We’ve all felt the frustration—you check the denials report, and there it is…rejected claims due to inaccurate coding and billing. Now your billing staff must chase that money to capture the revenue rightfully earned by your cardiology practice. It seems like a never-ending problem that frustrates improvement efforts and is further complicated by changing payment structures.
As evidence that practices continue to move forward, focusing on current issues, the Medical Group Management Association (MGMA) found that over 65% of claims denied were never followed up and resubmitted for reimbursement. This abandoned revenue, which can exceed 5-10% in some practices, is left uncollected due to frustration with the denials process.
Cardiology Coding and Billing Pain Points and Possible Solutions
There seem to be three identifiable categories that constitute the largest share of denied claims. First, a lack of accurate documentation, followed by changing insurance payer rules and guidelines regarding policy, and last, the changes to codification structures and how payers recognize them. In an industry like healthcare with its complex payment system, changes are inevitable and practices can position themselves to respond proactively and effectively.
While the other challenges are largely driven by governmental or regulatory entities and private insurance payers, documentation is uniquely controlled within the practice. Your cardiology practice EHR/EMR system is only as accurate as the information entered. Simultaneously, as a specialty practice, you are working with referring providers that may or may not have provided accurate documentation as well.
A recent JAMA Network Article and Study concluded that only 38.5% of system reviews and 53% of physical examination entries matched the actual patient encounter. Likewise, coding and revenue capture suffers from poorly documented encounters, and it stands to reason that overall care is down-coded due to missing or misstated information.
Addressing these documentation challenges needs to be a paramount consideration moving forward and can be accomplished through steady training and review of the existing EHR/EMR systems, as well as supporting outreach to referring practices if necessary. This may not only reduce your claim denials and corresponding rework but also increase revenue by accurately reflect the work performed.
Billable Diagnosis Coding
Staying current on procedure and diagnosis coding has always presented a challenge. Not just the annual updates, additions and exclusions to the CPT and ICD-10 codes, but how they’re applied through the different insurance payers. A code used for a cardiology procedure or test at one carrier may be inadequate when billing another carrier because it lacks the depth of detail required.
While your practice may be able to meet the challenge of staying current with changes and the layered nuances from payer to payer, another more cost-effective solution may be to partner with a third-party coding specialist group. By collaborating with an affiliate that is focused on the vast payer landscape, your in-house team can concentrate on patient access and care.
Ever-Evolving Insurance Payer Policies
Separate from coding-specific challenges, each insurance payer releases company-exclusive updated policies throughout the year, and cardiology practices are obligated to comply as directed. Staying current can be overwhelming, to say the least.
There are over 900 health insurance companies in the US today and, while not all are operating in your area, there’s a good chance that as a specialty provider, you are contracted with anywhere from 10 to 25 different payers with seemingly countless groups and plans. Again, this may be where an outside organization can take the burden of staying current with policy changes and then applying that to your coding and billing functions on your behalf.
One thing is for sure in today’s healthcare marketplace; practices need to maximize the patient experience while capturing the revenue due to the practice for the work performed. A third-party support partner may be able to strengthen your coding and billing functions and add to your bottom line.
Contact us today to explore the ways expert coding support can improve your practice’s revenue stream.