and Chronic Heart Failure Develop at Same Rate

Truth: Acute heart failure develops suddenly, and the symptoms are initially severe. On the other hand, chronic heart failure usually develops slowly, over time.

“Patients with chronic heart failure have a previous history of heart failure and are on long-term management such as medications to control the heart failure,” says Carol Hodge, CPC, CDEO, CCC, CEMCcertified medical coder of St. Joseph’s Cardiology in Savannah, Georgia explains. “Chronic heart failure is an established form of heart failure that can be controlled, but not cured.”

Coding solution: If the physician documents acute diastolic congestive heart failure, you would report I50.31 (Acute diastolic (congestive) heart failure). However, if the physician documents chronic diastolic (congestive) heart failure, you would report I50.32 (Chronic diastolic (congestive) heart failure).

Myth 2: ADHF Doesn’t Involve Worsening of Heart Failure Symptoms

Truth: Acute on chronic heart failure (ADHF) is the sudden symptomatic worsening of heart failure (established known heart failure), says Julie-Leah J. Harding, CPC, CPMA, CEMC, CCC, CRC, CPEDC, RMC, PCA, CCP, SCP-ED, CDIS, AHIMA-approved ICD-10 trainer and ambassador and director of revenue operations-cardiovascular surgery at Boston Children’s Hospital in Boston, Massachusetts.

ADHF typically includes dyspnea with physical activity and or lying flat, the patient may have gasping for breath while walking, lower extremity swelling, fatigue, pulmonary edema (chest congestion), palpitations, loss of appetite, weight loss, low urine output, confusion and memory issues, according to Harding.

When chronic heart failure becomes uncontrolled, it is referred to as acute on chronic, and symptoms such as increased shortness of breath and pedal edema, may occur, according to Hodge.

“The worsening of these symptoms on top of the chronic condition is referred to as ‘acute on chronic,’” Hodge explains. “Once the acute phase isresolved, it is returned to being referred to as ‘chronic.’”

Coding solution: The physician documents acute on chronic right heart failure. You should report I50.813.

Myth 3: Specificity Not Important in Heart Failure Documentation

Truth: When it comes to heart failure documentation, specificity is vital. As Harding emphasizes, “You can offer any magnitude of ICD-10 codes, but if it is not documented, you cannot report them.”

“The most common mistake I see in reporting heart failure is that documentation only supports heart failure, unspecified,” Hodge says. “Providers need to be educated to document whether the heart failure is systolic, diastolic or combined. And, is it right or left heart failure? “

Harding talks about her experience from the congenital heart disease perspective.

“In the congenital heart disease world, most of our patients have a form or element of heart failure, according to Harding. “Our struggle, and it is common in the acquired world as well, is the lack of specificity in provider/clinician documentation.”

We seldom receive “acute,” “chronic,” or “acute on chronic” written in the patient record, Harding adds. We often query the providers for clarification.

Myth 4: You Can Ignore “Code First” Notes

Truth: You should also pay close attention to “code first” notes in ICD-10.

For example, a “code first” note under category I50- (Heart failure) tells you to sequence heart failure due to hypertensive heart and chronic kidney disease.

A common error she sees is coders not using the combination codes or the hypertensive with heart disease codes, according to Hodge.

“These codes should be used to indicate hypertensive heart disease followed by the code for the type of heart failure,” Hodge adds. “Kidney disease very often occurs with hypertension and congestive heart failure, and those guidelines should be followed to correctly sequence those codes.”

Coding solution: The physician documents that the patient has hypertensive heart and chronic kidney disease with acute systolic (congestive) heart failure and with stage 5 chronic kidney disease. You would report the codes in the following order: I13.2 (Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease); I50.21 (Acute systolic (congestive) heart failure); N18.5 (Chronic kidney disease, stage 5).

-originally posted on TCI supercoder, June 26, 2018