Tag: medisoft

Medisoft v24
ICD-10medical billingMedical Billing and CodingMedisoftpatient payments

New Medisoft V24 Features

New Medisoft Version 24 Features

Medisoft released version 24 with several key new features. Among the new features is Transaction Entry Alerts. With alerts, you can create rules that notify billers of potential issues before sending a claim. Another new feature is enhanced eligibility response displays, which display distinct and expandable sections on a patient’s insurance eligibility, allowing for easier comprehension of eligibility status. Additionally, eMDs enhanced Medisoft’s mobile app with more information and better scheduling features.

Let’s take a quick look at each of these items.

Transaction Entry Alerts!

Is your billing department a one-person show trying to keep track of all the rules of billing your claims correctly? Do you have billing staff taking vacations and wanting to leave pages of notes for the person filling in while they are away? Or maybe you employ multiple billers working on your data simultaneously and need to enforce billing claims rules correctly the first time? Regardless of your billing situation, Transaction Entry Alerts may be a solution to creating cleaner claims during the entry process!

This new feature to Medisoft version 24 allows you to create rules based on many different criteria. Alert messages are displayed when saving transactions while you are still in the transaction entry screen. With these alerts, staff can resolve any issues before creating claims!

Below is an example of a simple alert that could easily shorten the processing time by days or even weeks if caught early in the process. The rule states that for a specific insurance company (MED03), when a data entry person enters a specific code (in this case, 99397), an alert appears within the Transaction Entry screen, notifying the user that the code is invalid. Furthermore, the message directs the user of the appropriate codes to use for Medicare (G0439 or G0438)

So, taking a few minutes to create an alert could save your company thousands of dollars or many hours working rejected or denied claims.

 Transaction Entry Alerts are one of the latest features added to Medisoft that allows you to take more control of your claim processing by ensuring your payers are getting the right information the first time a claim is submitted.

If you have a billing service or run multiple data sets within your practices, you can copy alerts created in one practice to any other practice, saving you time. We encourage you to check out transaction entry alerts. It may be the best thing you can do for yourself and your business.

Enhanced Eligibility Response Displays

This feature requires using a clearinghouse designed to integrate with Medisoft. Sunrise Services offers this through our clearinghouse partners at Change Healthcare. We recommend bundling electronic claims, insurance remittance posting, and eligibility services together. If you are already using and happy with a different clearinghouse, it may be possible to set up eligibility only through Change Healthcare, so you can use this new feature while maintaining your existing claims clearinghouse.

Eligibility displays are more readable and useful

With version 24, eligibility displays are more readable and useful.  They include expanding sections for better access to information. Here’s a screenshot from the new eligibility response display. Notice the different data sections, and you can click on a specific section to expand it and see more details. Version 24 provides a smoother workflow for your front-office staff to manage and find deductible amounts, coverages, and more.

General information appears in the header, as seen in the graphic below. Notice the green checkmark? It indicates that the patient has an active insurance health plan coverage.

Receive more detailed information in the sections below the header. Expand or collapse each section by clicking on the little arrow left of the section’s name. If the arrow points right, toward the section name, clicking the arrow expands that section, providing more details specific to that section. Expanding the section is called “drilling down” to see more information.

If the arrow points down, then clicking it collapses the section, and the detailed information becomes hidden from view. Drilling down into only the sections from which you want information makes for a cleaner and quicker query.

The example below shows an expanded deductibles section with the status of deductibles for both the individual and family. Please note that the information you receive is limited to what the insurance company releases through the clearinghouse.

In the below graphic, the bottom section, named Other Benefits, is a repository for other information not otherwise applicable to the other sections.

You can print the screen by clicking on the printer icon at the top left of the screen. Each section prints in its expanded or collapsed form, depending on how you are viewing the screen. For example, in printing this screen, the deductibles section includes detailed information because it’s expanded. The other sections are all collapsed and show no details on the printout. If you also wanted to print out Active Coverage details, then expand that section before printing.

You can also print a specific section by Right-clicking on that section and selecting the Print option.

Medisoft Mobile App v3.2

With Mobile App 3.2, eMDs implemented both back-end development upgrades and numerous new feature capabilities.

The patient’s middle initial is now visible on the patient card view. The middle initial also appears on the following screens: charges, patient search results, and new appointments.

The case number and its description now appear on the patient card. Which case appears depends on several factors.

  • If the patient is on the appointment list AND the appointment has a case, the information from that case appears
  • If there is an appointment, but no case was selected, then no case information appears because the entry operator could have selected a case and chose not to.
  • And finally, if there is no appointment and the patient has one or more cases, information from the case appears and is based on your Program Option settings.

eMDs added new information to the Patient Card screen as well.

You can now view Secondary and Tertiary Insurance information on the patient’s case. And for all insurances, policy and diagnosis codes from the listed case now appear on the patient card. You can also see diagnosis codes from the case and the patient’s balance views.

Medisoft features Guarantor (or family) billing. You can send one statement to an entire family that includes each member’s balance. The sum of all those balances is called the quick balance. In Medisoft, you view the quick balance by pressing F11. That balance was not previously available from the mobile app. Now, when you tap the balance on the screen, you can see the guarantor’s quick balance.

You can now select a case when creating an appointment in Medisoft Mobile. Previously, you could review existing appointments and add new appointments. Unfortunately, you could not edit, move, or delete an appointment. With version 24, you have much more control over the entire appointment entry system in Medisoft.

If you already have Medisoft version 24, you can view our online training videos at www.sunrize.com/Medisoft. Or, check the Medisoft help menu for more details. If you do not currently use version 24 and would like to upgrade, please contact our sales department 502-538-4665 option 1 or contact sales@sunrize.com.

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Communicating with Sunrise Services

Written by Jeffrey Stokes

We live in extraordinary times. When COVID-19 first began wreaking havoc on society and businesses, we posted an update on our website announcing our commitment and ability to maintain our support of clients using our RCM, practice management, EHR, consultant, and electronic services. With much of our staff working from home, we have maintained our support levels.

Even before COVID-19, Sunrise Services began a process to enhance the tools we use to communicate with your practice. Our new phone system is entirely cloud-based, allowing staff to work from multiple remote locations and still communicate with other team members in real-time. You have additional options for reaching out for sales, support, and RCM questions.

The easiest method for opening a service ticket is to email support@sunrize.com. Provide us with your

  • Practice name
  • Contact name and telephone number
  • Description of the issue or service request

Upon receiving the email, we validate you have a current support agreement. If so, we create the ticket and route it to the correct technician. If you have no ongoing support agreement, we still assign a ticket, then place it on hold, send you an updated support contract, and release the hold upon completion of the contract.

Sunrise uses a customer relationship management (CRM) system named ConnectWise for managing support tickets, service requests, and sales processes. Like how an EHR includes a patient portal for a provider to patient communication and data exchange, our ConnectWise Support Portal allows you to create new ticket requests, view updates on current tickets, and review previous support occurrences.

The support portal provides an excellent means for managing your overall support requirements. Contact our support department if you’d like to include the portal as one of your support tools.

Through our Support Portal, you have access to a new and expanding knowledgebase. Information within our knowledgebase is growing each month. Join the support portal and check it out. You may find information that alleviates the need for additional support.

Our website URL is https://sunrize.com. Along with the typical selections on Services, Support, and Products, you will also find a section specific to COVID-19 resources. You can review past newsletter articles and essential blog posts.

Sunrise has a robust social media presence. You will find our Facebook page at https://www.facebook.com/SunriseServicesLLC/. Follow us and Like us on Facebook. Our Twitter handle is @SunriseServices. Follow us on Twitter to receive occasional updates and newsworthy items.

And, of course, you can always contact us by phone. Our main telephone line is still (502) 538-4665. When calling, we present you with three options:

  • Option 1: Sales
    • Generally, option 1 is for new customers. If you have an established relationship with a staff member, please feel free to reach out to them if you want additional services or support. If you’re not sure who to contact, then option 1 is an excellent place to start.
  • Option 2: Support
    • If you need technical support on MDsuite, Medisoft, Medisoft Clinical, or our WAN hosting services, use option 2
  • Option 3: RCM
    • Our Revenue Cycle Management customers with questions or issues related to their billing should use option 3.
    • We provide a different contact number on statements for any patients with billing questions. If you are an RCM client and a patient calls your office with billing questions, please direct them to call the number provided to your office.
  • Option 9: Dial by Name
    • Want to speak to someone specific, but do not know their extension? Press 9, and you can enter in part of their name.

We are working hard to provide many options for requesting and receiving help and advice. If you believe we can do better, or if you have suggestions, please email Jeff Stokes at jstokes@sunrize.com, or call (502) 538-4807.

Navigating eRx in Medisoft Clinical
MedisoftElectronic Medical RecordsEMREHRelectronic patient record

Navigating eRx in Medisoft Clinical v11.2.1

Sunrise Services recently concluded Medisoft Clinical upgrades to version 11.2.1. The latest version incorporates a new ePrescribing module based on an enterprise service. One tremendous advantage of the enterprise version is the elimination of downloading, installing, and managing insurance formularies and drug interactions. Instead, Medisoft Clinical incorporates these features into the service!

NOTE:  This article is for Version 11.2.1 only. If you have not updated to version 11.2.1, please contact us so we can guide you on any requirements to upgrade

As the lead Medisoft Clinical support technician for Sunrise Services, I’ve experienced with you, first-hand, how any change in a feature can affect your workflow. Therefore, I’ve compiled some of the most common questions, issues, and confusions clients experience with the new eRx service:

When you look under the ‘RX/Medication’ tab in a patient chart, you may notice several different status codes.  You must look at the entire picture to get an understanding of what the status is for the selected prescription.

Pending – The prescription has not yet left the system. No action required unless the status changes to ‘Error’,

Queued – The order is in the system and queued up to send to Surescripts and the pharmacy.  If the RX remains queued for more than 10 minutes, contact support to investigate.

Verified – The pharmacy received the prescription and confirmed receipt with a message sent through Surescripts.

Error – The prescription did not make it to the pharmacy, resulting in an error message received from Surescripts or the pharmacy. If the error message appears to be one you can remedy, correct it yourself. Otherwise, or if in doubt, call Sunrise for support.

Completed – The Rx was put in the system for a different provider and is complete. Completed prescriptions occur when you perform a ‘Medicine Reconciliation.’ Remember to remove the medicine when it is no longer active.  Just highlight the medication and move to ‘Historical.’

Sent – You’ve received no additional information from Surescripts or the pharmacy after sending the prescription.

Let’s take a closer look at the ‘Sent’ status:

If you created a paper Rx, then it is ok to have a ‘Sent’ status. On a printed prescription, the system has no way to validate whether the pharmacy received the order, so the system marks it as “sent” to indicate completeness. 

If you made an Electronic Prescription, or eRx, and the status is stuck on ‘Sent,’ then you must investigate further. The ‘Sent’ status indicates the prescription did not make it to the pharmacy, or the pharmacy sent back a denial.  You’ll see this status typically when a refill request is filled and is older than 14 days.  When you have a refill request present on the eRx Worklist, it’s in your best interest to address it as soon as possible.

If the eRx status has a sent Status, usually after about 10 minutes, you can see any associated errors by doing the following:

  • Click on Maintenance > Setup > Prescriber Management.  The Prescriber Management window will open. 
  • Click on Message History (Bottom Right).  Insert the patient’s last name and click on Search. 
  • If the status is ‘Error,’ click on the eye icon on the right to open the raw message where you can find the denial reason. 
  • If you see no reason provided, it is more than likely that the refill request is out of the date scope for the pharmacy.  To rectify, remove the eRx from the medication list and make a new one.  You should have a new status in under 5 minutes. 

NOTICE: Any eRx refill request received in the Worklist that does not have a corresponding Medication in the current medications list will result in a pop-up box. To rectify the problem, you can match the refill request from the medication on the left to a medication in the drop-down list, OR you may deny the request and select the Proceed button. The pharmacy will receive a denial request. You may also deny the eRx now and submit a new medication.

If, after you perform these steps, you require further assistance, please call Sunrise Services Support line @ 502-538-4665.

Medisoft Clinical’s latest upgrade includes several other advancements to help in your staffs’ daily workflow.

A new Prior Auth button is available in the eRx Worklist: Click the ‘Prior Auth’ button to access the CoverMyMeds ePA Dashboard.  For more information on enrollment, contact Sunrise Services support.

When you discontinue medication and select either Adverse reaction or Allergic reaction as the discontinue reason, a new section expands to enter details about the reaction. Select the severity from the drop-down options and type or select the reaction description.

A CCDA based on selections clicked in the clinical summaries is now sent to Updox (Patient Portal). Make your selections within the Special Features section of the Configuration drop-down.

The most significant changes in the new RX process are behind the scenes.  No longer is Medisoft Clinical using the PMSI application, but rather the more stable PMSI Interoperability service. This change frees up memory and allows the program to operate at a premium level.

For additional information on Medisoft Clinical’s new features and how to incorporate them into your workflow, give Sunrise Service’s support team a call at (502) 538-4665.

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Medisoft V24 A/R Tracker

Are you on version 23 or 24 of Medisoft Advanced or Network Professional? Have you looked at the new AR Tracker yet? If you answered “No” to either question, keep reading.

A new feature added in version 22, the “AR Tracker” module deserves an award. It is a very flexible tool that can save you time and much money by getting better control over your Accounts Receivable. It doesn’t matter if it’s just you or a staff of 20. The AR Tracker can help keep your AR efforts under control and more focused.

Do I have your attention yet? Many of you have a system of reports, notes, Final Draft messages, and color codes to help in your efforts already. You don’t have to change the way you do everything! However, you may find many of your AR efforts obsolete in a matter of minutes!

Accessible from the Activities drop-down menu, the AR Tracker pulls much of the critical information you need into one location, tying together AR management into one cohesive workflow, with advanced filtering to track and collect Insurance and patient balances.

Find and sort claims and statements in ways you didn’t know to wish for! Search results filter down by the provider, then insurance, the patient, and finally the claim number, where you can see any transaction color-coding, aging information, and so much more. From those results, you can create a task for a Medisoft user and track the outcomes.

“As an administrator, you can make sure that tasks are getting worked on and completed by their assigned follow-up dates.”

A simple right-click on a claim or statement will open the door to many of the tools you need to assist your AR process.

  • Add or view notes that are date stamped (so you can keep track of what has been done by you or others in your office)
  • Assign Status and Task codes then assign them to another staff member or yourself with a follow-up date (which a user can then use in the tracker to find his or her tasks to target the AR before it is lost)
  • Open and edit the insurance, patient, or claim and return right back to the AR Tracker list. Go straight to the patient’s transaction entry screen or to their case. Even check eligibility if you’re a Change Healthcare user.

If you have created a task for a Medisoft user, you can then create a filter template specifying the user and, or task code. The user then quickly opens the AR tracker and selects their templet to immediately target claims and statements they need to work on and enter follow up notes.

As an administrator, you can make sure that tasks are getting worked on and completed by their assigned follow-up dates.

Medisoft version 24 further enhances the module with a new field in the insurance carrier screen to enter the timely filling days. While editing an insurance, in the Address tab you’ll find the new Timely Filing Days field. Enter the number of days this insurance allows for a claim to successfully adjudicate. Back in the AR Tracker, you will notice a new column in the Details grid for claims: Days to File Pri. This column shows you the number of days before this claim reaches the timely filing deadline for that insurance carrier when it is the Primary insurance.

And it’s not just your billers that will benefit from the AR Tracker. Your front desk person using office hours can benefit from seeing Patient AR Status codes while scheduling or checking in patients. Data entry persons can get Pop-up messages when entering charges based on the same codes.

MDSuiteMedisoftRevenue Cycle ManagementValue Based Care

Vaping: How Are We Supposed to Code This?


At the time this article was written, eight people had lost their lives due to severe respiratory illness from the use of e-cigarettes, also known as “vaping.”  That number is expected by healthcare professionals to rise as this trendy alternative to cigarettes becomes more and more popular, especially in the younger population. According to the Center for Disease Control and Prevention (CDC), as of early September, there are over 450 possible cases of e-cigarette related lung illness. With this recrudescence spreading and becoming a common issue, the fact that there is no specific ICD-10 code for this diagnosis is problematic.

In March of 2017, and again in September of 2018, the American Thoracic Society (ATS) requested specific ICD-10 codes for e-cigarettes. They stated:

The development and marketing of e-cigarettes, e-cigars and other electronic nicotine delivery devices poses significant challenges to health care providers, researchers, patients, public health officials and for ICD-10-CM coding. Currently, there is no effective way for health care providers to specifically code patients who use ENDS [electronic nicotine delivery systems] products. Given the growth in its usage, both domestically and internationally, the lack of a unique code set for these products will pose a barrier for the effective use of ICD-10-CM for health surveillance and research purposes. (1)

United States. Center for Disease Control and Prevention. Coordination and Maintenance Committee. “ICD-10 Coordination and Maintenance Committee Meeting.” Cdc.gov. Page 31. National Center for Health Statistics. March 2017. Web. 30 September 2019.

No one in the healthcare community doubts the harm that vaping can cause, especially in young people. However, when documenting a patient’s diagnosis, the available ICD-10 codes do not cover e-cigarettes specifically. The ICD-10 codes one would use are F17.200 – F17.291, which indicates nicotine dependence, either unspecified, cigarettes, chewing tobacco, or other tobacco product (like snuff), and either uncomplicated or in remission. None of these would accurately describe e-cigarettes as these vaping products affect the respiratory system in a different way than cigarettes, chewing tobacco, and other tobacco products.

E-cigarettes deliver a vaporized dose of nicotine, along with various chemicals, including, but not limited to, glycerin, propylene glycol, and flavorings. When someone vapes, they inhale vapor instead of smoke. No long-term studies exist to back up claims that inhaling vapor is less harmful than traditional smoke. Cancer takes years to develop, so it’s unclear if a product causes or increases the risk of cancer until that product has been out for at least 15-20 years. We know little about the long-term health effects of vaping.

The FDA Commissioner announced in the fall of 2018 that middle and high school students using e-cigarettes and vaping had reached epidemic proportions. This issue has only grown since then, but the codes for nicotine dependence haven’t changed since they were new codes in 2015. The new ICD-10 codes for 2020, which set for release by the time this article runs, do not include any alterations to the nicotine dependence codes, specifying e-cigarettes, nor are there new codes for this wide-spread, still growing health issue. It seems like we will be waiting another year to accurately document and survey the prevalence of developing respiratory issues caused by this possibly deadly trend.

If you need more information or assistance from trained coders and billers, contact us to purchase an “Ask Us Anything” support contract, and we will be happy to help.

Revenue Cycle Management

Reporting Cardiac Stress Tests

Interpretation only, or supervision, too? The answer affects your coding.

If coding for cardiac stress tests makes you want to pull your hair out, you are not alone. Understanding the nuances of the appropriate stress test codes can be tricky. Here’s how to avoid the confusion so you can seamlessly report stress tests.

Notice What Happens During Stress Tests

Cardiologists use stress tests, also known as treadmill or exercise tests, to see how well a patient’s heart deals with work.

When a patient takes a stress test, the cardiologist (or tech) hooks up the patient to heart monitoring equipment, and the patient walks slowly on a treadmill. Next, the treadmill’s speed increases and tilts to simulate the patient going up a small hill. During the test, the cardiologist monitors the patient’s heart rate, breathing, blood pressure, and level of tiredness.

Stress tests allow the cardiologist to diagnose coronary artery disease, determine a safe level of exercise for the patient, and diagnose a possible heart-related cause of symptoms such as chest pain, shortness of breath, or light-headedness.

stress test

Grasp 93015 — Several Codes in One

When it comes to reporting stress tests, the CPT® manual gives you the following options:

  • 93015, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharma­cological stress; with supervision, interpretation and report
  • 93016, … supervision only, without interpretation and report
  • 93017, … tracing only, without interpretation and report
  • 93018, … interpretation and report only.

Problem: The way that the CPT® manual lists the above codes could suggest that they work together. This interpretation isn’t correct, but the manual does not offer any extra explanation beyond the descriptor language for the codes’ appropriate usage.

Solution: You can look to an article in the January 2010 CPT® Assistant to see the close connection between the stress test codes.

According to CPT® Assistant, 93015 represents a complete cardiac stress test procedure, which includes the technical and professional components of the service — 93016, 93017, and 93018. To correctly report 93015, one cardiologist must perform all three components in a nonfacility setting like an office, clinic, or diagnostic testing center.

If the cardiologist does not perform a complete 93015, he should report just the code or codes that best represent the service he did perform (93016-93018).

Reporting stress tests in the hospital: If the cardiologist reports stress tests in a facility setting like the hospital, the facility would report the technical component (93017), and the cardiologist would report the service he performed (93016, 93018, or both).

Bonus tip: The PC/TC indicators for these codes in the Medicare Physician Fee Schedule also can help you use these codes correctly:

  • Code 93015 has indicator 4, meaning it’s a global test code that describes selected diagnostic tests where there are associated codes that indicate (a) the professional component only and (b) the technical component only.
  • Codes 93016 and 93018 have indicator 2, meaning they are professional components only. Codes 93016 and 93018 describe the physician work portion of selected diagnostic tests where there is an associated code that describes the global test.
  • Code 93017 has indicator 3, meaning it is the technical component only. Code 93017 indicates the staff and equipment costs of selected diagnostic tests where there is an associated code that describes the professional component of the diagnostic test only.

Understand the Individual Component Codes of 93015

Let’s dig deeper into each component of 93015 — 93016, 93017, and 93018 — to see what it means when a cardiologist reports these codes.

1. Code 93016 is a professional component you report for the physician’s supervision only, without the interpretation and report. Medicare’s diagnostic test supervision guidelines require this component.

Expert tip: Report 93016 only if the physician provides direct supervision of the stress test. Physicians should document they supervised in order to use this code.

2. Code 93017 represents the service’s technical component such as technicians, providing the equipment, paying for rental space, utilities, supplies, etc. You use 93017 for tracing only, without the interpretation and report.

Expert tip: For tests performed in a facility setting, only the facility reports 93017.

3. Code 93018 is a professional component.

Expert tip: Report 93018 if the provider provides an interpretation and a written report.

Learn more-

Cardiac Stress Test 

Cardiac Health

~Excerpt taken from the 2018 Cardiovascular Survival Guide

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

Integrated Cloud Based Solutions

ICD-10 Walking Through the Workflow

With less than a year to go until the ICD-10 code set implementation deadline, physician practices should be pursuing a comprehensive plan designed to ensure a smooth coding transition with minimal cash flow disruption.

A key step in any ICD-10-CM transition strategy is to conduct a detailed assessment of existing workflows and processes to determine which elements will require modification, according to Bess Ann Bredemeyer, a consulting director with McKesson Business Performance Services (BPS).

By identifying each point in the claims lifecycle that ICD-10- CM will touch, appropriate adjustments can be made and simulations conducted to test the new processes against real-world conditions.

“The best way to proceed with an assessment is to begin at the patient encounter and then move through to the claim drop and denial management,” Bredemeyer said. “That way you won’t miss anything.”

Clinical Documentation  Whether the clinical documentation is sent directly to a coder or to data entry personnel, it is also important to ensure that any changes in National Coverage Determinations (NCDs) and payer’s Local Carrier Determinations (LCDs) are incorporated and reflected in the claim. A good approach includes:

  • Identifying the top 50 most utilized diagnoses codes
  • Evaluating where additional documentation will be required
  • Mapping out modifications to support appropriate reimbursement
  • Updating charge tickets, super-bills and other revenue cycle tools

This is a Test  With all the elements theoretically in place, it is critical to begin testing your new workflow to determine if it can handle ICD-10-CM. Code audits can assess both clinical documentation and coding to determine whether the claims should come through clean or not. A real-world testing process may also reveal previously unknown problems that would otherwise remain hidden until the ICD-10 go-live.

Don’t Be Denied  Because of the complexity of ICD-10-CM and the sheer magnitude of the change, it’s reasonable to assume that even the best-laid plans may encounter some unexpected problems. For that reason, it makes sense to be prepared for a rise in denials. For physician practices, that means ensuring that staffing is adequate to manage an increase in volume, and that problems will be quickly identified and remediated.

“There is no denying that the transition to the new code set will require planning and resources to mitigate the burden of change,” Bredemeyer said. “That’s why you should get started now on developing a workflow analysis impact assessment that will help you develop a detailed ICD-10 timeline and budget.”

Article Resource:

ReveNEWS, Industry Spotlight, “Walking Through the Workflow- An Important First Step,” November 2013 edition located on the McKesson ReveNEWS website