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Succeed in Billing and Coding

Consider these steps to maximize medical reimbursement.

Richard S. Kattouf, O.D., D.O.S.

Q In attempting to implement medical billing and coding, my staff and I constantly experience road blocks with unaccepted modifiers, use of a diagnosis code that does not support the procedure and unpaid claims. What can we do?

Dr. S.L. Pugh
via e-mail

A: Most O.D.s do not maximize their medical reimbursements. In fact, their fee structure is well below that of M.D.s for the same procedure or treatment, and they have a low ratio of re-appointments for medical testing or treatment compared with comprehensive examinations.

Ask the right questions

What do successful practices do differently? First, they ask medical case history questions that prompt very specific answers that may uncover a medical condition. For example, they do not ask the patient, “Do you have dry eye?” Instead, they ask several questions, often based on lifestyle, such as, do you ever experience a dry, itchy, gritty or a burning sensation in your eyes: A) at the end of the day?, B) when indoors?, C) when outdoors?, D) at the computer?… and so on.

When the patient answers “yes” to any of the questions, these practices then elicit a subjective medical response by asking, “Would you grade the sensation as mild, moderate or severe.”

This line of questioning can better establish the need for medical testing. It is a mind-set that, once established, can grow your medical practice.

Consider a rate increase

In addition to testing, you can maximize medical reimbursement by adjusting medical fees. Most optometrists use the Medicare maximum allowable fee schedule to establish their medical fees — for example, $80 for a threshold perimetry evaluation. But let's say the M.D. in your region charges $150 for the same procedure (92083). If the state Medicare pays 69.11, both the O.D. and M.D. will get the same reimbursement from Medicare.

However, if the patient is insured by a private insurance carrier, which uses a different maximum allowable fee schedule, say, one that reimburses at a rate of 80%, then the M.D. would receive approximately $120, while the O.D. would receive $64. The bottom line: Charge at the level of ophthalmology in your region.

A third-party solution

For years, Kattouf Consulting Services (KSC) was a proponent of “in-house labor.” However, due to the ever-changing and complicated nature of coding and billing, we strongly recommend outsourcing this area to experts.

In our experience, most staffers who perform billing and coding services are not highly trained. Their compliance knowledge is minimal. And the investment is steep — at $15 per hour, you pay $30,000 a year, not including benefits, for coding services. Outsourcing to experts costs a fraction of this amount.

Most consulting services, including KSC, can provide a list of reputable coding consultants. Make sure that any company you interview has compliance experts on staff to protect your practice from fines and denied claims, as well as ensure you are billing at the highest acceptable level.

By making intelligent choices in the area of billing and coding, you increase your unit sale per patient, render a higher level of quality care to your patients and protect yourself from significant fines. OM