Can I Bill For That?

I get this question quite often, and wanted to write an article to specifically address what you can and cannot bill for.

Technically you can “bill” for anything that you do; this is not the true question. The real questions is…  should you?

Submitting medical claims includes some very specific legal requirements and practices that could be considered abuse, such as bundling and un-bundling, false reporting, up coding for more money, and improper diagnosis selection to name a few. However, how are these items identified?

We’ve all heard of audits, and dread them when they come. What triggers this type of scrutiny? Payers have sophisticated algorithms programmed into their claims processing systems that identify when a code is billed more than the average practice, when a modifier is used regularly, to detect un-bundling, to detect overuse of a specific code level, and other patterns that will trigger an audit. They are continuously updating these to match new codes, or in response to audit results in a specific region.

Overuse of a particular code can also raise flags, such as in diagnostic testing, as unnecessary testing is on the radar for most payers due to large whistle-blower cases resulting in millions of dollars in refunds.

Some common flags are inappropriate overuse of modifiers 24, 25 and 59. Always billing at a level 4 or 5 office visit, and always performing and billing for the highest level of diagnostic testing, even on follow-up studies.

Other errors include billing under the wrong rendering provider number, or billing for a rule-out or unconfirmed diagnosis. These common scenarios have their own specific guidelines to negotiate too.

Learning to recognize when a service is valid to bill and when it should be dropped entirely from a claim, or treated as a cash service, is a skill that a professional coder and biller is taught, but the rules are numerous and sometimes confusing which makes it hard for the average practice to navigate. Ideally your practice will have personnel with this training on staff, but if one is not immediately available in your office, having your processes voluntarily reviewed by a qualified outside source would be another option.

With heightened scrutiny seeming to come from all corners now, what billing practices will raise flags is something you can’t afford Not to know.

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