Medical coding and billing is an increasingly complicated endeavor. The rules change frequently, different payers have different requirements, and getting accurate information at registration is far from easy! Consultation in the areas of coding and reimbursement can help to maximize your reimbursement by:

• Assessing the accuracy and completeness of CPT and ICD-9 coding
• Evaluating the continuum of billing operations from registration through payment posting and report analysis
• Analyzing payer mix and PPO/HMO contracts for profitability and risk
• Exploring options for optimizing in-house or outsourced receivable management systems

Sample projects in the coding and reimbursement arena include:

• Coding audit for a 35 physician multi-specialty clinic: The management team of a multi-specialty clinic wanted an independent evaluation of the coding practices of their 35 physicians. Were the physicians under-coding and leaving money on the table? Were they overcoding or not providing adequate documentation for the charges and thus open to fines and sanctions when audited by an insurance carrier? Or (even worse) both? I reviewed a small random sample of charts for each physician and provided management with the information they needed in a format they could use: the executive overview showed that most physicians had solid coding and documentation practices, while a few physicians were consistently undercoding for their services. Management also received a report for each physician, detailing my assessment (by patient and date-of-service) of coding and documentation and including, where necessary, specific suggestions for improvement. At the management team's request, I discussed my findings with physicians, reinforcing good practices and offering suggestions for improvement where possible. Subsequently, revenue for the practice increased.

• Coding audits for large academic medical practices: Two teaching hospitals (one in the southwest, one on the east coast) had similar questions: with their heavy clinical, research and teaching responsibilities, were the physicians giving adequate attention to chart documentation and coding? I spent a few days on site at each practice, and, to keep costs down, prepared the reports at my office for subsequent discussion by phone. In one case, the audit indicated a pattern of serious undercoding for some services and an even more serious problem with lack of adequate documentation for services rendered. In the other case, documentation and coding were both very good but I found selected procedures where additional reimbursement could legitimately be claimed.

• Billing operations evaluations: Paying bills is no fun -- that's not news -- but sending them out is hard work, too. With a half-dozen or more steps involved in getting paid for the simplest office visit, there are too many opportunities for errors and inefficiencies to ignore. I've worked with single practitioners and multi-site, multi-specialty clinics to review the workflow from charge entry through claims submission, payment posting, appeals filing, accounts receivable follow-up and report generation. For each client I was able to make specific, implementable recommendations to improve cash flow and/or total reimbursement.

• Analysis of billing system options for a multi-site, non-profit clinic: A large non-profit clinic with nearly a dozen sites was faced with the limitations of a custom-written billing system that did not provide management at any level with the reports needed to spot and fix problems. I analyzed their needs and presented costs and benefits for three options -- two in-house systems from vendors with large installed bases and one outsourcing option with a vendor specializing in Medicaid/Medi-Cal billing. One of the in-house systems was chosen and customized to meet the operational and reporting requirements of the organization. Not only has the new system provided more detailed accounts receivable reports and better practice management reports, but the organization has seen revenue increases as well. They believe the revenue increase is largely due to improved charge capture made possible by implementation of the new system.

• Payer mix and reimbursement analysis for a solo practitioner: A solo practitioner in the San Francisco Bay area was concerned about practice vulnerability because a large percentage of patients were enrolled in a particular IPA. I analyzed the practice's payer mix and reimbursement from the top fifteen payers who constituted the bulk of the practice. Specific recommendations were made regarding which contracts should be renegotiated and which contracts were most beneficial to the practice.

Whether you are concerned about why revenues are decreasing or simply want to know that you are being paid everything you are due, I can provide analysis of your reimbursement picture and recommendations about how to make it brighter.