The Ultimate 2025 Guide to Neonatology Billing for Healthcare Professionals
Establishing the Scene: Why Neonatology Billing Differs from Other Fields No other area of medical billing demands the same level of precision and understanding of coding rules as neonatology. In contrast to general pediatrics or adult medicine, neonatology billing is characterized by its intricate nature high-acuity cases, extended hospital stays, numerous daily encounters, and an endless array of codes that may appear similar yet convey vastly different meanings. As we move into 2025, neonatology billing is undergoing continuous transformation, influenced by updates in CMS reimbursement, specific payer regulations, and ongoing modifications in CPT and ICD-10-CM coding. Providers and billing teams who do not keep abreast of these changes risk facing delayed payments, denials, or underpayments, which can have a significant adverse effect on revenue. Consider this blog as a guide. In the following sections, we will explore: The CPT and ICD-10-CM codes pertinent to neonatology billing The billing and coding guidelines that are specific to this specialty The reimbursement updates for 2025 and their implications for your revenue cycle Helpful tips, tables, and FAQs to simplify daily billing tasks Essential Neonatology Billing Guidelines for 2025 Neonatology billing adheres to regulations that are markedly different from those of standard pediatric billing. Below are some of the key guidelines for 2025: 1. Age-Specific Coding Neonatal codes are applicable solely to infants who are less than 28 days old. Once the infant surpasses this age, providers must transition to pediatric critical care or subsequent hospital care codes. 2. Per-Day Billing Inpatient services in neonatology are generally billed on a per-day basis rather than per visit. For instance, CPT 99468 pertains to the initial day of care for a critically ill neonate, while 99469 is designated for each subsequent day. 3. Prohibition of Double-Dipping Only one neonatologist or qualified provider is permitted to bill per day for the same patient under neonatal critical care. If multiple providers from the same group attend to the infant, only a single claim should be submitted. 4. Critical Care vs. Intensive Care Critical care codes (99468/99476) are designated for critically ill neonates who require life-sustaining interventions. Intensive care codes (99477/99480) apply to patients needing high-level care that is less acute. What are the Common CPT Codes in Neonatology Billing? Here is a simplified table outlining the most commonly utilized CPT codes in the field of neonatology: Code Range Description When to Use 99468 Initial neonatal critical care (per day) For the first day of critical care for neonates under 28 days old 99469 Subsequent neonatal critical care (per day) For each subsequent day of critical care 99477 Initial hospital care, neonate intensive care For non-critical intensive care on the first day 99478–99480 Subsequent intensive care, per day Categorized by weight: <1500g, 1500–2500g, >2500g 99460–99463 Newborn hospital care Routine care for normal newborns, not critical 99464 Attendance at delivery For the neonatologist’s presence during delivery 99465 Delivery room resuscitation Applicable when active resuscitation is conducted Tip: It is essential to document birth weight, gestational age, and interventions meticulously these factors frequently influence the appropriate CPT code. What are the common ICD-10-CM Codes in Neonatology Billing? Accurate diagnosis coding is equally crucial. Insurance providers require precision, and any unclear ICD-10 coding may lead to claim denials. Below are general ICD-10 codes relevant to neonates: Category Examples Prematurity P07.01 (Extremely low birth weight), P07.30 (Premature newborn, unspecified weeks) Respiratory Issues P22.0 (Respiratory distress syndrome), P28.5 (Respiratory failure) Infections P36.0 (Sepsis of newborn due to Group B streptococcus), P39.9 (Neonatal infection, unspecified) Jaundice P59.9 (Neonatal jaundice, unspecified), P59.0 (Neonatal jaundice associated with preterm delivery) Hypoglycemia P70.1 (Neonatal hypoglycemia) 2025 Reimbursement Changes to Monitor As we enter 2025, there are several significant updates that neonatologists and billing teams need to adjust to: RVU Adjustments: CMS has made a slight increase in RVUs for neonatal critical care codes (99468–99469) to more accurately reflect the level of care provided. Bundled Payments: Certain private payers are testing bundled payments for extended NICU stays, which may result in changes to daily billing practices under specific contracts. Telehealth in NICUs: The range of CPT codes for telehealth consultations in neonatal environments has broadened, although reimbursement remains dependent on the payer. Pro Tip for 2025: Always verify payer-specific policies. While Medicare sets the standard, commercial insurers frequently impose stricter regulations, particularly in the field of neonatology. Neonatology Billing in 2025: A Comprehensive Guide for Providers How Can You Ensure Precise Documentation for Neonatology Billing? Documentation serves as the foundation for effective neonatology billing. If the notes lack clarity, coders are unable to assign the correct CPT or ICD-10 code, leading to potential denial of reimbursement by payers. The positive aspect? By employing the right strategies, providers can capture every essential detail that substantiates billing. Here’s what must consistently be included in neonatology documentation: Birth weight and gestational age: These factors determine the applicability of intensive care or standard newborn codes. Interventions conducted: Such as ventilation, resuscitation, central line insertion, or phototherapy. Daily progress: Changes in condition must be recorded to validate ongoing billing for critical or intensive care. Consultations or procedures: Each intervention should be linked to the medical necessity documented in the medical record. Example: A premature infant weighing 1200g, receiving ventilator support, diagnosed with respiratory distress syndrome, corresponds to CPT 99468 (initial neonatal critical care). A stable term newborn needing only standard monitoring post-delivery corresponds to CPT 99460 (initial normal newborn care). Tip: Instruct providers to document with billing considerations in mind. A few additional lines of clinical information can avert denials in the future. What Are the Most
CPT vs HCPCS: What’s the Difference in Medical Billing Codes?
Medical coding mistakes result in an annual cost of approximately $36 billion to the U.S. healthcare system, with as many as 12% of claims exhibiting inaccuracies, a degree of loss that jeopardizes numerous practices. With 420 updates to the CPT codes in 2025 alone, which include 270 new codes, 112 deletions, and 38 revisions, along with quarterly updates to HCPCS, the importance of precise code selection has never been more paramount. A single incorrectly interpreted code can determine whether a practice receives $150 in reimbursement or nothing at all. Such inaccuracies frequently lead to audits that can incur costs of tens of thousands of dollars in legal fees and staff time, even if the practices are ultimately deemed compliant. This guide equips healthcare providers with the essential skills required to accurately decode CPT and HCPCS codes, make well-informed selection choices, and safeguard practice revenue through correct code interpretation. Breaking Down Procedure Code Formats Grasping the structural logic underlying CPT and HCPCS codes is fundamental to accurate code selection. CPT Five-Digit Numbers Format CPT codes adhere to a logical five-digit numeric structure that conveys information regarding the service category and its complexity: Code Range System: The six primary sections of CPT Category I codes and their sequences are: Evaluation and Management (98000-98016, 99202-99499) Anesthesia (00100-01999, 99100-99140) Surgery (10004-69990) is further subdivided into smaller groups based on body area or system within this code range Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) (70010-79999) Pathology and Laboratory (80047-89398) Medicine (90281-99199, 99500-99607) CPT Codes Categories: CPT Category I: The most extensive collection of codes, comprising those frequently utilized by providers to report their services and procedures. CPT Category II: Additional tracking codes employed for performance management. CPT Category III: Temporary codes utilized to report emerging and experimental services and procedures. Example Decoding Process: Take CPT code 99213: 99: Represents the Evaluation & Management section 2: Denotes office/outpatient visits 13: Signifies established patient with moderate complexity The numerical sequence within ranges generally suggests an increase in complexity or time requirements. Code 99213 necessitates more effort than 99212, yet less than 99214. Category Identification: Category I: Standard five-digit codes (99213, 27447) Category II: Four digits plus the letter “F” for quality measures (4000F) Category III: Four digits plus the letter “T” for emerging technology (0001T) HCPCS Letter-Number Combinations HCPCS functions as a two-tier system where comprehending both levels is crucial for precise code interpretation: HCPCS Level I HCPCS Level I is composed entirely of CPT codes, which are the same five-digit numeric codes upheld by the AMA. When billing Medicare or Medicaid, these CPT codes effectively transform into HCPCS Level I codes: Example: CPT code 99213 transitions to HCPCS Level I code 99213 when billing Medicare Structure: Five digits, all numeric Usage: Physician services, procedures, evaluations Interpretation: Identical to the CPT decoding process HCPCS Level II Level II employs a more straightforward categorization system where the initial letter directly indicates the type of service: Key Letter Categories: A-codes: Transportation and medical supplies (A0426 = ambulance service) B-codes: Enteral and parenteral therapy (B4034 = enteral feeding supply) C-codes: Outpatient PPS temporary codes (C1725 = catheter) E-codes: Durable medical equipment (E0118 = crutches) G-codes: Medicare temporary procedures (G0442 = annual wellness visit) J-codes: Injectable drugs and biologics (J0135 = adalimumab injection) L-codes: Prosthetics and orthotics (L3300 = ankle foot orthosis) Example Decoding Process: Consider HCPCS Level II code J0135: J: Clearly denotes the category of injectable drugs 0135: Unique identifier for adalimumab, 20 mg dosage The four-digit number in Level II offers precise identification within each letter category, often encompassing dosage, size, or duration details. What Code Structure Tells You As a healthcare provider, it is essential to comprehend the code structure alongside the format identification of CPT and HCPCS. This understanding is vital for grasping the billing regulations, complexity levels, and payer stipulations. CPT Structure Insights HCPCS Structure Insights Higher numbers within ranges generally signify more intricate procedures. Letter category dictates billing regulations and documentation necessities. Sequential codes frequently denote related procedures of escalating intensity. Numbers typically indicate precise quantities, dosages, or equipment specifications. Modifier-exempt codes come with specific billing limitations. Equipment codes often differentiate between rental and purchase options. Choosing Between CPT and HCPCS for Similar Services When both CPT and HCPCS codes are available for the same or comparable services, selecting the incorrect code may lead to denials, diminished reimbursement, or triggers for audits. Medicare Preference for HCPCS Level II Medicare consistently shows a preference for HCPCS codes whenever both options are available. This is particularly applicable to: Equipment and supplies: Always utilize E-codes for durable medical equipment. Injectable drugs: J-codes are necessary for billing medications. Transportation: A-codes are obligatory for ambulance services. Prosthetics: L-codes are essential for coverage. Example: If a patient requires a wheelchair following surgery, use E1130 (the wheelchair HCPCS code) for Medicare billing, rather than solely relying on the CPT training code. Commercial Payer Variations Commercial insurers frequently favor CPT codes over HCPCS alternatives. They may: Compensate differently for the same service based on the type of code used. Mandate prior authorization for HCPCS codes but not for CPT codes. Implement network limitations for specific HCPCS codes. Specificity Advantages HCPCS codes typically offer more precise descriptions: Drug codes: Indicate exact dosages (J0135 = adalimumab 20mg compared to the generic CPT injection code). Equipment codes: Detail specific features of devices. Service codes: May define patient demographics or timing. This level of specificity minimizes claim ambiguity and enhances approval rates. Reimbursement Rate Differences Payment amounts can differ significantly between code types: Omitting HCPCS drug codes: Can result in a loss of over $1,000 per injection. Equipment billing: Distinct HCPCS codes can generate additional monthly rental income. Bundling variations: Certain codes may package services in different ways. How Coding Errors Result in Financial Losses With 270 new CPT codes set to be introduced in 2025 and quarterly updates to HCPCS, practices are at a heightened risk of errors: Usage of deleted codes: The submission of outdated codes leads to automatic
Cardiology Billing & Coding Manual: 2025 CPT, ICD-10, and Reimbursement Essentials
Cardiology is one of the most intricate and high-stakes specialties within the medical domain, resulting in a similarly intricate billing landscape. By 2025, modifications in CPT/ICD-10 coding and the introduction of new reimbursement frameworks have shifted the focus on accuracy and compliance to a new level. Core Cardiology Billing & Coding Guidelines in 2025 Cardiology billing generally encompasses: Evaluation & Management (E/M) services Diagnostic testing (e.g., EKGs, echocardiograms, stress tests) Interventional procedures (e.g., stent placement, ablation) Follow-up care & chronic disease management General Billing Best Practices Tip No. Billing Practice 1 Always verify payer-specific regulations before billing. 2 Correctly align CPT and ICD-10 codes to demonstrate medical necessity. 3 Employ modifiers (e.g., 26, TC, 59) to clarify the role or portion of a procedure. 4 Maintain thorough and consistent documentation of the codes used. 5 Monitor denials to enhance pre-bill scrubbing. Common Billing Modifiers in Cardiology Modifier Purpose 26 Professional component TC Technical component 59 Distinct procedural service 76 Repeat the procedure by the same physician. 91 Repeat diagnostic test Most Common CPT Codes in Cardiology (2025) Below are commonly billed CPT codes along with their general descriptions (always confirm current descriptors and regulations): CPT Code Description 93000 Electrocardiogram (EKG) with report 93306 Echocardiogram with Doppler and color flow 93458 Left heart catheterization with imaging 92928 Coronary stent placement (initial vessel) 93656 Electrophysiologic ablation therapy 93015 Cardiovascular stress test (includes supervision) Pro Tip: Ensure to document whether the cardiologist interpreted the test or if it was conducted at a different facility to accurately apply modifier 26 or TC. ICD-10 Codes Frequently Utilized in Cardiology Correct coding for diagnoses is essential for establishing medical necessity and influences reimbursement: ICD-10 Code Description I25.10 Coronary artery disease without angina I10 Primary hypertension I50.9 Unspecified heart failure I48.91 Unspecified atrial fibrillation R07.9 Unspecified chest pain Z95.1 Presence of aortocoronary bypass graft Reimbursement Trends for 2025 (Overview) Medicare and private insurers have modified relative value units (RVUs) and have bundled certain services as part of value-based care initiatives. There is a heightened focus on: Documentation of medical necessity Appropriate use criteria (AUC) Time-based evaluation and management (E/M) codes Bundled payments for diagnostics and interventions Reimbursement has seen a slight increase for high-risk procedures such as electrophysiology ablation, while there has been a modest decline for routine EKGs and stress tests following new CMS efficiency evaluations. ICB Interventional Cardiology Billing and 2025 Reimbursement Coding Interventional cardiology presents challenges not only in clinical practice but also in billing. Whether performing a catheter-based stenting procedure or complex electrophysiological ablation, high-value services necessitate precision in coding. A single error could result in denial or underpayment. Interventional Cardiology: Essential Coding and Billing Information Interventional procedures typically encompass several components: Diagnostic catheterization Angioplasty Stent placement Imaging guidance Intracoronary devices (such as atherectomy) Note: Numerous interventional procedures are either mutually exclusive or bundled. Be familiar with your NCCI edits. Key CPT Codes for Interventional Procedures CPT Code Description 2025 Notes 92928 Coronary artery stent placement. Still billable separately, but documentation must demonstrate necessity. 93458 Left heart catheterization with imaging. Use only when not bundled with another service. 92975 Coronary thrombectomy CMS is now bundling this in most STEMI cases 92933 Atherectomy with angioplasty Reimbursement has increased by approximately 3% for 2 93580 ASD closure via catheter Time-based RVU adjustment ensures a full intraoperative note Reimbursement Rates for 2025 (Medicare Averages) Procedure Avg. Reimbursement (2024) Avg. Reimbursement (2025) Change Coronary stent 92928 $1,050 $1,020 -2.9% Left heart catheterization 93458 $810 $790 -2.5% Atherectomy $1,200 $1,236 +3% Ablation for Afib 93656 $1,500 $1,560 +4% Tip: Private payers generally reimburse 20–30% more than Medicare, yet they frequently adhere to CMS bundling policies. Common Reasons for Denials in Cardiology Billing Reason for Denial How to Avoid It Missing or unsupported documentation Ensure to include procedure reports, imaging, and symptoms. Incorrect modifier usage (26, TC, 59) Confirm the setting, provider role, and equipment usage. Duplicate billing Utilize modifier 76 or 77 when repeating in the same session. Procedure not medically necessary Attach the relevant ICD-10 codes and AUC documentation. Exceeded frequency limit Review payer rules for stress tests, echoes, etc. Pro Tips to Maximize Revenue in 2025 Bundle Smartly: Understand when to separate components or bundle services. Use Real-Time Eligibility Checks: Prevent unexpected denials due to inactive coverage or authorization requirements. Stay Informed on RVU Changes: Minor percentage adjustments can significantly affect annual revenue. Document Operator Skill: For catheterizations and interventions, ensure it is recorded that a cardiologist performed the procedure, not a technician. Diagnostic Assessments, Evaluation and Management Codes, and Telecardiology Billing Practices in 2025 Although high-tech interventions receive considerable attention, the core of cardiology billing often relies on non-invasive diagnostics, follow-ups, and remote cardiac care. In 2025, CMS and private payers will continue to refine their strategies regarding telehealth, chronic care management (CCM), and time-based evaluation and management (E/M) coding. Diagnostic Cardiology Testing: CPT & ICD Pairings These examinations may be standard, yet erroneous billing can still incur costs. Be cautious of the distinctions between professional and technical components, global billing practices, and the alignment of documentation. CPT Code Test Type Modifier Needed 2025 Tip 93000 Standard 12-lead EKG Global (no modifier) Still widely covered, but verify frequency limitations 93010 EKG interpretation only 26 Utilize if conducted at the facility, but interpreted remotely 93306 Echo complete with Doppler Often, global Codes combine with ICD codes such as I50.9 or I25.10 93350 Stress echo Global/26/TC Medicare is intensifying scrutiny – must demonstrate symptoms 93224 Holter monitor, 24-48 hours Bundled service Ensures transparent reporting of all components ICD-10 Codes That Support Medical Necessity ICD-10 Code Description R07.89 Chest pain, other specified I42.0 Dilated cardiomyopathy I48.91 Unspecified atrial fibrillation I49.5 Sick sinus syndrome Z13.6 Screening for CV disorders (rarely reimbursed unless risk-based) Tip: Echo or EKGs requested without any symptoms or cardiac history may be rejected as screening, even if the patient is over 70 years old. Always connect to a symptom or diagnosis. E/M Coding for Cardiology in 2025 Evaluation & Management (E/M) services continue to
What Is Accounts Receivable (AR) in Medical Billing? Everything You Need to Know
In medical billing, AR stands for accounts receivable. It represents amounts owed to healthcare providers for services already provided. This includes outstanding patient and insurance payments. In this article, we’ll discuss the importance of AR, common challenges, and tips for managing AR effectively. Quick Info Accounts Receivable (AR) is the money a medical practice is owed for services provided. Effective AR management includes tracking charges, payments, adjustments, and denials to ensure your medical practice’s financial health and liquidity. Outsourcing AR management can improve efficiency and cash flow, allowing you to focus on patient care while reducing operational costs. What is Accounts Receivable (AR) in Medical Billing? In medical billing, accounts receivable (AR) represents amounts owed to a medical practice for services already provided. This is money that has not yet been paid by the patient or insurance company. AR monitoring allows healthcare providers to track amounts owed by patients and insurance companies, giving them better visibility into their financial situation. Effective accounts receivable management ensures a healthcare practice’s liquidity and financial stability, allowing it to provide quality patient care without interruption. AR Medical Billing Process The AR medical billing process includes several important components that impact the financial success of the entire medical practice. These elements include fees, payments, adjustments, and denials. Charges: The amount charged to the patient or insurance company for services provided. Payment: Money received from the patient’s insurance company, Medicare, Medicaid, or other payers. Payments come from a variety of sources, including: Adjustments: When contracts, discounts, and depreciation reduce the fee billed. For example, if an insurance company pays $800 for a $1,000 bill, the $800 is reflected in the accounts receivable balance. Denials: When a payer denies reimbursement for services provided to the medical practice. Effective accounts receivable management ensures your practice’s liquidity and financial stability. Monitoring your accounts receivable helps you maintain the cash flow you need to pay employees, pay invoices, and invest in new technology and services. Late payments can be devastating to a practice’s finances, making it difficult to pay employees, pay invoices, and invest in new technology and services. A strong accounts receivable system ensures that invoices are paid on time, ensuring stability and continuity of your medical practice’s operations. Monitoring your accounts receivable helps you avoid lost revenue and missed collection opportunities. AR vs. AP: What’s the Difference? Understanding the difference between accounts receivable (AR) and accounts payable (AP) is important to managing your medical practice’s financial success. AR represents amounts due to your medical practice. AP represents money your medical practice owes to suppliers and creditors. Managing accounts receivable ensures you receive payment for services provided, which is important for cash flow and financial stability. Managing accounts payable ensures you pay invoices and vendors on time, which is important for maintaining good relationships with suppliers and avoiding late fees and interest. Effectively managing accounts receivable and payable is important to the financial success of your medical practice. Challenges with Medical Billing, Accounts Payable Several common challenges with medical billing and accounts payable can affect the financial success of your medical practice. These challenges include: Insurance claim denials Bad debt Disorganized debt collection process Insurance claim denials Insurance claim denials are one of the biggest threats to a healthcare provider’s financial stability. If a claim is denied, you won’t get your money until the claim is resubmitted, which can take months. Bad debts Bad debts occur when patients don’t pay some or all of their medical bills. This can happen when patients are uninsured or underinsured, or when they receive high medical bills but can’t pay them. Bad debt can be a big challenge for healthcare providers, especially those with a high percentage of self-pay patients. Disorganized debt collection process A disorganized debt collection process can affect a healthcare organization’s ability to effectively manage accounts receivable. Lack of proper tracking of accounts receivable leads to late payments and an increase in accounts receivable balances. A disorganized debt collection process can be caused by a lack of manpower, a lack of training, or a lack of technology. Unpaid patient liability Expensive health insurance contracts and rising medical costs have led to an increase in unpaid patient liability amounts. When patients shoulder a large portion of medical expenses, they are more likely to delay or ignore payment. Medical Expense Deductions Medical expense deductions represent amounts that a medical practice writes off as uncollectible. These include unpaid patient debts and bad debts. Unjustified write-offs of medical expenses can have a devastating effect on a medical practice’s financial success. Effective accounts receivable management can help minimize unjustified write-offs and reduce lost revenue. Disorganized debt collection process Another common challenge healthcare settings face when managing accounts receivable is a disorganized debt collection process. A disorganized debt collection process can lead to confusion and delays in payment collection, leading to increased outstanding balances and delayed refunds. A disorganized debt collection process can be caused by: Lack of standardized procedures Unclear or missing documentation Poor communication between the front office and the billing staff Best Practices for Accounts Receivable in Medical Practices Managing medical billing accounts receivable can be difficult, but there are some proven methods you can use to overcome common challenges. These best practices include: Regularly monitor accounts receivable Automate your accounts receivable processes Collect patient payments at the point of service. Collecting patient payments at the time of service is one of the most effective ways to reduce outstanding balances and increase cash flow. Collecting patient payments up front allows you to avoid issuing invoices and chasing outstanding balances. This is especially important in practices with a high self-payer population, such as dermatology and plastic surgery. Offering financing options and no-interest payment plans to patients can help you collect more funds up front. Provide patients with cost estimates. Providing patients with cost estimates before a treatment or procedure is important for patient financial planning.
12 KPIs for RCM: How to Monitor and Improve Performance
How well is your medical practice’s revenue cycle going? No matter where you are currently, there’s always room for improvement and eliminating inefficiencies. But which KPIs should you pay attention to? In this article, we’ll look at 12 key metrics that can help you achieve a strong financial position. Why are revenue cycle KPIs important? Running a successful medical practice or healthcare business requires tracking a variety of metrics. Revenue cycle KPIs are especially important because they help you track essential financial indicators and assess the overall health of your operations. They also reveal areas where you can improve your processes. A strong revenue cycle keeps your business stable and maintains a steady cash flow. This stability allows you to allocate resources more effectively and strategically scale your team, so you can care for more patients or expand your scope of practice. Revenue Cycle Management Challenges and Pain Points Inefficient patient access for appointments and registrations The revenue cycle starts with patient access, and this is where many problems begin.Inefficient or confusing scheduling systems can lead to missed appointments and low utilization of services, and often fail to meet today’s expectations for easy online booking. Implementing online self-scheduling empowers patients to book their appointments, reducing no-shows and making better use of physician time.Key metrics to look at include missed appointment rate, which indicates ease of appointment availability and better use of physician time; and tracking online registration usage, registration errors, and patient satisfaction. Manual management of claims and denials Processing claims often requires a lot of manual work, from checking payer updates to classifying billing codes. Not only is this stressful for staff, but it also increases the chance of errors and denials, which can slow down cash flow. To improve this, focus on good claim rates and frequency of denials. Automating the claims process with a cloud-based EHR can help reduce denials by predicting and preventing issues, making your team’s work easier. Inconsistent Patient Intake As patients are expected to pay more of their medical costs, a clear and effective billing approach is important. Simplifying billing and offering convenient payment options is key to improving collection rates. Here’s what you can do: Use data analytics to identify trends and patterns in billing and collections to better understand and solve problems. Provide patients with out-of-pocket estimates before their visit. This helps set expectations and avoid surprises. Accept a variety of payment methods, including credit/debit cards, online payments, and mobile wallets. Send reminders about upcoming payments and past due amounts via multiple channels (email, SMS, phone). Get actionable insights This complexity makes it difficult to understand the connections between different areas like patient access, collections, claims management, and payer contracts.To make sense of the data, use revenue cycle analytics tools that consolidate information and provide real-time insights.A well-designed dashboard can help you track important KPIs and identify trends over time, turning complex data into actionable information. What is a KPI Dashboard? Revenue cycle KPI dashboards are valuable tools for healthcare organizations that provide real-time insight into billing and revenue metrics.Because it is integrated into your Revenue Cycle Management (RCM) platform, it can be customized to highlight the key performance indicators that matter most to your business.This dashboard allows practice managers to closely monitor important financial transactions, which in turn allows for more informed decisions and improved overall performance. Revenue Cycle KPI Dashboard helps to: Improve cash flow Reduce bad debt ⢠Improve overall financial performance Identify operational inefficiencies Predict the future Improve patient satisfaction Days Receivable Ideally, this number should be low, as it means your cash flow is in good shape.If you wait more than 50 days, it could be an indication that you have issues with cash flow and covering expenses.To reduce this time, consider tightening your payment policies or offering early payment incentives. To determine your days receivable, use this formula: Days receivable = (Total accounts receivable / Average daily sales) Accounts receivable past due rate This metric helps you understand how long your unpaid invoices have been past due.Split your accounts receivable into time categories such as 0-30 days, 31-60 days, 61-90 days, and over 90 days.If many of your accounts receivable are over 90 days past due, it’s time to rethink your collection strategy to get paid in the first category (0-30 days). This can be calculated using the following formula: Receivables by Due Date Ratio = (Number of Open Receivables in Time / Total Number of Open Receivables) * 100% Perfect Claims Allocation This tracks the percentage of claims that were processed without issues, such as rejections, missing information, and errors.A higher ratio means that your billing and management processes are up to date.A lower rate can mean you have to work harder to avoid payment issues. To improve your clean claims set, try these tips: Train your team thoroughly in medical billing practices Establish and follow clear procedures to ensure consistency Use the following formula to calculate your clean claims rate: Unconfirmed claims rate = (Unconfirmed claims / Total claims) * 100% Claim denial rate This metric indicates the percentage of claims that are denied by the insurance company or the patient.A high denial rate can wreak havoc on your revenue cycle and overall operations.Common reasons for denials include coding errors and incomplete information.Keeping an eye on this rate can help you address issues before they escalate. Denial rate = (number of claims denied / total number of claims) * 100% Appeal rate Your appeal rate indicates the percentage of denied claims that you appeal.The decision to appeal all claims or only high-value claims depends on your practice’s approach. To calculate your appeal rate, use: Appeal rate = (number of claims disputed / total number of claims denied) * 100% Bad Debt Ratio This key figure tells you the percentage of accounts receivable that are uncollectible and need to be written off.A high bad debt ratio indicates that you need to improve your debt collection process.Some bad debts are inevitable, but you can
Physician Billing vs. Hospital Billing: What’s the Real Difference?
Physician billing and hospital billing are often confused, but there are some key differences. Both present their challenges and necessitate expertise to navigate their complexities. A clear understanding of these billing processes is critical for financial management, improving patient care, and streamlining revenue cycle operations. Physician Billing Requirements: Physician billing necessitates meticulous attention during the treatment process. This includes: Carefully recording patient visits classifying services provided It is important to take note of any necessary subcodes/modifiers to ensure complete reimbursement. Healthcare providers maintain comprehensive documentation for each patient visit, which includes demographic information, medical history, symptoms, diagnosis, treatment plans, and other pertinent data. The utilization of alphanumeric medical codes alongside any required supplementary information facilitates the accurate assessment of physician reimbursement. Hospital Billing Requirements: Hospital billing employs a standardized set of codes; however, it is more intricate due to the diverse array of services offered within hospitals.Hospital billing begins when a patient is admitted to a facility and continues until they are finally discharged. Hospital billing necessitates the use of a chargemaster, a comprehensive database that catalogs all the services for which a facility can issue charges. Healthcare professionals thoroughly document every aspect of the patient’s care during the stay, including diagnosis, treatment, procedures, medications, and any additional services provided. Key differences between medical billing and hospital billing Scope and extent of services Physician billing focuses primarily on individual patient visits in clinics and private practices, and billing staff must use only a small portion of the codes. However, hospital billing employs nearly all sections except for the most specialized ones, and larger hospitals might utilize the complete code set, necessitating more skilled coders and billing staff. Documentation and coding practices Effective hospital billing depends on a collaborative effort in documentation and coding. Many health care professionals work together to fully and accurately document patient interactions and services provided. Physicians and staff can do this at the point of care, making it more targeted. Revenue Streams and Reimbursement Models In this system, healthcare providers are compensated for each service provided based on a pre-determined fee structure. This structure incentivizes healthcare providers to deliver a broader range of services, as their compensation is linked to the volume and complexity of patient visits. Hospital billing, on the other hand, employs various reimbursement methods, including prospective payment systems (PPS), diagnosis-related groups (DRGs), and value-based reimbursement contracts. These systems determine payment based on the patient’s diagnosis, length of stay, and case complexity. Administrative Workflow and Responsibilities The administrative workflow associated with physician and hospital billing varies greatly depending on the scope of each.Medical billing may occur within an individual practice or a medical group. Hospital revenue cycle management and billing operations require a dedicated billing department or an experienced medical billing expert service. Optimize Hospital and Physician Billing If you are dealing with medical or hospital billing, it is essential to have an effective process in place along with a skilled billing team.With the right support, providers can receive maximum reimbursement and minimize the burden of revenue management. Medical groups looking to improve their revenue cycle management and billing can benefit from partnering with a MedEx MBS. MedEx MBS has a proven track record in revenue cycle management, giving our clients the confidence to outsource their administrative billing processes to us so they can focus on providing excellent patient care. Our RCM solutions increase efficiency and revenue potential, enabling our clients to succeed in today’s challenging healthcare environment.
Challenges in Dermatology Medical Billing and Coding
Coders play a key role in setting these codes, and billers prepare claims based on these codes. These claims are submitted to government agencies and commercial payers to pay for services provided by a dermatologist. This includes government payments such as Medicare and Medicaid, as well as private insurance providers. Given the diversity of medical practices, including cosmetic, medical, and surgical procedures, billing can be difficult. In this process, accurate diagnosis of skin and wound types is essential, including details of procedures such as excision, scar removal, and biopsy. The world of dermatology billing and coding is fraught with challenges due to constantly changing insurance reimbursement policies. Addressing these complex issues requires a thorough understanding of healthcare regulations, proficiency in implementing changes, and ongoing compliance with ever-changing billing guidelines. The Role of Dermatology Billing and Coders The role of medical billers and coders is essential. They manage patient data, including treatment and insurance information. The financial health of a medical practice or facility depends on the strength of its billing team. However, the complexity of dermatology billing stems from the combination of medical and surgical specialties. This requires a thorough understanding of the various uses of the current and revised Comprehensive Terminology Codes (CPT). Dermatology Medical Billing Process In the initial stage of dermatology medical billing, bills are sent to patients “just in time” to avoid confusion and ensure transparency of financial transactions. This initial communication is not only clear but also effective to follow. However, denials can occur for a variety of reasons, including incorrect medical codes or information about missing patients. Therefore, maintaining the accuracy and traceability of patient records is essential to effective prevention management. The final stage of dermatology medical billing is billing, which has two functions: pre-billing and payment processing. Pre-payments are intended to provide patients with information about outstanding balances as a means of managing costs. Dermatology Medical Coding System Dermatology medical coding relies on two main systems: the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). CPT, on the other hand, includes a comprehensive set of codes for inpatient and outpatient procedures and services. Medical coding systems use CPT codes to accurately bill a variety of treatments, including extractions, scrapings, surgeries, and skin biopsies. They must include a detailed patient history, laboratory findings, and management decisions. General Medical Billing Codes Related to Dermatology Dermatology procedures and treatments are often assigned specific medical billing codes to facilitate accurate billing and recordkeeping. Below are the CPT codes found on medical billing statements for a variety of skin-related problems. CPT Codes Lesion Removal The different types of lesions include: precancerous lesions, malignant lesions, and malignant lesions, which can be removed using a variety of methods including cryotherapy, chemotherapy, laser therapy, and electrosurgery. When multiple lesions are removed in a single surgical procedure, multiple CPT codes are used to describe each lesion. Some of these codes include: 17000: This code is used for the removal of cancerous lesions; primary lesion (such as actinic keratosis) 17003: This code is used for the removal of cancerous lesions; 2-14 lesions (e.g., actinic keratosis) 17110: This code is used for the removal of malignant lesions other than hemorrhagic lesions up to 14 lesions. 11403: This code is used for the removal of malignant tumors, including the extremities, legs, arms, or trunk 11603: This code is used for the removal of malignant tumors, including the extremities, legs, arms, or trunk CPT Codes for Mohs Micrographic Surgery Mohs micrographic surgery is used to remove skin cancer. It usually occurs in multiple stages. The procedure involves removing tissue in stages and examining it under a microscope to ensure complete removal. The appropriate CPT codes are: 17311: This code is used for Mohs microsurgery with the cranial technique 1; 17312: This code is used for each additional section after the first section of Mohs microsurgery: hand, neck, foot 17313: This code is used for Mohs microsurgery of the hand, neck, and trunk using the cranial technique. 17314: This code is used for each additional section after the first section of Mohs microsurgery: hand, neck, and foot Pathology CPT Codes Pathology procedures are the examination of tissue and skin samples at the cellular level. Common pathology CPT codes are: 88304: Level III – This code is used for invasive disease, gross and microscopic examination. 88305: Level IV – This code is used for invasive diseases, microscopic and microscopic examination. 88312: This code is used for special annihilation procedures, including interpretation and reporting 88341: This code is used for immunohistochemistry or immunocytochemistry diagnostic procedures Phototherapy and Laser Therapy CPT Codes Phototherapy and laser therapy are used to treat a variety of skin conditions. The relevant CPT codes are: 96920 and 96921: These codes are used for laser treatment of inflammatory skin conditions. 96900: This code is used for radiation therapy (ultraviolet radiation) 96910: This code is used for photochemotherapy; tar and UVB, or petroleum jelly and UVB 96567: This statement focuses on phototherapy using external light to destroy cancerous or malignant lesions. J7308: This code is used to administer aminoacetyl propionate hydrochloride in phototherapy. What Modifier 25 Means Modifier 25 is a very popular term in the dermatology billing field. It is widely used, but it is often misused. This modifier represents evaluation and management (E/M) services provided by a single physician on the same day of surgery. Failure to do so can result in audit risk. The E/M designation is a significant component of medical billing, allowing healthcare providers, including dermatologists, to receive reimbursement from government payers (Medicare and Medicaid) and insurance providers. It is important to note that the (25) change should only be associated with E/M codes, not procedural codes. Key Challenges in Dermatology Medical Billing and Coding Dermatology medical billing and coding is challenging due to the complexity and ever-changing procedures, policies, and regulations. It is very difficult to document and understand the accuracy of changes. It takes a long time to obtain insurance
CPT MODIFIERS IN BILLING AND CODING
The CPT modifier (Current Procedural Terminology) consists of a two-digit code predominantly utilized in medical billing and coding practices. It serves to convey details about the medical procedures or services that healthcare providers offer to their patients. The two-digit CPT code elucidates specific treatments, variations, or circumstances involved in the care provided. CPT modifiers enhance the clarity by offering additional insights or descriptions related to the physician’s services. These modifiers distinctly articulate the medical procedure by altering its definition. This article will illuminate some of the frequently utilized CPT modifiers in medical billing, along with their interpretations. CPT Modifier 25: This modifier applies to the evaluation and management of services or procedures that the same healthcare provider provides to the patient on the same day as another professional introduces a new service or procedure. The patient can receive the services and procedures outlined by this code, necessitating further evaluation and management beyond the usual preoperative or postoperative care. This evaluation and management are driven by the patient’s condition, and it mandates reimbursement for both the procedure and the evaluation and management (E/M) components. CPT Modifier 50: This modifier signals the execution of additional procedures on both sides of the body during the same operative session. It is relevant for procedures performed symmetrically on body parts such as the eyes and knees. CPT Modifier 51: Modifier 51 indicates that two or more procedures are performed simultaneously in the same operative session. It signifies that the payer is required to provide additional reimbursement for the new procedure in the medical billing process. CPT Modifier 58: This modifier is employed for pre-arranged and documented therapy received by a patient following a major surgery. The surgical modifier 58 within medical billing is recognized as a new procedure, necessitating reimbursement for subsequent medical procedures during the postoperative period. CPT Modifier 59: Modifier 59 is used when multiple procedures are performed on the same patient on the same day, but they are not bundled together. It indicates that separate reimbursement should be provided for additional procedures in medical billing. These procedures are unrelated and may require different physicians to execute them in conjunction with the same organ or system on the same or different days. Consequently, reimbursement in medical billing is contingent on the sub-surgical CPT modifier. CPT Modifier 76: This modifier is relevant for the repetition of medical procedures on the same day due to specific medical conditions. It signifies that services or medical procedures should be repeated on the same day after the original procedure. Modifier 76 clearly distinguishes between repeated and duplicate services. CPT Modifier 78: This modifier indicates unplanned postoperative procedures, signifying the unexpected return of a patient to the operating room or procedural space immediately following the original treatment. It reflects unforeseen outcomes of earlier surgery, such as infections, hemorrhage, or debridement, which necessitate the urgent return of the patient. Importantly, the second procedure must be directly related to the initial medical procedure. Moreover, surgical modifier 78 is not exclusively for addressing complications, but also for managing all aspects of postoperative care. CPT Modifier 79: This modifier is applied when patients return to the same healthcare provider during the postoperative period to receive unrelated medical services. It involves performing different procedures or services on the same anatomical location by the healthcare provider during this time. Conclusion The article has touched on several examples of CPT modifiers. A variety of CPT modifiers exist to communicate specific information relevant to the service period. It is essential to refer to the official guidelines of CPT coding to ensure that payers can adequately compensate for the precise services coded for billing purposes. Accurate medical billing with the correct modifiers results in fewer claim denials and ultimately enhances reimbursement rates. This assists healthcare professionals in conserving funds for medical establishments.
What Makes a Laboratory Billing System Successful?
Charging strategies for Laboratories are part of the same general coding and charging framework used in various healthcare areas throughout the US, but charging services for research facilities are unique in several ways. One of the key contrasts between laboratory and other sorts of therapeutic workplaces is the number of claims prepared. A laboratory typically benefits numerous more patients each day, resulting in a large number of claims being submitted. Another distinction, and one that makes charging for such healthcare organizations especially challenging, is that laboratory claims are for relatively small sums. This makes it troublesome to give time to taking care of each dissent or dismissal since labor costs can rapidly exceed the value of the claim. The issue with giving up on refusals is that the accumulated sum of unpaid claims can quickly rise to an unsustainable sum, putting the laboratory at risk of coming up short as a commercial entity. The Best Administrations Have a Solid System For research facility administrations to be maintainable, it needs to be based on a framework that includes all angles of the laboratory as a trade and incorporates the points of interest of charging for each understanding from contact through installment. Having a framework in place builds up a rehashed plan, so time isn’t spent on figuring out how to do things that have as of now been done, and scheduling issues with claims don’t result in misplaced revenue. How to Select a Lab Charging Company The framework ought to incorporate training of all workers on the roles they are involved with, from the front office that takes the arrangement to the charging staff who send statements to patients when they have an adjustment due after testing. The framework, moreover, needs to incorporate a strategy for producing reports so that the income cycle administration (RCM) metrics are analyzed and principals are mindful of how successful that angle of the laboratory is. Tips for Fruitful Billing Address any doubts about utilizing the charging program that is always being overhauled. Codes are upgraded yearly, but safeguards and government payers make changes at diverse times. Verify qualification and decide that you have the legitimate authorizations when an arrangement is planned or an understanding arrives as a drop-in. Collect the patient’s portion of the charges when they check in. It’s much less demanding to collect forthright than to get installments for a charge in the future. Code claims ceaselessly. Permitting work to amass some time recently, it is charged lets more gets neglected and perplexities are more troublesome to sort out after more time has passed. Scrub claims day by day. An experienced restorative biller ought to check each claim for errors some time recently it is submitted. These administrations are much more productive when they incorporate a strategy for scouring that is repeated for each claim. Track claims until they are paid. Dismissals and dissents frequently get put aside and not revamped, so they never get paid, but this comes about in up to 25% of income being misplaced, which is more than a therapeutic laboratory can afford to lose. The framework ought to incorporate a way to track claims and a plan for following up on unpaid claims. Review reports, analyze issues, and communicate comes about with staff. It is critical to confirm that the sum you are paid is expanding at a rate of the sum you are charging, and the time it takes to Laboratory charging is challenging, but there are five basic ways to maintain a strategic distance from refusals for expanded collections. When it comes to dissents in research facility charging, there are two particular types of hard and soft claims. Difficult claims cannot be switched since the income has been totally composed off due to the age of the account or other components. Delicate claims; be that as it may, are, as in were, transitory refusals and can be turned around if the claim is rectified within the designated time. The five most common reasons for denied claims in research facility charging are insufficient protection scope, benefit as of now settled, copy claims, lapsed recording time, and lost data. Underneath is a breakdown of each claim denial. Getting paid is diminishing (or at the least sensible time). Dismissals and refusals ought to be surveyed to decide if there are specific payers that are issues, so the related issues can be found and addressed. When issues are found, it is vital to come up with an arrangement and ensure that any doubts, all staff involved are educated, so that no one makes the same mistakes in the future. 5 Ways to Maintain a strategic distance from Refusal of Research facility Charging Claims Laboratory charging is challenging, but there are five straightforward ways to dodge dissents for expanded collections. When it comes to dissents in research facility charging, there are two unmistakable types: hard and soft claims. Difficult claims cannot be switched since the income has been totally composed off due to the age of the account or other components. Delicate claims, in any case, are, as it were, transitory refusals and can be turned around if the claim is rectified within the designated time. The five most common reasons for denied claims in research facility charging are lacking protection scope, benefits as of now settled, copy claims, expired recording time, and lost data. Underneath is a breakdown of each claim denial. Common Causes of Denied Claims Eligibility: When a method, test, or benefit is not secured by a patient’s protection arrangement, and they did not affirm their benefits at the time recently administered services were rendered. Service arbitrated: This is when the administrations are secured by the patient’s protections; be that as it may, a claim has as of now been submitted as part of another service. Duplicate claims are claims submitted multiple times by the same supplier for the same service on the same day. The constraint for recording terminated: This sort of research facility charging dissent
Confused About PHR EMR EHR? Here’s What They Are and How They Differ
When the movement to digitize medical records began, the new terminology was not very clear, and electronic medical records (EMR) and electronic health records (EHR) were often referred to as EHR/EMR, so it is no wonder that people were confused about the terminology. Adding to the confusion, the two terms were often used interchangeably by people who did not know the difference or who thought it would be easier to use only one term. With the introduction of electronic systems and the addition of personal health records (PHRs), it is time for all of us to clarify what these various records are and how they are used. Electronic Medical Records – Patient Records on a Computer The simplest way to describe electronic medical records is that they are electronic medical records or digital medical records. EMR refers to the records or charts of individual patients, including notes on diagnoses and treatments, maintained by each facility. When you consider how easy it is to access information in digital form, the benefits of EMRs over paper records become very clear. Practices can easily send reminders for routine and preventive checkups. EMRs also allow doctors to view a patient’s medical history and track changes over time, which is very difficult when all the information is on different pages in a folder full of different reports. These combined benefits empower healthcare providers to deliver quality care overall. Electronic Health Records – Patients Networking Service Providers Traditionally, specialists have been very limited in their access to information from general practitioners and vice versa. Similarly, specialists at different facilities could not easily review a patient’s medical history from another healthcare provider. This could mean that highly relevant information is missing in medical decisions, such as when a cardiac patient suffers a stroke or a diabetic patient is involved in a car accident. Having full access to a person’s medications, medical history, and expected condition can be extremely helpful in diagnosis and treatment. Laboratories, hospitals, and specialists can all access this much-needed information. If a patient relocates to another city or state, new doctors and other health care providers can access the patient’s medical history through the electronic medical record, so important information isn’t lost every time a doctor changes. Personal Health Records – Patient Involvement in Their Own Care The same type of information found in electronic health records is also included in personal health records, but they are designed to be managed by the patient, who can access and enter their records. Personal health records include diagnoses and medications, but also store family medical history and immunization records. PHRs allow patients to update and access their information from the comfort of their own home. PHRs can be linked to EHRs, eliminating the need for patients to add all of the information themselves, resulting in a more complete record. EMR/EHR Caveats Electronic health records (EHRs) and electronic medical records (EMRs) often come with software that will “advise” you on coding. This consulting software is touted as helping you take your CPT to the next level if you document more, leading to increased revenue. Fully documenting can turn a level 3 visit into a level 4 or even level 5 visit. Level 4 and 5 claims are easily spotted and challenged. Don’t think that automated code advisors with electronic medical record software have solved these problems. Somewhere in the software documentation, there will be a disclaimer explaining that the code consultant only determines and provides advice on the appropriateness of coding, and that responsibility for the actual coding remains with the physician. Also, look at the diagnosis. The level of service provided must also correspond to the diagnosis being treated. The level of care requirements may all be well documented, but are the diagnoses being treated commensurate with the level of service? Increasingly, payers are using computer-based models to compare CPT codes to diagnosis codes and identify patterns of what may be considered overpayment for listed diagnoses. For example, it would be difficult to justify an ear infection in an otherwise healthy patient with stage 5 E/M, even if the stage 5 was fully documented per documentation standards. MedEx MBS offers a full range of healthcare revenue cycle management (RCM) services for healthcare providers of all sizes. Our innovative medical billing and practice management systems are proven to increase revenue and reduce stress for your customers. Request a demo to discuss how we can help you achieve your business goals