What are EOB Claim Adjustment Group Codes?

A Claim Adjustment Group Code consists of two alpha characters that assign the responsibility of a Claim Adjustment on the insurance Explanation of Benefits.

These 5 EOB Claim Adjustment Group Codes are:

CO	Contractual Obligation
CR	Corrections and Reversal
OA	Other Adjustment
PI	Payer Initiated Reductions
PR	Patient Responsibility

These Group Codes are combined with Claim Adjustment Reason Codes that can be numeric or alpha-numeric, ranging from 1 to W2. Claim Adjustment Reason Codes are associated with an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

Top 5 examples of EOB Claim Adjustments are:

CO-45 indicates claim amount that must be written off based on payer contracted fee schedule.

CO-97 indicates the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

OA-23 indicates the impact of prior payer(s) adjudication including payments and/or adjustments.

PR-1 indicates amount applied to patient deductible.

PR-2 indicates amount applied to patient co-insurance.

For a complete list of claim adjustment reason codes, visit Washington Publishing Company's website by clicking here.

Let's look at Claim Scrubbers and how they function to optimize reimbursement of medical claims.

Let's look at Claim Scrubbers and how they function to optimize reimbursement of medical claims.

The best medical billing software will have a built in scrubber that analyzes the procedure codes on the claim for any conflicts to the NCCI edits.

If the scrubber finds no conflicts, then you can proceed with submitting your claim without any changes or corrections.  If the scrubber does show conflicts between two or more codes, then you now have the opportunity to review and adjust your claim before it is denied.

The billing software should indicate why there is a conflict and maybe all that is needed is a modifier.  For example, if it states one procedure is a component of the "larger" procedure, you know to not submit the component procedure.

When you submit a claim that is denied based solely on lack of a proper modifier, you then have to resumbit a "corrected claim".  Even thought they are indicated as a "corrected claim", you can now enter the duplicate claim denial loop. You may end up waiting months for reimbursement and wasting countless hours working with the payer to get the claim paid.  By taking a few minutes to "pre-check" the claim, all this would be avoided.

Investing in a medical billing system with an integrated claims scrubber you will see greater and faster returns in the reimbursement of medical claims.





Infrastructure is Key in Medical Billing Systems Software

Do you need have an Apple computer and require Mac medical billing software?

Do you want to get rid of that clunky server under your desk?

Do you want access to your billing system online from anywhere, even home, day or night?

Is having the ability to create workflow that fits your billing needs important?

Do you value real financial accountability?

If you have answered yes to any of these questions, then infrastructure is a driving factor when selecting the best medical billing software for your practice.

As you evaluate different medical billing systems software,  look for these key items:

• A web based system without special hardware requirements
• Compatible with Windows, Mac, Linux and other operating systems
• Remote servers maintained by the software provider
• A system truly designed around the biller's workflow
• Customization of reports and in-depth accounts receivable analysis

Finding medical billing software that offers these features will enable you and your staff to work at your highest efficiency.  You will also save money ordinarily spent on special computer hardware required by some medical billing software.

Understanding Medicare Fiscal Intermediaries LCD’s and How They Affect You

Each Fiscal Intermediary (FI) has the authority to produce their own “Local Coverage Determination” (LCD), based on national guidelines. The LCD basically defines under which circumstances a particular procedure is covered under the patient's Medicare benefits. As new procedures are developed, the FI will then set out to create an LCD. The FI will also review existing LCDs to see if changes are necessary based on treatment advances, statistical data, industry standards, etc.

How do LCDs affect you? If a procedure is planned, but the criteria of the LCD is not met, you will get a very swift denial, that turns into months of waiting for responses to appeals. If you are familiar with the parameters of the LCD, you may be able to avoid the denial or at least have the exact medical documentation needed that addresses the specific potential cause for denial. Most LCDs do contain the “Medically Necessary” clause. If your documentation can prove that the case is an “exception” to the rule and the procedure is medically necessary, you will likely be successful in your appeal.

The websites for all FIs include a search for LCDs. You can quickly and easily enter a CPT or HCPC code to get the most recent version of the LCD. Many times you can also enroll for automated email updates regarding new or changing LCDs. This also allows you to become involved in the creation/modification of the LCD, as the FI offers comment periods before making them active.

Why are Internal Chart Audits Important?

Many people are intimidated by the word “audit” and run in the other direction. Why should every practice do chart audits? It is important to inspect and verify your charts and billing practices before an insurance company calls for medical records. Doing regular chart audits sets you up for a sense of calm when the auditors do come knocking. Audits help you learn more about billing, the hierarchy of treatment, and what to expect from an insurance company before you send the claim.

When a patient is finished with treatment, the documentation needs to be matched up with the billing. It is not unusual to perform ‘spot’ audits during a course of treatment and helps the final audit process go very smoothly. A billing ‘roadmap’ or guideline is a handy tool to have available. If you use a billing guide, be sure to exercise flexibility in auditing, due to patient factors. There are no hard and fast rules when billing radiation oncology services, because every patient is different.

Steps:

First, read the original consult notes to gain understanding of the patient history, the current diagnosis, medications, and the treatment plan. You are going to use this information to form a logical sequence of events.

Next, sort the billed charges by date and read over the CPT codes. They should follow a pattern, such as pre-planning stage, treatment weeks, boost planning, etc. The dates in billing should match the documentation in the patient’s chart. Exceptions to this are acceptable (within a day or two), as long as the practice consistently bills the same way for all patients.

Pay attention to the units billed and match the number of beams or tangents with dosimetry charges, or the number of blocks with units billed for the immobilization device(s).

Count the number of treatments that were expected to be given, the number that were billed, and the number reported in the final completion note. In a perfect world, all should match, but patients get sick, discontinue treatment, or other events can change a treatment course. Just document on a checklist or in the final treatment notes what caused the discrepancy so you will remember later.

Verify that every weekly treatment management charge that you billed has a doctor’s report, and that the number of treatments divided by five equals the number of treatment management codes billed. However, keep in mind that you may have three or more additional treatment deliveries at the end of the patient’s treatment course that would result in one additional weekly treatment management charge.  The date ranges for your weekly treatment management charges cannot overlap.

Also count any port films and weekly physics codes and match them to your documentation and the number of treatments received.  Many of these documents may come from different departments. Check that all documents have been signed, initialed, or electronically signed by the doctor who is overseeing treatment.

At this time, I also like to look at the payments and/or denials that have been received in the patient’s A/R’s. This gives me an opportunity to share any research that can guide my A/R or billing person as to the reason why a service was denied improperly or should not have been billed.  It becomes apparent which services will always be bundled if billed together, or which services may require a modifier.  Refund situations can also be quickly identified and you will be in the good graces of any insurance company when you voluntarily send a refund for a billing error.

Basically, when you perform a chart audit, you are making sure that every billed charge has a document to support its existence. If you use a billing guideline or checklist, it can be included in the chart with notes or exceptions that you would like to remember later, such as why a code was not billed or why a patient did not receive the number of treatments originally planned. This way, if a chart does get pulled for an external audit, the internal audit checklist can really take the pressure off and you are not scrambling to find explanations for any inconsistencies.  A typical internal chart audit takes only 15 – 20 minutes and is well worth the time in the long run.

Knowing the difference between global, professional, and technical charges

Medical practices are almost as diverse as people in regards to the arrangements and agreements that exist between physicians and facilities. The existence of different fiscal arrangements requires that medical entities bill their charges based on the specific level of service that the entity is providing to the patient.  CMS has created billing rules to accommodate these different scopes of service by standardizing medical billing for the entire insurance industry. When a biller understands the definition of the CPT-4 codes, and modifiers, they can then bill according to CMS’s requirements. This leads to fewer denials and better payment history.

The NHIC (National Health Information Center) conducted independent audits for CMS and found that more training was needed. Specifically, their findings showed that the medical industry continues to incorrectly bill (or not bill) modifiers that are required to distinguish between the global, professional, and technical components of services. The modifier codes that distinguish these services are ‘26’ for professional components, and ‘TC’ for technical components.

The explanation per CMS, in a nutshell, is this:

The professional component of a charge covers the cost of the physician’s professional services only.  When billing for the physician’s time and expertise, a 26 modifier is added to certain CPT codes.  For example: a patient has a CT scan and the doctor interprets the results. A biller may code 77014 – 26 to indicate the charge is for the professional services only.  By adding the 26 modifier, the biller is alerting the insurance company that the claim is requesting payment for the physician’s services only and not the use of the facility, the use of the CT equipment or other support staff’s services.

The technical component of a charge addresses the use of equipment, facilities, non-physician medical staff, supplies, etc. Technical charges do not include the physician's professional fees, but include the use of all other services associated with the visit. Using the same example, a patient has a CT scan and the results are sent to the doctor for interpretation. A biller may code 77014 – TC to indicate the charge is for the technical component only.  In this case the medical claim is seeking payment for the use of the CT equipment, the facility costs and the costs associated with all supplies and staff except for the physician.

A biller will bill global charges when there is no division of the costs associated with a medical service because the service was provided by a single entity. The global charge includes both the professional services as well as all ancillary services (like use of equipment, facilities, non-physician medical staff, supplies, etc.) associated with a patient’s care.  Global charges require no modifier.  For example: a patient has a consultation with the doctor.  A biller may code 99203 with NO modifier.

Many CPT-4 codes are intended to be billed globally and may not be separated. In the practice of radiation oncology, one example is 77414 which is the delivery of radiation (by the equipment and technician). This code is billed globally with no modifiers. If the physician has a special agreement with the facility allowing her/him to bill for this service, then it would be billed globally by the doctor and not at all by the facility.

The need to separate components can be difficult to remember when billing, but is easily achieved by the use of software that recognizes when to add a modifier, and which modifier to add. Iridium Suite, for example, may be configured to bill certain code modifiers based on the objective of the treatment course, or the place of service in the case of a physician who bills from several different facilities or offices. It is important, therefore, to understand the literal description of the code being billed, as well as the fiscal agreements between the physician and facility(ies) where the physician treats patients.

Separating codes into their components can be confusing to not only practitioners and billers, but to patients as well.  The insurance company sends EOBs showing what the patient may interpret as duplicate billing due to the facility and the doctor charging the same CPT codes.  Since the majority of patients do not understand the need to separate codes into their components, it is important to understand component billing so we can explain it to the patient. Insurance companies may also ‘miss’ a modifier.  Knowing when and how to use modifiers is important in resolving claims denials and results in a better payment history in the long run.

What is Real-Time Eligibility?

Historically, when a patient with insurance came into a medical office, the staff obtained a copy of the insurance card and, if there was time, they made a call to the insurance company for eligibility status, benefits, and stop-loss information. Today, medical technology is all about networking with other systems in order to save time and increase billing success. Real-time eligibility increases staff efficiency and affords us the most accurate up-to-date patient data by performing payer inquiries online.

Real-time eligibility verification streamlines the patient intake process. In Iridium Suite for example, Real-Time Eligibility is able to verify patient insurance coverage before a patient comes through the door. Personnel can use the payer’s eligibility response to auto-generate accurate patient demographics, thus removing the need to re-key patient information and eliminating possible errors in data entry.

Real-time eligibility information returns not only the effective start and end dates of the patient’s policy, but also provides detailed benefit information with important co-pay and deductible status. Thus, we aren’t relying on what the patient can remember about their benefit plan or which out-of-pocket costs have been met in other offices. We can know in many cases what the patient’s out-of-pocket cost will be for the visit, enabling the accurate collection of fees up-front.

Using real-time eligibility, billers won’t receive claims denials for eligibility anymore, which is very costly in both time and money. The biller who receives eligibility denials has to phone the patient or the insurance company, make adjustments to demographic and insurance data, re-submit claims, and potentially wait another 30 days for the insurance company to re-process. In this day and age, there is no reason to go through all that angst!

Setting up real-time eligibility in Iridium Suite is fast and painless, requiring only a few steps. It saves the busy medical practice hundreds of dollars and hours by averting eligibility errors. Real-time eligibility is worth the effort to implement.