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Healthcare Management Systems (HMS)

Posted by Lisa Velasquez in Fi-Med Services, Mergers and Acquisitions

Healthcare Management Systems (HMS) maintains two divisions operating complimentary functions.  Working together, they strengthen the products and services provided to the medical community.  Richard Usry, HMS Senior Vice President, said “Because HMS bills and collects for medical practices, Turnkey users can be confident the software provided to them includes the latest collection and information tools available.  

Similarly, while operating billing offices for the Management Division, HMS is constantly learning through actual experience and continuously updating the Medical Management System for the benefit of Turnkey users. 

The Turnkey Division combines powerful industry-standard hardware and the HMS Medical Management System software for practices that desire their own independent billing operation. The software provided is specific to each hospital-based specialty, with the focus of automating as many functions as possible, providing the easiest functions for day-to-day operations, and including the most comprehensive reporting available to guide important practice decisions.

The robust HMS software retains its edge because HMS has a unique process for prioritizing its enhancements.   The HMS Users Group, wholly-independent from HMS, meets twice each year to recommend ideas for enhancements to the system.  The group is led by its board of officers and funded by annual membership dues from the client members.  HMS attends all of the meetings, and therefore, knows just what its clients need all the time. 

The Practice Management Division provides billing outsource solutions for groups who do not wish to face the challenge of an internal billing operation.  HMS employs experts to monitor the changes pertaining to each specialty, and maintains memberships in the key organizations that propel and monitor changes in the medical billing and practice management industry, which gives their clients confidence about their investment in the future.

Learn more about Healthcare Management Systems, A Fi-Med Company.

Meaningful Use Defined: When Good Ideas Go Bad

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

Had she been alive today, today would have been the 101st birthday of actress Ann Sothern. A quick glance at her acting credits includes appearances in dozens of movies and her own situation comedy that ran for three seasons across an acting career that spanned nearly six decades.

You may ask why I’ve opened a blog that deals with medical billing, coding, compliance and health information with a short biography of an old actress. Please bear with me for a few paragraphs.

There is one credit on Ann Sothern’s resume that sticks out in my mind and is relevant to today’s dissertation. In 1965, Ms. Sothern played the voice of a dead woman in a television show that most critics now point to as one of the worst shows in the history of television. That show was My Mother, The Car. The show followed the exploits of a young man who one day buys an antique automobile from a used car lot. When he turns on the radio in the car, who should be on the radio but his dead mother offering life advice from beyond the grave. Mercifully, this show only lasted one season and to my great glee is not available on DVD.

As we stand back and look at this plot line, we begin to wonder not only why such an atrocious idea ever made it to air, but what person, when this idea was pitched to them, thought that something like this would appeal to the viewing public. Worse yet, the young man in the show was played by Jerry Van Dyke, whose entrance onto the American entertainment landscape acts as the ultimate symbol of what happens when we let a talented person’s less gifted siblings share a piece of the spotlight.

I brought forward the example of My Mother, The Car to illustrate that no matter what the quality, all any idea really needs is a benefactor; someone who hears an idea and states “I think that’s great! Let’s run with it”.

Which brings me to the proposed rule defining “meaningful use” of electronic health records (EHR) that was released on December 31st by CMS. In early 2009,when it was announced that physicians would receive incentive payments for the meaningful use of EHR in mid-2011, there was much excitement that a new day was dawning in the way our health care infrastructure managed and shared patient medical information.  Before meaningful use was defined, the Certification Commission for Healthcare Information Technology (CCHIT) created a certification for EHR systems that would meet the standard. Some systems gained CCHIT certification prior to the release of the proposed rule, which I pointed to in an earlier post as premature. 

Since the proposed rule listing 24 specific requirements needed to meet meaningful use was released on the last day of 2009, many practices who took the plunge and purchased an EHR prior to a clear definition of what was needed to meet the standard are experiencing buyer’s remorse, realizing that a large investment has been made for systems that may not meet the standards if the proposed rule is implemented as written.

The requirements demonstrate high ideals of treatment and public health. An example of this is the idea of EHR’s being able to share important patient condition information with immunization registries and public health agencies. Under this proposed requirement, at least one test must be performed to assess the EHR’s ability to provide electronic lab results to a public health agency. We heard a lot about interoperability when the discussion of meaningful use began in earnest last year, but a requirement such as this can only work if the relevant public health agencies have the ability to receive the information electronically.

Also put forth is the proposal that any certified EHR system be able to provide patients with an electronic copy of their health information upon request. The key word in that phrase is “electronic”. While some more sophisticated EHR systems and larger health care institutions now have this capability, this requirement places a large privacy and security burden on smaller practices that lack the IT infrastructure support to create a secure electronic pathway from the office to the patient.  

It is the intersection of high ideals and the execution of the same that presents itself as a formidable challenge to any idea. Between now and the release of the final rule, which is expected sometime after March of this year. I encourage those that have yet to purchase an EHR system, and even those who have implemented an EHR in their practice believing it would meet any standard, to review the proposed rule. If these requirements outlast scrutiny and become final, this may someday be seen as an idea that slowly took on a life of its own, consuming everything in its path until it was too late. This would be similar to the thought all those years ago that a dead mother talking to her son through a car radio would be appealing to a wide audience.

Billing For Consults After “The Apocalypse”

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

“Orchestral music rises as the first glimmers of an ominous sunrise brings light to a dusty and desolate landscape, where once-plentiful streams of revenue have been vaporized by statute. Small bits of paper with numbers such as “99254″ and “99241″ blow across the feet of our stethoscope-clad hero, as he faces a future full of financial uncertainty and unwanted adventure…”.

We are now two weeks into a world where Medicare has eliminated reimbursement for inpatient and outpatient consultation codes. To many specialists for whom consultations have become a way of life, it is tempting to see themselves as a manufactured post-apocalyptic film character similar to the one above. It is my duty, as a compliance officer, certified coder and budding writer of screenplays to inform you that it doesn’t have to be that way.

In a previous post on this blog, I demonstrated one way to navigate the imperfect crosswalk that exists between inpatient consultations and the CPT codes for initial inpatient encounters (99221 through 99223) that are now to be used in its place. In the past weeks, the Medicare administrative carriers have released their own guidance about what should be billed in place of a consultation code if the documentation does not meet the requirements of CPT code 99221.

For Palmetto GBA, First Coast and WPS, the suggestion is that CPT code 99499 (Unlisted evaluation and management service) be utilized for services formerly billed as 99251 or 99252. When using this code, be aware that it lacks a set payment. The reimbursement of this code is driven on a case-by-case basis and is determined by carrier review of documentation for the service. When billing 99499 to a carrier that accepts it, always be certain to include the documentation for the service.

National Government Services, as well as other carriers, is suggesting that the appropriate inpatient follow-up code (99231 through 99233) be billed in place of a low-level consultation. The choice of code would depend on the depth of the documentation for the service.

The second challenge that has been brought forth is the question of consultations when Medicare is the secondary payer (MSP). In the final revision of the new consultation policy in MedLearn Matters article MM6740,  there are two solutions that can be used. You can either choose not to bill consultations at all to a commercial payer and be reimbursed for E/M services by both commercial and MSP, or you can bill the consultation to the commercial payer, then report the amount paid and bill an equivalent E/M code to Medicare to determine whether additional reimbursement is due.

The first solution is the path of least resistance, as this eliminates consultation billing from your practice immediately and entirely. Financially, this may not be the most advantageous approach. While commercial payers are expected to eventually follow CMS’ lead and eliminate reimbursement for consultations, these codes are still active with commercial payers at reimbursement rates that are typically larger than equivalent E/M codes based on documentation.  Contractually, if you are still receiving healthy reimbursements from commercial payers for consultations, the second approach may be more to your advantage.

The reimbursement landscape has changed, but it has not been irrevocably altered for the worse. The road to reimbursement commensurate with services performed now has a few more detours than it did a month ago, but water recedes and bridges can be rebuilt. With increased attention to documentation detail and increased awareness of the new rules of the road, providers can successfully navigate a world without consultation reimbursement.

Paul Spencer CPC, CPC-H

E-Prescribe Reporting Easier for 2010

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

We are surrounded by cliches in our culture. We hear them virtually every day in our society from one source or another. From my point view, one topic that always plummets into cliche is the topic of change. I’m now past the halfway point in my life, and it’s safe to say that the next person who approaches to me with a happy, revelatory look on their face and says “The only constant is change” as if they have just discovered the Ark of the Covenant has a 50/50 chance of forcibly eating the chair I’m currently sitting in.

Having said that, I’d like to reveal what I feel are two great changes with regard to the reporting of the utilization of electronic prescriptions to Medicare and the reimbursement for this reporting under the current e-prescribe bonus program.

Beginning on January 1, 2010, if a medical provider electronically prescribes at least one medication electronically, this will be reported with the new e-prescribe HCPCS code of G8553. The prior reporting codes of G8443, G8445 & G8446 will be deleted. This change will eliminate any confusion concerning what code to choose. If you e-prescribe one or more medications, G8553 will be reported. If no prescriptions are electronically prescribed, nothing is reported.

In addition, the qualifying for the incentive bonus payment is about to get easier. Currently, in order to qualify for the e-prescribe bonus, a provider must have a 50% rate of electronic prescribing for all prescriptions generated from his or her practice. For 2010, the physician will only need to electronically prescribe 25 times a year in order to qualify.

There are a few things to take into account as we approach these changes. The reporting code must always be reported with a unique face-to-face patient encounter in order to count towards the 25-visit minimum. Also, the definition of electronic prescribing does NOT include faxes.  

In conclusion, if you want an illustration of negative change, as a resident of Milwaukee, I need only look at where the temperatures stood on Thanksgiving and compare them to today. The temperature has dipped into the low teens, and I’ve spent the bulk of the time trying to stay warm at my desk as I type this by playing the more raucous portions of my mp3 player’s catalog. Who knew that Husker Du’s Zen Arcade had a legitimate business purpose? Sometimes, it is of huge advantage to avoid cliche.

Denial Management Made Easier With Version 5010 Billing Standard

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

We are often told that life has no instruction book. Personally, I have seen this blatantly come true in the form of my daily dealings with my 3-year-old son. I also longed for a better set of rules back in 1990, when I found myself briefly dating a woman who thought she was telekinetic, but was actually a hypochondriac. No worries, though. I came out unscathed and not once was she able to throw me across the room using only the power of her mind.

In the realm of Medicare denials, currently, under Version 4010 of the X12 electronic billing standards, Medicare offers very little in the way of pointing the EOMB recipient to a solution for a denial. With time, an experienced follow-up specialist can train themselves to understand in what direction each claim adjustment reason code (CARC) and remittance advice remark code (RARC) is pointing, leading to faster resolution.

Version 5010, set to be implemented by CMS beginning on January 1st, 2012, is slated to make this process much easier. As part of Version 5010, if a claim is denied due to a conflict with a Local Coverage Determination (LCD) or a National Coverage Determination (NCD), the Explanation of Medicare Benefits will indicate what LCD or NCD is being applied in the denial of this claim.

Given that local carriers now have their LCD’s categorized on the CMS website, first by carrier, then in alphabetical order (which is helpful roughly 30 % of the time),  referring the follow-up specialist to the exact coverage determination will cut down on the amount of time needed to research these denial issues.  As someone with daily involvement in Fi-Med’s denial management process, I cannot begin to tell you how I welcome this change.

While there are many other benefits to Version 5010, such as compatibility with ICD-10 and the removal of some redundancies found in the current version, finding a clearer path to a denial solution may turn out to be its most substantive change.

I look forward to the day when my lack of psychic powers ceases to be an impediment to the timely correction of Medicare denials. This whittles down my list of  ”50-10″ challenges in my life down to what happens in 7 years when I’m 50 and my son is 10. I really need to get in shape….

Referring Physician PECOS Phase II Delayed

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

Following up on an earlier post here, CMS announced today that Phase II of Change Requests 6417 & 6421, dealing with referring physician mismatches between the NPI database and the PECOS system, has been delayed until April 5th, 2010.

Phase II of this change request orders the denial of any services referred by a physician who has a conflict between information found on the national NPI registry (NPPES) and the PECOS system. The change to the implementation schedule is being undertaken to give those physicians with conflicting information sufficient time to correct any irregularities.

For the present time, providers who bill for services referred by providers with this conflict will continue to get warning messages stating that the referring physician’s information is inaccurate. If this information has not been updated by the referring provider by April 5th, 2010, these services will be denied.

Calling Health Care Fraud What It Really Is

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

I’ve got theft on my mind this week.

Last Saturday night, while I was spending some spare time acting as the opening musical act for a handful of stand-up comedians, someone took a football-sized rock and threw it through my passenger-side front window. Aside from the costs of repairing the damage, I was relieved of my satellite radio player and a pair of $3 sunglasses.

This episode taught me a little something about crime, and that is that criminals aren’t know for their skills of selection. The satellite radio player is virtually worthless, as it is only good as long you have an antenna, power supply and a subscription. Perhaps they thought it was in actuality a GPS device, but a cursory check of my back seat would have shown them all they needed to know, as there was a rather large road atlas in plain view. My thesis has now morphed into the idea that it takes a special combination of hubris and stupidity to be a criminal on any level.

Which brings me to the world of Medicare compliance. I read a variety of trade publications from week to week that catalog the numerous billing violations – and subsequent fines paid – by health care providers around the country. To highlight just a few from the past few weeks:

  • An Atlanta radiologist found himself under federal indictment for falsely claiming that he had personally reviewed thousands of x-rays and radiological studies over a period of 8 months, when in fact the work was done by non-physician radiology techs;
  • A New York podiatrist was charged with multiples counts of fraud for billing out complicated surgical procedures of the feet, when in actuality, he was performing the less-complicated act of clipping his patients’ toenails;
  • A Boston man pleaded guilty to a 54-count indictment that accused him of enlisting people to stage auto accidents in the greater metropolitan area, then turning around and billing insurance companies for therapy services at his clinics stemming from “injuries” sustained in the fake accidents.


These are only three of the more egregious examples among dozens of other cases nationwide, and remember that these are all within the last month.

When I present Fi-Med’s compliance plan to new employees, I define “health care fraud” as “theft”. In a world where “stewardesses” have transformed into “flight attendants”, and “shell shock” is now “post-traumatic stress disorder”, it is tempting to use less pointed language to describe all-too-common objects and occurrences. Yet whether it is Medicare, Medicaid or a commercial insurance plan, the thieves such as the ones highlighted above exact a heavy toll not only on the resources of the insurer, but on the entire health care infrastructure with the increased costs of premiums and enforcement.

Having grown up in a family with 5 physicians of different specialties, one of the happier aspects of my job as a compliance officer is working together with health care providers to find simple solutions, whether it be for front desk processes or documentation, that keep them from inadvertently slipping onto the wrong end of the regulatory process. There is usually a “light bulb moment” in each of these conversations when a satisfactory conclusion is reached and where peace of mind is achieved.

While health care fraud has more subtlety than the mentally prehistoric toss of a rock through a window, it is no less an act of theft. Going forward, with a major national health care overhaul on the horizon, it particularly falls on those of us in the medical reimbursement field to give the best guidance possible to the providers we service to assist them in avoiding the sinkholes along the regulatory highway.

Time Documentation in the Post-Consult Era

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

I don’t wear a wristwatch. 

I have three basic reasons why you’ll never find a time piece in my possession. The first being my dislike of all things related to jewelry. I’ve been married for nearly 5 years and I still play with my wedding ring, which is my only piece of jewelry. The second is I am surrounded by clocks at all times.  As I type this, I have a clock on the phone, computer and fax machine in my work area. Why complicate it by putting something on my wrist? The third is more cultural. Having a bloodline that is 1/2 Mediterranean in descent, the odds of my arm hair covering the face of any watch I own increases with each passing day, and not even I want to see that.

Having said all this, as we approach January 1st, 2010, a date which marks the end of Medicare’s acceptance of consultation codes for reimbursement, a wrist watch could very well end up being the best friend of specialists nationwide who suddenly find themselves without a longstanding reporting tool for patient encounters.

Evaluation and management documentation guidelines state that if more than 50% of your face-to-face time with the patient is spent in counseling and/or coordination of care, the E/M service can be selected based on time. For a specialist who invests time determining a proper course of treatment in either the office or hospital setting, this rule deserves a second look.

As an illustrative example, one problem that has presented itself is in regard to what used to be considered consultations in the hospital setting. Physicians will now bill an initial hospital care code (CPT codes 99221-99223) upon their first encounter with the patient in the hospital. On the surface, one can immediately see a problem, as there are 5 inpatient consultation codes, but only 3 initial hospital care codes. Because of differing documentation standards, there is no clear crosswalk between the two code sets. 

Now let’s look at two of these codes for comparison. CPT code 99252 (level 2 inpatient consultation), strictly from a documentation standpoint, requires an expanded problem focused history, an expanded problem focused examination and straightforward medical decision making. Using Southern California in 2009 as a reimbursement benchmark, CPT code 99252 is listed in the $81 range. Compare that to CPT code 99221 (level 1 initial hospital care). This code requires either a detailed or comprehensive history, a detailed or comprehensive examination and straightforward to low medical decision making. Using the same reimbursement benchmark, 99221 is listed at around $96.

Now on the surface, it appears that the documentation standards work against the specialists if given the choice between the two codes, but let’s add the documentation of time spent in counseling and/or coordination of care into the mix. The average total time for a 99252 is 40 minutes, but the average total time for a 99221 is 30 minutes. The lesson taken away from this is that an awareness of the time you are spending with the patient could lead to less of an investment of total time, but for a higher reimbursement.

Before jumping headlong into time-based billing, it is in the physician’s best interests to remember the two most important things with regard to documenting for this type of code selection. First, the medical decision making portion of your E/M documentation must detail the counseling and/or coordination of care. It is not enough to use generic statements such as “Spoke w/ Dr. X” or “Orders written”. The documentation must include the results of that conversation and detail about the physician’s care orders for the patient. Second, and most importantly, your time caveat statement must show that more than 50% of the total encounter time was spent in counseling and coordination activities. This can be stated either by using the exact minutes or as a clear statement of percentages. Good examples of this are:

  • I spent 50 total minutes with the patient, 30 minutes of which were spent in counseling and coordination of care.
  • I spent 50 total minutes with the patient, more than 50% of which were spent in counseling and coordination of care.

Documentation that simply states “I spent 30 minutes with the patient” is insufficient for choosing your CPT code based on time.

And while I’m on the subject of time, from previous entries on this blog, you know that I was recently in Georgia doing some musical recording. That particular investment of time on my part has yielded an unexpected dividend, as one of my songs that I recorded during my stay was selected as the Track of the Day in the Folk Rock category on yesterday. In an ironic twist, my friend in Georgia who recorded this track is employed by day as a high-end watchsmith. I may not wear a watch, but I guess it helps to befriend people who do. Have a great weekend!

A Quick Glance at the Medicare 2010 Physician Fee Schedule

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, J. Paul Spencer, CPC CPC-H

As I stated in a previous posting here, I have a long-standing interest in Russian literature. Developing a love of the novels of Tolstoy and Dostoevsky requires a large amount of free time as well as a hearty concentration level. Yet possessing both of these things does not remove oneself from the fact that War & Peace, owing to its size, works better as a doorstop than most bricks.

Which brings me to the Final Rule for the 2010 Part B Physician Fee Schedule. Weighing in at 1,669 pages, it was a lot to take in. Unfortunately for me, unlike War & Peace, there is no corresponding movie to simplify and edit its contents, yet onward I plunged. Many of the changes were specific to services and specialties, but there were a few things that jumped out at me that I’d like to share with you.

Beginning on January 1, 2010, consultation codes (99241-99245 for office/outpatient, 99251-99255 for inpatient) will no longer be reimbursed by Medicare Part B. In the preamble to this portion of the Final Rule, CMS decided that after many years of attempts at education and clarification of the rules for consultations, there remained mass confusion as to the rules regarding consultation vs. transfer of care, as well as widespread documentation deficiencies and problems with consultation code selection.

To make up for the loss of revenue for consultation codes, There will be a 6% increase in the RVU value on outpatient E/M services (99201-99205 for new patients, 99211-99215 for established patients). Going forward, in the office environment, rather than considering a consultation code for patients referred to their practice from another provider. the physician need only choose an E/M code based on whether the patient has been seen within three years of the service date.

Selecting hospital services in the absence of consultation codes will be a little trickier. CPT codes 99221-99223, which in the past have been used solely by the admitting physician, will now be used by all physicians upon their first encounter with the patient. In order to differentiate from the admitting physician and other physicians providing care to the patient, the admitting provider will be required to add a modifier to his service signifying that he/she is the admitting physician. The modifier to be used was not indicated in the Final Rule, but should reveal itself upon release of the 2010 HCPCS.

One specialty reduction of interest affects chiropractic services (CPT codes 98940-98942). These codes will be subject to a 2% reduction beginning in January.

For advanced imaging services such as nuclear imaging, CMS is now requiring that facilities providing the technical component for these services meet an accreditation standard in order to be reimbursed for these services.  

Of course, the biggest adjustment in the Final Rule is the CMS-projected 21.2% pay cut for physician services. As in past years, this cut is expected to be adjusted by Congress prior to the new year.

In any document almost 1,700 pages thick, there is bound to be information that I have left out. For your reading enjoyment, the Final Rule can be found at the following link:

NCCI Updates-Version 15.2

Posted by Lisa Velasquez in Hot Topics, Industry Updates, Webinars

The National CCI database now contains 626,582 edit pairs of procedure codes that, when billed at the same time for the same patient by the same doctor on the same day, either will not be paid at all or will be paid at a reduced rate. Within the database are some hidden data points that could be critical to your reimbursement and/or compliance, such as duplicates, triplicates, reversals, etc. The data you download from the CMS website does not contain these data points nor can you always determine new and terminated pairs for a given period by just looking at dates. This quarter, there are over 5,000 edit pairs that have been terminated retroactively to April, 2009.

In this short, free webinar, Frank Cohen, analyst and developer of the most popular CCI search engines, will walk you through a brief introduction to the NCCI policy but more importantly, will show you the updated data pairs and the data points that are most often missed. Registered attendees will receive a list of worksheets that contain the duplicates, triplicates, reversals, additions and terminations for Version 15.2, which are effective July 1, 2009

Space is limited. Reserve your webinar now by visiting Frank’s website.

Did you find this information helpful? If you have information that you think would be valuable to the medical community and would like me to post the information on our blog, please submit your request for review to my attention at (or via DM on Twitter @fimed).