As much as coding and billing is an art; it can also be a science. One insurance company wants a certain CPT code with one modifier, another wants no modifier at all, and yet another insurer wants a totally different modifier for that same code. That is one of the unpleasant aspects of coding and billing which makes it an art; among many other egregious insurance company practices that keep us all guessing as to what they really want.
In this issue we will focus on the aspect of coding and billing that makes it a science. It is, of course, in constant flux, and the wise biller will daily revise her or his numbers to keep as accurate a log as possible. Our goal is to learn what each insurance company pays in our individual localities on every procedure performed in our clinics. This will allow us to make a monthly forecast of the coming month’s insurance receipts.
We must also do this for each patient, by procedure code.
The way I do this for my clients is through two spreadsheets that I have created for their practices. The first lists our five major insurance companies; Aetna, Blue Cross, Cigna, Medicare, and UnitedHealthcare. Then, one column lists the lowest amounts either paid or allowed by that insurer, and the other column lists the highest amounts. I like to use paid so that I have a more accurate reflection of what we can expect. Additionally, when you use allowed, you may not know at what percentage the insurance company will pay in every case.
That method gives you an accurate lowest and highest amount paid for each code by each insurance company. This is good for keeping you ever mindful of the relative values of codes, which is vital information to a healthy practice. Keep in mind, just because the CPT assigns a RVU (relative value unit) to a code, it does not mean the insurance company will agree. Sometimes insurance companies use statistics for how many doctors are performing that code in a specific geographic area and what they charge. For example, in my West Palm Beach client’s office, Aetna assigns a higher relative value unit to 97530 than it does to 97112, which is actually right in line with the CPT. However, in my Hallandale Beach client’s office, they give 97530 a much lower relative value than 97112.
If I had to choose between both of these methods, I would choose this latter; collecting information by patient, by procedure code, using EOB (explanations of benefits) to aggregate the data. After the initial visit (E/M, x-ray, etc.), I could then calculate based on the treatment plan. For instance, say “Patient X” is scheduled for three times per week for four weeks. Perhaps we bill a 98941, 97112, and 97110. Maybe this patient has Aetna. On these, in our locality, let us say 98941 gets $50, 97112 gets $46, and 97110 gets $44. The total is $140. If the treatment plan calls for the 12 visits to contain these same three codes, then we can multiply $140 by 12 and see that we will likely receive at least $1,680, assuming the deductible was met by the initial visit. If the treatment plan calls for something else, then we can use our general spreadsheet and make an educated guess as to what will pay on the codes we will use in our plan.
These two spreadsheets, used in concert, will give you the useful information that will help you grow your practice, predict monthly insurance income, and make coding and billing even more exciting (if you are the geek that I am when it comes to these things).
In closing, think of the fun you could have as an office if each month you set goals for each procedure performed. For instance, let us say you want at least 20 new patient exams this month. Let us say, three are Aetna, five are Cigna, seven are Blue Cross, and five are UnitedHealthCare. (Medicare will not figure in that number until / unless they actually pay for E/M in the chiropractic setting.) Then, you can make a board that lists your monthly goals, by procedure, by insurance company, and keep it updated daily or weekly. The wise chiropractic office would create an incentive to encourage this practice among its staff!
That brings us to our topic for the next issue; an accurate insurance verification.
Edward M. Tucker codes, bills, and works on appeals for clients in Arizona and Florida. Ed has worked in both Chiropractic and Medical Offices since 1996. While Ed has performed coding and billing for medical doctors, optometrists, and psychologists, his passion is Chiropractic, because he sees it as the “ounce of prevention that is worth the pound of cure.” He has also taught Medical Coding and Billing, Introduction to Allied Health, and Medical Office Procedures, among other classes, at a local college in West Palm Beach, Florida. Additionally, Ed is a textbook reviewer, and has completed three assignments for Prentice Hall/Pearson Publishing. One of his greatest accolades came just this year, as he was listed in the current edition (17th) of the ChiroCode DeskBook in the Acknowledgment section for his ongoing work on various “chirocentric” projects. He is a graduate of the University of Alaska, Anchorage, with a B.A. in Political Science.
To contact Edward M. Tucker - Coding / Billing / Appeals Consultant