Grand Rounds-Practice Management Part I: How to Run an Efficient Neurosurgery Practice

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- Hello, ladies and gentlemen, and thank you for joining us for another session. Today, we have a very exciting webinar again, with Kim Pollock from Karen Zupko Consulting Company. Kim has been a great teacher in teaching CPT coding and practice management consulting for neurosurgical practices, during the double NS and CNS meetings. We're really lucky to have her with us again today. We're also lucky to have with us, Derek Cantrell, he's the Executive Director of Goodman Campbell Brain and Spine, one of my dear colleagues, who will be moderating the session with Kim. Again, thank you for joining us.

- Thank you, Dr. Cohen, for that nice introduction! And hello, Derek, how are you today?

- Hi, Kim. I'm doing well today.

- Great, thank you. This time is "Practice Management 101 for the Neurosurgeon," and we hope that you will pick up at least three pearls on helping you to manage or understand the practice management side of your business. The presentation is supported by Osteomed. And as I mentioned, I hope that you find at least three ways that you can improve your practice by increasing revenue or decreasing expenses. The first thing that I'd like to talk about is the revenue cycle. This is the activities that are required to be performed in a logical and efficient manner in order to guarantee revenue, successful revenue, to your practice. So we think of the Revenue Cycle Process as somewhat like a train. The analogy is a train. We have folks who work on the frontend of your practice, and these folks do activities, or have duties, that involve patient interaction, and that's what we call the frontend duties of the Revenue Cycle Process. And then we also have duties that have to happen on the backend side of the process, and that usually means the back office. These activities usually do not require any patient interaction. So, the information that the folks on the frontend of the Revenue Cycle Process obtain really drives the success of the people in the backend, who are doing what we you might think of as the actual collections of money. So, if we have an error made at the frontend, that will affect the backend's ability to collect. So, what are those frontend responsibilities? Well, we have things like appointment scheduling, insurance verification, check-in, the activity that you provide, which is the actual patient encounter, coding of that encounter. Then we have any tests, scheduling, or surgery scheduling, ideally your surgeon, so the goal is to schedule surgeries, and then checkout. So, as we look at each of these activities individually, I'd like to make just a few comments to provide you what we at Karen Zupko and Associates consider to be successful and efficient processes. So, the first is appointment scheduling. This is where we answer the phones, talk to the patient, find out what their chief complaint is, assign which physician the patient should see. But then we also need to collect demographic and insurance information when we make that appointment. It's important nowadays to collect that demographic and insurance information, as you'll see on the next slide, because we want to verify that the patient actually has the insurance that they claim to, because unfortunately, sometimes patients are mistaken about the insurance that they have, or the policy allowables. So, we'll make the appointment, get the demographic and insurance information. Some of our clients have a no-show policy that says that there will be a charge if the patient no-shows, and this is completely quote "legal." Medicare allows you to do this to Medicare patients, and so you can do this to any patient, but check your payer's guidelines for that. The point is that the patient pays, your no-show fee is not billed to the insurance company. Many of our clients have a patient portal on their website so that patients can go to the portal and either enter the info, their demographic and insurance information, into the system themselves, or at least download your health history forms, and other types of insurance forms, or HIPAA forms, so that the patient can have those forms ready to fax those to you before the patient appointment. At this point, then, after the appointment's been made, it could be immediately after, or it could be a few days later, or prior to their appointment, we would make sure that we verify their insurance eligibility. And we can do this electronically online, generally with our practice management information system clearing house, or we can go straight to that payer's website. But the point is, we want to verify that the patient actually has the insurance that they said that they did. We want to verify that there's any pre-existing conditions, their deductible, and what's unmet this year, what their co-insurance might be, or what their mandatory copayment is. And the reason why we do that is because we want to collect any unmet deductibles, co-insurance, and certainly mandatory copays when the patient sees you. That's called the Time of Service Payment. We'll need to obtain any managed care referrals, or authorizations for the visit at that time. Prior to the appointment, we do not want to wait until the patient shows up in your office, only to find out that a referral is needed, and you have to call the primary care physician, because that makes you late, it frustrates the patient, and just, it's inefficient all around. So, then we would make a reminder phone call, or we would text patients, or email patients, or automate phone calls for reminders. But the point is, we want to know about the patient's insurance coverage before the first visit. And we really do want to verify insurance before follow-up visits if you haven't seen that patient in a couple of months, because a patient's insurance can change. Then when it comes time for the appointment, we ask the patient to check in at your receptionist, or the check-in desk. We want to verify the demographic information that you've collected over the phone, so we would print out a face sheet from your practice management information system, and we would just ask the patient to verify that information is correct. If it's incorrect, the patient would change it on the form, sign that form, and then we could change that in the computer system. Now again, the reason why we do that, and we don't have the patient fill out another completely separate registration form, is that you've already collected that information. So, if you've done that, collected demographic and insurance information over the phone, there's no reason for the patient to fill out a separate form. That's duplicate work for the patient, and they get frustrated. We want to verify the patient's identity, and we will use a photo ID to do that. We compare that to their insurance card information to make sure that the patient who you're going to treat is actually that person, so we verify the identity of that person. We've seen too many cases of identity theft, where patients might use somebody else's insurance card to obtain treatment from you. And when that happens, the insurance company is not obligated to pay you for a service that wasn't actually provided to the member. We scan the insurance card and their ID. You might take the picture for your electronic medical record, or your electronic health record, so that then after, if we take a picture for the electronic medical record, you do not have to verify, or you do not have to ask for the photo ID after each visit, at each visit. We'll scan in any documents brought in by the patient, forms that are signed, or records, collect any mandatory co-pay and prior balances. So now, the patient is ready to go, and ready for you to see them.

- Kim, a couple of comments about copays, and balances is one. You may not think those 15 to $25 copays are significant, but if you're not collecting them, those would tend to add up. And the other way to think about it is, that's an agreement the patient has with their insurance company too. For the premium they're paying, they're obligated to pay that payment. So, don't think you're doing the patient a favor by trying to waive a copay for that visit that day, that's kind of a trap to fall into that you want to avoid.

- You're absolutely right, Derek. The other thing is, when you don't collect the copay, then you are still obligated to attempt to collect any financial obligation that the payer assigns to the patient, and the payer will assign that 20, $25 copay to the patient, so now you have to send at least three statements to that patient, and the industry estimates it costs you anywhere from 8 to $12 a statement to send one out. So now, you've just knocked off any profit margin you have by trying to send three statements for a $25 bill. The other issue is that that $25 amount copay is part of the payment that gets factored in when the insurance company says they pay you, say Medicare, plus 20% in the managed care agreement, they're factoring in that patient's copay. So, when you don't collect that, you essentially decreased your own payment to you. Okay. So at the time of the visit, the actual patient encounter, the physician, it's your responsibility to actually code the service. That's the CPT code, which is the procedure code, and then the ICD-9, or the diagnosis code. And you do this either circling codes on a paper encounter form, or you do it electronically through your electronic medical record and practice management information system. And it is your responsibility to also document for that visit. And some practices won't bill a code, any code, or any claim, until they actually see the documentation, so we want to make sure that the documentation does support the code or the service that you provided. And that was the topics of our previous webinars that we did on coding. Now, there are lots of great charge capture tools out there, because one of the areas that I've lost revenue that I see is particularly hospital consults, and hospital visits, when they're not in a global period. So, I'm very much into mobile charge capture on your iPhone, or your iPad. And there are a couple of good systems out there, one is Charge MD, and the other is Max RVU. And my disclosure is, I do not get a cut of profits, I do not get a kickback or a referral fee, I just am passing along good information, and what I've seen works with my clients. One of the systems, Charge MD, actually does interface with Centricity practice management information system, which is really nice because then that charge capture can go straight into Centricity, and be held for somebody in your billing office, you know, to review and release. Whereas if it's not integrated with your practice management system, it just goes to an email to your coder, or your biller, and then it has to be re-keyed into the system. Now, at checkout, we want to verify that the front desk or check-in collected the mandatory copay. And otherwise, we'll collect that at checkout. We want to make sure that we've collected any mandatory copays before the patient leaves, deductibles, co-insurance, prior balances. The best chance you have of collecting from the patient is when they are physically in your office. Because if you wait, and just send patients bills, they tend to be ignored. The charge entry and payment posting would happen real time at the time of service. And then some clearing houses allow you to have what's called a real time claims adjudication process, where you enter the payment in the system, and then the information about the actual payment and what will be paid pops up so that we can collect exact amounts for co-insurances and deductibles.

- Kim, I'd like to make a comment about the whole process of, just the interaction with the patient about their bill, and their balance.

- Yeah.

- I think practices that are able to tell a patient while they're there, what they owe, and what their balance is gonna be gives them a feeling of confidence that your practice is able to get through kind of all the steps of health care. And if you can do it quickly and accurately, my experience has shown that you're able to collect that money much easier, because they're confident in your abilities too, that you're able to understand their own insurance, and help them with that. Because a lot of times, they don't understand themselves.

- Yes. And I think you have to have somebody in that position at checkout, and at surgery scheduling, which we're just about to talk about, that is comfortable talking about money to patients, comfortable asking for money. I don't want the neurosurgeons asking patients for money, but I think that having staff surrounding the neurosurgeon who are just very matter of fact about what the cost is, and what the payment is, yet empathetic, is so important, they're worth their weight.

- I agree.

- So then at the time of surgery scheduling, ideally you've recommended surgery for the patient, that's what we like to do, is operate, so we want to make sure that we have, we might need to verify insurance benefits, again, if there's been a time lag between the time that you originally verified insurance at the first appointment, until today, when we are going to schedule surgery. Also, if you operate on a lot of Medicaid patients, you might want to re-verify benefits again if their surgery is planned for after the first of the month, because in many states insurance eligibility renews at the beginning of every month. We want to complete the pre-certification process. Some of the procedures that we do might require written prior authorization, like artificial disc, and x-stop placement in some of these newer minimally invasive procedures, because many insurance companies don't really want to pay for those, so I want it in writing that they actually will pay. And then once we found out from the insurance company what their allowable is, and after the pre-certification process, we can sit down with a patient, or workup a surgical quote for the patient that discusses what your fee is, what you expect to be paid from the insurance company, what the allowables are, what the patient portion is. And then we collect a surgery scheduling deposit. And ideally, the surgery scheduling deposit is a patient's unmet deductible and estimated co-insurance. If that's a big number, maybe we collect half before surgery, and half at the first postoperative visit. I recommend that you collect surgery scheduling deposits at the time surgery is scheduled, not up until five o'clock the day before surgery. Because if the patient can't come up with the money at five o'clock the day before surgery, then you're left with a hole in your schedule, and you're scrambling to put someone else in there. So, if I'm scheduling my surgery today, and surgery is four or five weeks out, then I would say collect the surgery deposit today so that we can hold the time on the operating room schedule for you, Mrs. Smith, just to make sure that you've got the payment. If the patient is gonna have financial problems, you want to know that sooner rather than later. And then we want to audit all of our surgery charges to make sure that all procedures were coded and billed so all charges are captured. We recommend that you work with your hospital to get a list of cases performed by each physician on a monthly basis. And that way you can compare that list to what your charges were entered in the computer system. Some people will actually schedule a surgery appointment in your appointment scheduling system so that your computer is actually looking for a charge for that procedure. But the problem is, emergency cases, and cases that aren't scheduled from your office, we don't always know what the doctor did in the operating room on the nights and the weekends, so we have to rely on the doctor to tell us with mobile charge capture tools, or the hospital operative records. Little pieces of paper, like post-it notes, and three-by-five cards stuffed in lab coat pockets, ideally we can eliminate those by using mobile charge capture tools now.

- Our practice, we've implemented a procedure where the physician just checks in after his night in the hospital, just to make sure that if they did a procedure, they have the paperwork to turn in. And if they don't show up by like 10:00 in the morning, then somebody is getting hold of them to see, "Did you do anything last night? Do you have charges to turn in?" Because that is really where you might lose some charges, is the stuff that happens at night.

- Right, and who do they check in with Derek, somebody in the billing office?

- We have a designated person at the office. It's a secretary who kind of keeps track of emergency room business and night business. And that way it's a designated person, it's the same person every day, and everybody knows what that procedure is.

- Okay, great. The whole process of surgery scheduling isn't quite so easy anymore. Many insurance companies have forms that have to be filled out, particularly for lumbar fusions, lots of hoops to jump through, InterQual surveys to complete. So my point is, don't expect to add on a case tomorrow, unless it's a dire emergency. Availity is one example of a clearing house that has the ability to calculate the patient's estimated responsibility on procedures, whether they're surgery or office visits. Other insurance companies, you can go directly to their website, like United Health Care has a claims estimator that you can use. If patients can't afford to pay in a lump sum, we recommend a recurrent payment plan. This is similar to what you do right now with your mortgage, where it's directly deducted from your checking account every month. I know some people do this at their church, they have an amount that's deducted, we automatically deduct it from the checking account, goes to the church or the gym. And the reason why we recommend this is because I want you to get your money, and your payment, within the shortest amount of time possible. We can no longer afford to collect $5 a month on $5,000 balances. It's just not reasonable today. So we want, again, to ensure that you collect the maximum possible. And these recurring payments, we recommend you have a third party do these, so that you're not keeping credit card numbers and checking account numbers in your system. There's a safe way to do this. Check with your bank, check with your clearing house. Solveras is another company that allows for recurring payments. Now on the backend, now that you've seen the patient and it's time to submit the claim to the insurance company, and hopefully get paid, so let's walk through those steps. After surgery, we would expect that you might bring your charges in to somebody in the billing office, whether it's a coder, or a biller, and bring those charges in, or send those electronically through one of your mobile charge capture tools. And that person would verify that the codes are correct, discuss any discrepancies with the physician, and then enter the charges into the practice management system. So then, the claims go out the door, usually electronic. Some motor vehicle work comp payers want paper claims, but in general, we're sending all of our claims electronic. And even some clearing houses by Real Med do now send some work comp and motor vehicle accident claims electronic these days. So they go to the clearing house, the clearing house sort of scrubs the claim to make sure it's clean so that it will be paid correctly. They'll send back an error report to you. Want to make sure somebody in your practice is looking at that error report every day, and fixing those errors so that the claims get released. I was with the neurosurgery group last week, and I asked to see the clearing house edit report, and nobody knew what I was talking about. And this three doctor practice had about 700 claims just sitting there in never-never land with issues, and the claims had never gone out the door. So, we want to make sure that somebody is looking at the claims, edit their error report, and correcting those edits every day.

- I would also say that when the errors are found, that not only are they corrected, but some training is done to kind of prevent recurring errors. Because like Kim said earlier, all of this starts at the frontend of collecting the correct data from the patient. So, if somebody just corrects the error on the backend, and isn't retraining or helping someone understand what the whole process is, you'll just keep getting those errors over and over.

- You're exactly right, Derek, and I actually recommend that when you get an error, for example on a registration issue, the birth date was transposed, or the member ID on the insurance card wasn't accurate, that that error actually be given to the person who made the error to correct and fix. Because I agree, as you point out, that person needs to understand what errors were made, and it can be a training tool. And it can also be, unfortunately, used to monitor somebody's performance, and disciplinary action may result. Then after the claims go out the door, we sort of cross our fingers and hope that we'll get paid. And so we've got lots of different ways that payments come into the practice these days. Back in the old days, everything used to be mailed, now most of our payments are coming electronically. That's called EFT, Electronic Funds Transfer. And so we sign up for that with the insurance company, the insurance company sends your payment directly to your bank. We like that. The fewer checks and the less money we have floating around the office, the better it is, there's less of a chance for embezzlement. Your EOBs, your Explanation Of Benefits forms, describing why you got paid and how much electronically, that's called the Electronic Remittance Advice. And payers will now electronically send the payment information to your computer system, and it can be automatically posted to your computer system. I want to make sure somebody in your practice is still actually looking at each posting line-by-line to make sure it was done correctly. So then at that point, take any contractual adjustments, and as I said earlier, reconcile the electronic payment remittance files, the ERA. So, this next slide is just another way to show about how payments come in to your practice. ERA is the actual Explanation Of Benefits forms, EOBs, so that's Electronic Remittance Advice. That information goes straight to your practice management information software in your computer, and then the actual money, or the check, Electronic Funds Transfer, goes to the bank. Some bigger groups use a lock box at the bank, and the bank then deposits the checks and sends the copies of everything to you for posting of, say, smaller insurance company checks that don't do EFT or ERA, and then as well as patient checks, because those usually will come directly to the office.

- Kim, today's technologies is come so far that now banks are, even if a paper check comes in, the banks are now turning those into ERAs, so that you get an electronic remittance instead of a piece of paper in the mail from the bank.

- Yeah, exactly. And that's something that I forgot to mention up here on this slide, the Remote Deposit Capture. So, banks will do that. The paper check will come in, and they'll scan it, or you can actually have that capability in your office. It's a USB port device, you slide the check through, just like they do at the grocery store, it gets automatically deposited into your checking account, and then now, we don't have to go to the bank to make deposits anymore. Technology's amazing today. Analyzing the EOBs, this is a step that I think oftentimes is forgotten. So, we want to make sure that there is somebody in your practice who is getting that microscope out, and looking at the EOB to make sure that you got paid the dollar amount you were supposed to be paid for that CPT code. And then because sometimes insurance companies just pay 15, 20, $30 less on a code, and that adds up, and also to be sure that they've applied any reductions appropriately. So as we talked about in the last webinar, when we use modifier 50 or modifier 51, we expect a payment reduction, so who's calculating that reduction to make sure it was appropriate? Or are we getting paid 100% of the allowable for add-on codes? This is important to look at. Some practices are so large, Derek, I think yours is one of them that you actually have a software that does this, Medical Present Value, MPV software, is one example of that software that can be purchased to do that analysis, and a variance report is generated every day so that we know exactly what payments were low, or what wasn't paid.

- Yeah. We use MPV, and there's a lot of setup to make sure you load your contracts, so then it can compare the payment that comes in with what you're supposed to get paid. And then it also helps you analyze, on a new contract, how they paid the old claims versus what they're saying they're gonna pay the new claims at. So once again, technology in the last 10 years has really helped all sizes of practices do this part of it much easier, instead of having to look at every EOB individually.

- Yeah, exactly. And your computer system, you know, for small practices, the computer system ought to be able to run some sort of reimbursement report that shows the payments that came in, and what the allowables were, and to do some comparison. And when you find an underpayment, or a no payment, the next step is to appeal that denial, or to appeal that low payment. So, we have great success at appealing. I think sometimes all it takes is just one reminder to the insurance company. "Oh, did you forget to pay this?" Or we'll use the CPT guidelines saying, "The microscope is not included in X code, though you inadvertently failed to pay, please reprocess for payment." And many times, all it takes is just asking once. Rarely do we have to go up several chains of command, if you will, in terms of the appeal process. But I want to track those common denials, because it could be a trend with that payer, and then we can maybe do some things proactively coding-wise in terms of modifiers to maybe avoid some of these denials. Because the goal is to submit a claim once, and get paid. And then when you're not paid, the next step would be accounts receivables follow-up. So, we recommend an organized method of doing this. Typically we do, we work for the AR followup by payer group, so that one person is working, a single payer, or a group of payers, so that they better understand the payment guidelines of that insurance company. And some insurance companies actually have forms instead of having to write appeal letters. There are forms, for example Massachusetts Tufts Blue Cross Blue Shield, uses a standard form, and you just check box what you want to be reviewed specifically, and provide your supporting documentation. So, that, I have found to help streamline the appeal process. And then finally, we want to make sure that you've got internal controls happening, particularly in the areas where people handle money. This is a statement from a client of mine who called me saying, you know, "My staff, I've got one person in the billing office, three doctors, three neurosurgeon group, she's so loyal, she stays late, she never goes on vacation. I just am so worried about what would happen if she left." And actually it turns out she was embezzling money from the practice, and this is why she didn't want any help in the billing office. She wanted all the control, she handled all of the charges and deposits, and she embezzled about $165,000 in one year. So, internal controls, making sure people don't have the ability to enter a charge and zero out a payment. The fewer checks in cash people handle, the better. So when mailed in checks come in to the practice, maybe the office manager or the receptionist actually opens the envelopes, completes the deposit slip, and the money gets sent to the bank immediately so that in the billing office, the poster is just working off of photocopies, so there should be no need for cash floating around the office. I've got just a couple of comments about, in my 15 years of consulting experience, how I've seen neurosurgeons sabotage reimbursements, and so I want you to avoid these behaviors. One is remaining in the dark about your practice business operations. I encourage every physician to be involved in the business operations. I realize you have a heavy patient care load, and this, you know, could be perceived as more work for you, but let's not forget that this is your practice, and nobody should care about your practice more than you do. And so your behavior will show the staff around you how much you care. And just, I know we trust our office managers, but quite frankly, sometimes the office manager, it's just not appropriate to place so much of a load on that person's shoulders. So, taking some responsibility and interest in your practice is just essential. Some more mundane things, like not dictating operative reports right after the case, or at least the same day, is a problem, because now, you know, technically, we should have an operative note before we bill for a procedure. Having no idea that the ASC is two weeks behind in transcription, so again, we can't send a claim out the door unless we have an operative note. Now, I know some practices do, and then work on the backend to make sure that there's an operative note. I quite frankly like to have it in my hand so that I know that it was done, and there aren't any blanks in it, so that it's a completed, signed document. Submitting surgery or hospital consult charges late, or never, is another way to lose out on revenue, and this is where the mobile charge capture tools really can help you. Remaining ignorant about coding, contracts. I urge you to go to a AANS coding course every year, or have some neurosurgical education provided on-site to the physicians. Codes change every year. Even doctors who tell me, "Oh, I know all of the codes backwards and forwards," tell me it's so worthwhile just to hear it over and over again. When you think about how repetitive learning to operate is, think about the need for that type of education with the relationship to coding. Not completing your electronic health record notes from business on the same day, this is a nightmare. This typically means we can't get those charges out the door either. One practice I went with, the first thing that they did when they got into a little bit of a financial squeeze was to cut two people from the business office. And that obviously put a screeching halt to a lot of the work that was being done on the backend. Now I agree, in this practice, there needed to be some FTE reorganization, but yeah, we were able to do it in a manner where we actually cut one person on the frontend, and one person on the backend, it just wasn't the business office that was overstaffed. Setting astronomically high fee schedules can also be a disaster, your write-offs become just huge. So, actually setting your fees is almost an art these days, you have to know what your managed care contracts are paying. If you're out of network, we need to know what your market will bear, and what will not put you on the front page of the newspapers. And then finally, telling patients not to worry about their bill. Because guess what? That's the only piece of advice that they listen to. And they take your bill, and they throw it out every month, because you tell them not to worry about it. So, we want patients to worry about their bill, because this is how you are compensated, and your office doors stay open, so let's make sure that we have some staff in the practice who can talk to patients about their bill. And we're always happy to work out some sort of payment plan.

- Kim, one thing we do, and I think it applies to a large, or a small group, or a medium sized group, is for some of those things that we're trying to prevent, where you're either unwittingly, or wittingly, sabotaging your own cashflow is, if you track those types of things, like how long it takes for everyone individually to turn in to charge. We publish those to everybody. So a little bit of peer pressure seems to go a long way, at least in our practice, because a lot of times nobody wants to be last on the list. Everybody's pretty competitive. So, as long as you're tracking stuff, go ahead and publish it so everybody can see where everyone's at on certain of those items.

- Very good! I like that idea. Yes. Monitoring the charge lag between the date of service and the date the charge was billed, is a key performance indicator I think for the practice to monitor. Because again, the shorter the lag, the better. And I liked the fact that you would publish that so that everybody does see that. I think that's a great idea. The next topic is tips for successful charges and collections. Because we've got just a couple of ideas that can be useful to you and your practice. First thing I want to do is just review what a claim form looks like. And this is the paper claim form that gets sent to the insurance company, all of the information is the same when sent electronically. So your diagnosis codes are listed here, and then your CPT codes are listed here. And there are no words listed on the claim form in terms of CPT, it's all done in codes. And then the bottom line is that the physician's signature is at the bottom of the claim form, attesting to the fact that everything on the form is accurate. So, when I have physicians say to me, "Oh, I don't really participate in the coding process." My response to them is, "Well, when you send a claim out the door, you're saying that it's accurate, so how do you know it's accurate if you haven't participated in the coding process?" And in my mind, coding equals payment, and I would hope that every physician would want to be involved in the payment process, and making sure what you bill for is accurate. So, we always list our CPT codes in descending value order, whether that's your fee, or whether it's in Medicare's relative value unit order. If your fees are based on a percentage of Medicare's RVUs then it's easy, you're doing your fee and RVU order. The second is, because we do a lot of add-on codes, we can format our claims two ways. We can keep the add-on codes, like your additional level fusion code, 22614, in descending value order. Or we can use put that same code directly underneath the parent code, or the standalone code. So in the first example here, 22614 was listed in descending value order. And in the second example, 22614 was listed as the second code, directly underneath the parent code. Both formats are accurate. The point is that on the payment side we would expect to be paid 100% of the allowable for the 22614, regardless of where it's placed on claim. We need to know our payer preference for use of the units box versus the line item charging due for add-on code. So, if you've placed a peek device in two interspaces, the peek device code, 22851, would be billed twice. So, the one way of doing that is the line item posting, where we billed 22851 times one unit on the claim form, you bill your single fee, and we expect to be paid 100% of the allowable, because it's an add-on code. The second level of peek would be billed same code, 22851. We would append modifier 59 to show that this was a distinctly separate procedure performed at a different level. Also one unit, bill your usual fee, and again, we would expect to be paid 100% of the allowable. The alternative format is using multiple units for add-on codes. And that's where we would list 22851 times two units, double your fee, and we would expect to pay 200% of the allowable. Now, most Medicare carriers recognize the multiple units box, but not all private insurance companies do, so this is why we need to know how to bill it, and that somebody on the backend is actually analyzing the payment amount. Same for bilateral procedures, we have very few codes that we can bill with modifier 50 for bilateral, the 61154 for bilateral burr holes, for subdural, as an example, line item posting, again, is listing each CPT code on a separate line, modifier 50 on the second line. We expect to be paid 100% of the allowable for the first side, and 50% for the second side. Medicare recognizes the bundle format, where we bill the single code, we double our fee, and we expect to be paid 150% of the allowable. If we don't know what format the payer wants, then I would always bill the line item posting just be sure that you get paid appropriately. Now, we use them operating microscope code a lot, 69990, and I recommend that you list the add-on code for the microscope directly beneath, right under the primary procedure code for the service that the microscope was necessary. So in this example, we have a translabyrinthine removal of acoustic neuroma, 61526. And we did that as co-surgery with ENT, 62 modifier. And we also did 20926, which is a tissue graph for the abdominal fat graft. Now, on the left hand side of the screen, we listed the codes in descending value order, so the microscope code came last. Payers' software systems look at that microscope code, and then they say, "Oh, the microscope was done for the abdominal fat graft, which is the code right above the microscope code." And then they would deny payment for 69990, because obviously you don't need a microscope to do an abdominal fat graft, so this is why we list the microscope code directly underneath or after the primary procedures for which the microscope was needed. We bill our full fee for each CPT code when you're the primary surgeon, and except for the instances above where we doubled our fee. A couple of exceptions, modifier 22, which we talked about in a previous webinar where we increase our fee, and then our assistant surgeon, or assistant at surgery modifiers, we would decrease our fee, because our value or worth as the assistant is not the same as our value or worth as the primary surgeon. And then finally, understanding your obligations as an in-network or participating provider, versus out of network or non-par provider. And I won't go through each step of the way here, but the point is that if you are in-network, you're going to have contractual adjustments, meaning a discount off of your fee that you agreed to. You'll have an contractual adjustment posted to your computer system, along with the payment. When you're out of network, depending on your state laws, you can collect up to 100% of your fee, and so there really shouldn't be any contractual adjustments. So, that's the difference between in-network and out of network. Okay, at this point, we're going to start a new section of the Practice Management Series, called, "Measuring the Financial Health of Your Practice."

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