Case Study: You are assessing the payer–patient mix for a health care organization. Currently, your payer mix is 40% Medicare, 10% Medicaid, 25% traditional indemnity insurance, 20% managed care, and 5% self-pay patients. Complete the following:

• Assess the information for areas of improved reimbursement of at least 20% or more.

            In most cases, family physicians end up losing at least 20 percent or more of their reimbursements annually just because of poor or incorrect coding. The reason for that is not because health care organizations are not doing their work as required. One of the factors that cause this problem to persist is because physicians do not document and code the work they do properly (Deeken et al., 2018). As a result of that, one area for improved reimbursement is studying the CPT manual as well as documentation procedures needed to enhance effective E/M (evaluation and management) services. In other words, it means that a certain percentage of family members end up ender-coding just because of underestimating the value of the health care services they offer on a daily basis (Whedon et al., 2017). Other take conservative approaches deliberately with the motive of avoiding state audit.

            According to CPT, the percentage of the 99214 codes has the potential of becoming higher as compared to other codes. For instance, the research that was initially conducted comparing the choice of codes used by family physicians with those chosen by experienced coders revealed that such physicians end up under-coding one-third of the initial established patient visits (Klann et al., 2015).  In order to in the position of billing for the level four established patient visits, the guidelines provided by the current procedural terminology (CPT) demands that two out of three of its components to be fulfilled. These components include a detailed physical exam, detailed history, and a clear clinical decision-making method of moderate complexity (Venkat et al., 2015).

            Nevertheless, in the process of assessing the information that will assist in determining the areas of improved reimbursement, it is important to bill for the CPT code 99214 revisiting without having documenting or counting personal body systems or comprehensive examination elements.  The reason for that is because clinical decision-making and history indicate that high level of complexity exists. In this case, some of the examples dealing with moderately complicated decision-making process include a request for personal consultation, an order for X-rays or laboratory texts, or a new diagnosis with prescriptions. Therefore, when it is compulsory to verify that the family of physicians had managed to perform complete system evaluation to validate a 99214 claim, historical forms, which are always filled at the waiting room before being assessed with the patient, might be a valuable time-saver ((Venkat et al., 2015).

            Nonetheless, systematic data collection is important when it comes to the need of justifying the high level code, that is suitable when new patients presents complex clinical history demanding fresh diagnosis, specialty evaluation, and new medication. It is vital to be informed about the tendency of coding the patients’ visits based on the intricacy of the clinical analysis rather than on the degree of the clinical decision-making procedure involved (Klann et al., 2015).  For instance, family physicians might be aware of the patient who visits their medical facility for annual health care maintenance examinations, then desire to discuss his or her chronic chest pain or depression. In such a situation, the family physicians might be justified to bill both office visit and preventive clinical services using a certain modifier. This is what will assist in indicating that they had managed to provide outstanding separate services (Imbery et al., 2018).

            It is important to have the ability of separating the procedure to be followed from the evaluation and management services to be offered. For instance, in case the chronic or acute problem that the family physicians evaluates is relatively stable as well as closely associated to the preventive exam-for example properly managed asthma that do not require change in treatment, then presenting an evaluation and management code is not necessary (Whedon et al., 2017). Proper documentation will, of course, take into account the need of including the main complaints, assessment, diagnosis, as well as the medication plan. It is also vital to describe fully the developing nature of the E/M services so as to assist in justifying its billing. Despite that, it has been realized that Medicaid and Medicare often end up bundling emergency services together with other associated health care medical services. This is what makes third party payers to respond in a different way (Venkat et al., 2015). Therefore, taking into account the payers’ policy, billing for either level four or level five evaluation and management visit can be a more valuable option.

            The CPT and the billing services suggest that at least all Medicare beneficiaries are entitled to receive the ‘Welcome to Medicare’ examinations within six months after enrolling into such a program. This program comprises of various components and for the sake of reimbursement, they must all be presented. Equally, to be in the position of appropriately conducting and billing for this examination, it is important to develop a template that lists all the requisite components. An example of this listing should take into account a complete reviewing the social, medical, and family history of the patient (Jones et al., 2016). At the same time, it is important to the patient’s risk factors causing depression before reviewing his or her level of securing of functional ability.

            Consequently, through basing our analysis on the patient’s physical examination, it is vital to ensure that brief explanation, counseling, or education have been provided for the sake of assisting addressing any issue or issues that might have evolved during the provision E/M service, or preventive services and its associated billing exercise. Despite that, evidence obtained from CPT services indicates that a large percentage of patients end up presenting several diagnoses that are in return addressed at any time they make routinely office visit (Imbery et al., 2018).  It is possible to utilize them in billing for the services that could have been provided. As a result of that, selecting the main diagnosis for both coding and billing before listing them with their order of their importance enables third-party payers to have the ability of prioritizing patient health care. In return, it becomes possible for a person to evaluate whether he or she has been reimbursed accordingly. It is also vital to take time and list acute and active clinical conditions that were initially discussed on the counter form during the office visit (Jinjie et al., 2017).

• Evaluate the options available to change the payer–patient mix with consideration of related legal and ethical issues

            In order to be in the position of obtaining excellent value for any investment that a person make in health care, important decisions have evolved to highlight the best means of aligning health and economic incentives to realize these goals. Basing our focus on health care providers, it is important to scrutinize the significance of the existing fee-for-service reimbursement method. Often, when such incentives health and economic incentives are placed on volume and not on value, the truth is that the fee-for-service will not have the potential of creating incentives for care coordination and preventive care among providers (Jones et al., 2016).  Taking into account the number of hours physicians spend per week interacting with their health care plans, the administrative complexity developed by several documentations requirements to precertification, credentialing forms, and varying billing take time away from medical health care.   The failure to clearly distinguish the benefits and values of alternative medical attention, health care providers, and health plans is the one that ends up obfuscating the signals to potential customers (Whedon et al., 2017).

            In most cases, the time a physician spends with the patient or patients is ultimately vital for improving the quality of the health care services offered as compared to coding. For improved reimbursement, there is the need of focusing on how to collect historical information, the type of history to be performed, the type of examination to be performed, as well as the extent of clinical decision-making involved. The reason for that is because there are situations, for instance, counseling and health care coordination, in which time is greatly taken into consideration for coding purposes (Jinjie et al., 2017). In case a physician dedicates more time to coordinates care or counsel with the patient’s family or the patient as compared to the time he or she spends in handling office visit, it means that the total time consumed is the one can assist in determining the level of service. In an office, face-to-face time is the one that counts while when in the nursing home or hospital, the time consumed reviewing clinical records, interacting with nurses, and talking with patients or patients’ family is what counts (Khan et al., 2018).

            It should be remembered that counseling for evaluation and management services entail arranging a dialogue with the patients’ family or the patients themselves about several issues. Some of the issues to be discussed include things like recommended tests, benefits or risks of medication, diagnostic results, instructions for follow-up or management, prognosis, patient education, the importance of compliance, and so on. All these issues do not take into account individual psychotherapy.   According to current procedural terminology (CPT), despite that consultation might be requested by non-health care medical practitioner, for instance, psychologist, it is important to ensure that they have been executed and recorded in the physician’s note (Wei et al., 2017). In case the physician is executing consultations in his or her office, it is vital to give feedback to the physician who might have requested it through sending a letter.

            Despite the fact that the family of physicians ends up engaging in several consultations, they do not code for the myriad of consultations they make. As compared to routine initial clinical health care codes, everyday office visits or following clinical care codes, consultations usually reimburse much higher. Therefore, any request the physician may receive, either verbal or written, from another medical practitioner to examine the patient or to participate administering treatment and to return the report is all about consultation (Traynor, 2013). As a result of that, it is important for the physician to document it in his or her note in case he or she desires to code it later.

             Moreover, the majority of the medical guidelines point out that the Medicare patient ought to ensure that they have annual records regarding their reimbursement.  Despite that, it should be noted that annual physical are some of the services that are not covered by Medicare hence having nothing to do with its schedule. If a person has the ability of coding properly, it is possible to alter what you could have charged the Medicare patients as compared to that which could have been charged for non-Medicare patients for the physical exam (Khan et al., 2018). Since Medicare patients ultimately have several chronic conditions which require systematic follow-ups, it is important to submit preventive clinical services code.

            In some situations, the family physicians often do handle concurrent health care, particularly when offering subsequent clinical care that occurs when the evaluation and management services are offered at the same time by two physicians. In this case, it is important to seek the help of the physician to assist in coding the initial consultation as well as offer a subsequent clinical care code. Although it might be possible to be served by two physicians who will be coding for succeeding clinical care, whoever gets paid first, after sending the claim to the payer, will deserve it (Wei et al., 2017). It is, therefore, important to ensure that the insurance office has been notified to electronically submit that claim that same day for the service received.

• Propose a best strategy with justification and rationale based on effective decision-making tenets.

            In our contemporary health care industry, it has been realized that the existence of few non-clinical issues are the ones that have ended up creating several controversies as the CPT codes for E/M (evaluation and management) as well as the associated documentation guidelines.  As a result of that, they have managed to spur the cottage industry of cheat sheets, templates, toolkits, and scorecards. All of them are designed for the purpose of assisting a person to ascertain that his or her medical records have the documents required to support the codes selected (Jones et al., 2016).

            The CPT 99214 code as the established patient visit is one of the evolving detailed examination, detailed history, as well as a therapeutic decision-making protocol of moderate complexity.  Since coding is based on the history and the decision making, it implies that it gives a person an ample time of counting body systems or examination elements so as to validate the reported health care level. It is easy to recognize high-complexity or straightforward encounters, but low and moderate levels of decision-making often become ambiguous. As a result of that, it is important to regard decision-making as some of the means that can be used to enhance comparative analysis when reimbursement is to be made (Whedon et al., 2017).

            Nevertheless, in the process of determining the clinical decision-making procedure; it is important to consider understanding the seriousness of the problem at hand, or the extent of the differential diagnosis made. When family physicians are handling several medical problems, having an increased level of uncertainty, or having multiple data element to be reviewed, it is paramount to regard the clinical decision-making process as being a moderate exercise (Imbery et al., 2018). For instance, this could be a patient suffering from three stable diseases and who is being managed on prescribed drugs.

            The available evidence indicates that even if billing for problem-oriented and preventive health care is systematically done and documentation and the associated codes are submitted, a person may fail to be reimbursed for the two. Some third-party payers have the likelihood of paying a certain amount of each while other might decline incurring the extra claim completely. Conversely, there exist some health care plans that necessitate a patient who produces two charges in a day to pay two separate co-pays (Traynor, 2013). Because of that, chances are that one can have the opportunity of using higher level evaluation and management codes that are entirely based on time, despite of the complexities of the clinical history, decision-making, or physical examinations

            With the presence of personal plans aimed at maximizing the reimbursement of dermatologic procedures, it is important to be aware of the terms to use as well as the descriptive details to be recorded. The reason for that is because making use of the right terminology is the one that will assist in ensuring that he or she have been properly reimbursed for any procedure he or she might have performed. Additionally, CPT evidence suggests that what is not always factored into the compensation or reimbursement formula is the margins of the shaved lesion. It is, therefore, important to ensure that it is only the measurement of the lesion that has been documented (Deeken et al., 2018). The location of the ailment also assists in dictating the level of reimbursement that is usually lower for some of the procedures done on the arms, trunk, or legs as compared to those done in anogenital area or on the face.

            Thus, the CPT codes or the E/M codes that aid in describing are mainly used for the purpose of charging office encounter with an established patient or patients. As stated above, the majority of physicians end up under-coding chronically for the health care services that they offer just because they do not understand or underestimate the rules. Therefore, taking into account the working understanding of the evaluation and management coding is perceived to be the ultimate means of ensuring optimal conformity and avoidance of inadvertent under-coding (Traynor, 2013). On the other hand, family physicians who have the ability of understanding the idiosyncratic processes of the E/M recording can have the opportunity of commanding high return rates on their cognitive work as compared to E/M-savvy physicians or counterparts. This is to imply that for those physicians who clearly understand how to bill for the services they offer accurately, they have higher chances of getting paid for what they do.

            Last, but not least, to have the propensity of supporting the consultation or office visit code, it is the responsibility of the physician to ensure that he or she has had the chance of airing their views concerning a certain problem. This is to imply that the requests to be made can either be recommending health care for a certain problem or condition or determining whether to acknowledge responsibility for the current management of the health care (Khan et al., 2018). It is also important to make thorough checks the third-party payers to assist in ascertaining whether consultation codes are regarded as being the ultimate means for billing. This means that, in the place of the consultation codes, for instance, the CPT 99214s code, it is important for family physicians to ensure that they have used newer patient codes for all the services they could have executed in their respective office or in other outdoor facilities (Deeken et al., 2018). It is this guideline that will assist in boosting effective decision-making tenets.

 

 

 

 

 

 

 

 

 

 

 

                                                            References

Deeken-Draisey, A., Ritchie, A., Yang, G.-Y., Quinn, M., Ernst, L. M., Guttormsen, A., … Maniar, K. P. (2018). Current Procedural Terminology Coding for Surgical Pathology: A Review and One Academic Center’s Experience With Pathologist-Verified Coding. Archives of Pathology & Laboratory Medicine, (12), 1524. https://doi.org/10.5858/arpa.2017-0190-RA

Imbery, T. E., Nicholas, B. D., & Goyal, P. (2018). Analyzing Medicare payments to otologists. ENT: Ear, Nose & Throat Journal, 97(7), 208–212. https://doi.org/10.1177/014556131809700711

Jinjie Huang, Tattersall, R., Morse, K., Nickerson-Troy, J., Clements, E., Celauro, L., & Lovell, A. (2017). Assessment of reimbursement in a community hospital--based pharmacist-managed outpatient transition clinic. American Journal of Health-System Pharmacy, 74, S30–S34. https://doi.org/10.2146/ajhp160428

Jones, C. A., Acevedo, J., Bull, J., & Kamal, A. H. (2016). Top 10 Tips for Using Advance Care Planning Codes in Palliative Medicine and Beyond. Journal of Palliative Medicine, 19(12), 1249–1253. https://doi.org/10.1089/jpm.2016.0202

Khan, A., Massey, B., Rao, S., & Pandolfino, J. (2018). Esophageal function testing: Billing and coding update. Neurogastroenterology and Motility, (1). https://doi.org/10.1111/nmo.13158

Klann, J. G., Phillips, L. C., Turchin, A., Weiler, S., Mandl, K. D., & Murphy, S. N. (2015). A numerical similarity approach for using retired Current Procedural Terminology (CPT) codes for electronic phenotyping in the Scalable Collaborative Infrastructure for a Learning Health System (SCILHS). https://doi.org/10.1186/s12911-015-0223-x

Traynor, K. (2013). Transitional care CPT codes may include pharmacists’ services. American Journal of Health-System Pharmacy, (9), 748. https://doi.org/10.2146/news130034

Venkat, A., Kekre, S., Hegde, G. G., Shang, J., & Campbell, T. P. (2015). Strategic Management of Operations in the Emergency Department. Production & Operations Management, 24(11), 1706–1723. https://doi.org/10.1111/poms.12346

Wei, W.-Q., Bastarache, L. A., Carroll, R. J., Marlo, J. E., Osterman, T. J., Gamazon, E. R., … Denny, J. C. (2017). Evaluating phecodes, clinical classification software, and ICD-9-CM codes for phenome-wide association studies in the electronic health record. PLoS ONE, (7). https://doi.org/10.1371/journal.pone.0175508

Whedon, J., Tosteson, T. D., Kizhakkeveettil, A., & Kimura, M. N. (2017). Insurance Reimbursement for Complementary Healthcare Services. Journal of Alternative & Complementary Medicine, 23(4), 264. Retrieved from http://165.193.178.96/login?url=http%3a%2f%2fsearch.ebscohost.com%2flogin.aspx%3fdirect%3dtrue%26db%3dedb%26AN%3d122401274%26site%3deds-live

 

                                                            Appendix

CPT CODES	Desc	Allowed_Charge	Nonfac_pervu_06	Nonfac_pervu_Meth2	Fac_pervu_06	Fac_pervu_Meth2	Nonfac_cpep_lab
99213	Office/outpatient visit, est	2,561,989,081	0.69	0.70	0.24	0.26	0.35
99214	Office/outpatient visit, est	2,561,989,081	1.03	1.05	0.41	0.44	0.52
78465	Heart image (3d), multiple	2,561,989,081	12.34	9.26	12.34	9.26	2.12
99232	Subsequent hospital care	2,561,989,081	0.37	0.41	0.37	0.41
66984	Cataract surg w/iol, 1 stage	2,561,989,081	7.44	7.81	7.44	7.81	1.93
92014	Eye exam & treatment	2,561,989,081	1.41	1.41	0.47	0.51	0.59
99212	Office/outpatient visit, est	2,561,989,081	0.54	0.56	0.16	0.19	0.26
77418	Radiation tx delivery, imrt	2,561,989,081	18.07	13.08	18.07	13.08	0.92
93307	Echo exam of heart	404,154,418	4.22	3.92	4.22	3.92	0.78
88305	Tissue exam by pathologist	396,186,369	1.91	1.92	1.91	1.92	0.79
99244	Office consultation	358,779,829	1.83	1.99	0.92	1.22	0.62
99233	Subsequent hospital care	332,841,425	0.52	0.57	0.52	0.57
96413	Chemo, iv infusion, 1 hr	326,212,797	4.20	3.21	4.20	3.21	2.04
99215	Office/outpatient visit, est	325,319,618	1.32	1.40	0.65	0.69	0.62
97110	Therapeutic exercises	312,208,879	0.27	0.32	0.27	0.32	0.18
93325	Doppler color flow add-on	291,195,650	2.94	0.69	2.94	0.69	0.15
70553	Mri brain w/o & w/dye	262,746,291	25.73	18.52	25.73	18.52	1.12
92012	Eye exam established pat	253,573,162	1.03	1.00	0.29	0.32	0.42
93880	Extracranial study	247,325,787	5.57	5.86	5.57	5.86	1.17
99243	Office consultation	235,534,085	1.39	1.50	0.63	0.82	0.54
72148	Mri lumbar spine w/o dye	201,211,973	12.97	12.92	12.97	12.92	0.82
99223	Initial hospital care	199,452,406	1.03	1.08	1.03	1.08
99203	Office/outpatient visit, new	192,734,082	1.13	1.17	0.48	0.56	0.50
99254	Initial inpatient consult	192,071,770	0.98	1.22	0.98	1.22
93000	Electrocardiogram, complete	188,903,173	0.51	0.32	0.51	0.32	0.16
93320	Doppler echo exam, heart	184,045,367	1.86	1.70	1.86	1.70	0.50
76075	Dxa bone density,  axial	175,600,219	3.20	0.62	3.20	0.62	0.34
G0317	ESRD related svs 4+mo 20+yrs	173,100,212	2.87	2.35			0.76
99285	Emergency dept visit	170,208,505	0.72	0.62	0.72	0.62
99245	Office consultation	167,762,440	2.28	2.41	1.24	1.55	0.71
99204	Office/outpatient visit, new	163,341,428	1.50	1.52	0.71	0.81	0.61
17000	Destroy benign/premlg lesion	155,603,377	0.97	1.33	0.54	0.76	0.54
99231	Subsequent hospital care	154,208,063	0.23	0.26	0.23	0.26
93015	Cardiovascular stress test	154,062,244	1.96	1.81	1.96	1.81	0.94
99291	Critical care, first hour	140,453,235	2.58	2.13	1.28	1.21	0.62
99211	Office/outpatient visit, est	136,117,665	0.39	0.33	0.06	0.08	0.16
27447	Total knee arthroplasty	136,025,555	14.64	14.68	14.64	14.68	2.11
20610	Drain/inject, joint/bursa	135,386,346	0.95	0.88	0.42	0.48	0.38
98941	Chiropractic manipulation	135,087,168	0.30	0.27	0.17	0.19	0.07
99255	Initial inpatient consult	132,403,753	1.35	1.63	1.35	1.63
99308	Nursing fac care, subseq	125,309,537	0.45	0.47	0.45	0.47	0.17
92004	Eye exam, new patient	124,058,862	1.70	1.73	0.68	0.73	0.68
78465TC	Heart image (3d), multiple	119,584,318	11.82	8.32	11.82	8.32	2.12

 

• Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare).

Reimbursement from the Centers for Medicare and Medicaid Services =

            40% Medicare = (40/100) x $2,054,197,206

                                    = 0.4 x $2,054,197,206

                                    =$821,678,882

            10% Medicaid = (10/100) x$ 654, 8764,000

                                    = $ 0.1 x$ 654, 864,000

                                    =$ 65,486,400

• Using the same CPT code, 99214, determine the reimbursement for Medicaid (fee schedules should be available from the individual state).

            10% Medicaid = (10/100) x$ 987,650,100

                                    = 0.1 x$ 987,650,100

                                    =$ 98,765,010

• Using the same CPT code, 99214, create at least 3 other traditional indemnity insurance reimbursements. If possible, use the actual reimbursement from the insurance carrier. It may be possible to obtain actual reimbursement information from your personal insurance carrier. If the information is not available, assume reimbursement by traditional indemnity insurance is usually 200% reimbursed more than Medicare and Medicaid, and managed care is usually 133% more than Medicare and Medicaid.

                        Traditional indemnity insurance = (25/100x) $ 53, 210, 720

                                                                             = 0.25 x$ 53, 210, 720

                                                                           = $ 133,026,800

• Compose an accounts receivable benchmark from this information showing columns for current, 30–60, 61–90, 90–120, and greater than 120 days.

Amount charged ($)	Estimated duration (days)	Actual duration	Total reimbursement
$ 134, 509	0-30	30	$4,035,270
$ 107, 100	30-60	29	$3,105,900
$, 95,000	61-90	30	$2,850,000
$120,200	90-120	30	$3,606,000
$435,675	120 and above	N/A	N/A