How to Avoid Revenue Losses from Medical Coding Errors in Primary Care
Primary care physicians are the cornerstones of our healthcare system. They serve as the first point of contact for a wide array of medical needs, acting as trusted medical physicians, health and wellness advisors, diagnosticians, referral coordinators, and even emotional supporters for their patients.
From routine checkups and chronic disease management to immunizations, minor injuries, and mental health concerns, primary care doctors provide a full range of care, ensuring the overall well-being of individuals across all walks of life. But beyond the direct patient care, these dedicated professionals face another critical hurdle: the often-daunting and complex process of medical coding.
The Importance of Accurate Medical Coding
Significant losses to a practice can occur when medical coding is not processed accurately. A lack of proper coding and timely revenue reimbursement can jeopardize the financial health of the entire practice.
The complexity of medical coding in primary care is magnified by the wide range of illnesses, diagnostics, and treatments that primary care physicians handle. From common colds and flu to chronic conditions like diabetes and hypertension, these providers must accurately document every aspect of a patient’s visit.
Detailed notes are required on medical history, physical examinations, diagnoses, treatment plans, counseling, and follow-up care. Additionally, primary care physicians often coordinate care with specialists, requiring careful documentation of referrals and communication.
Primary care providers deploy a wide range of medical knowledge and experience to monitor wellness and diagnose conditions across a full span of ages, gender, some with complex medical histories. This necessitates not only a deep expertise in medical science, but a full understanding of medical coding guidelines and regulatory requirements across a wide spectrum. With this being said, accurate and efficient coding is a significant challenge for primary care practices.
Types of Primary Care Providers
Primary care providers (PCPs) focus on general medical care. They include:
- Family Medicine Physicians: Treat patients of all ages, from infants to seniors, providing comprehensive care for a wide range of health conditions.
- Pediatricians: Specialize in the care of infants, children, and adolescents, diagnosing and treating childhood illnesses and developmental issues.
- Internists: Provide comprehensive care for adults, addressing a variety of medical conditions.
- Geriatricians: Focus on the medical care of older adults, addressing age-related health concerns and providing preventive care.
In addition to physicians, nurse practitioners and physician assistants are also primary care providers. They work under the supervision of physicians to diagnose, treat, and manage various health conditions.
Primary Care Practices Can Overcome Challenges with Efficient RCM Processes
Primary care providers (PCP) have lower revenue per encounter than specialists making it even more important to have efficient coding, billing, and collection operations. PCPs need to recover every dollar earned in a timely manner to maintain timely cash flow for general operations.
The list below outlines the biggest headaches for primary care providers in the healthcare system, challenging even the most experienced practices. Given these concerns and challenges, it’s more important than ever for private practices to adopt smooth revenue cycle management (RCM) processes for accurate medical billing and on time insurance with timely payment reimbursements.
Organization and Operational Challenges
- Consolidation – More acquisition of primary care providers by hospitals and private equity groups.
- Workforce Shortages – The healthcare industry is facing significant labor shortages, including physicians, nurses, and other healthcare professionals. This drives up staffing costs and requires continual training in accurate medical coding responsibilities.
- Rising Operating Costs – Operating costs are rising faster than reimbursement.
- Competition – Healthcare has become fiercely competitive, with new players and disruptors entering the space. This competition is driving the need for organizations to innovate and improve.
- Administrative Burdens – Growing administrative burdens including prior-authorization, payer directives, new regulation, and data reporting are the third biggest challenges for medical practices.
- Provider Burnout – This includes high workloads, administrative burdens, emotional exhaustion, lack of work-life balance, financial pressures and the other challenges in this list. The implications are increased errors, reduced quality of care for patients, increased turnover, increased costs and decreased patient safety.
Medical Coding and Reimbursement Challenges
- In Network Reimbursement – providers need to refer patients in networks where their insurance will cover the services, requiring practices to stay current on their patients’ insurance plans and detailed requirements for reimbursement.
- Medical Coding Expertise in RCM – The scope of what primary care physicians can do is broad. They may be involved in many other ancillaries and elective services requiring knowledge in medical coding beyond general physician services.
- Declining Reimbursement – Adjusted for inflation Medicare clinician reimbursement has declined 29% from 2001 to 2024. – AMA. It’s critical that every practice has the expert medical coding knowledge to maximize opportunities for optimal reimbursement.
- Technology Adoption – Success in the healthcare profession today requires up-to-date technology that integrates the practice from registration to billing collections. While technology can improve efficiency and decision-making, it also brings unintended challenges in implementation, integration, overhead, and training. However, advanced technology can assist practices in more accurate coding, auditing, and maximum reimbursement.
- Regulatory Compliance – Changing regulations about receiving remuneration for patient referrals is common practice in primary care. In addition, changing regulations require constant monitoring with EHR, Quality Reporting (MIPS), Prior Authorizations, Coding Compliance, Billing, HIPAA, Documentation Requirements, Prescription Drug Monitoring Programs (PDMPs), Telehealth Regulations and Fraud and Abuse Laws such as the Anti-Kickback Statute and Stark.
- Ancillary Services – Independent physician groups need to stay nimble and flexible with subservices where it can make the most financial sense. These add-on services require specialized coding. Accurate coding reports can help the practice determine where they are making the most profit or losing money on services not needed to sustain the practice.
The above list of challenges and obstacles point out the need for every primary care practice to deploy best practices for revenue cycle management and billing processes.ƒ
Most Common Medical Codes for Primary Care Services
Here are the most common medical services rendered by primary care physicians and providers, which should be carefully documented and accurately coded to avoid revenue loss.
Most Common Medical Services in Primary Care
99213: Office or other outpatient visit for the evaluation and management of an established patient, typically 20 minutes.
99214: Office or other outpatient visit for the evaluation and management of an established patient, typically 30 minutes.
97110: Therapeutic exercises to develop strength and endurance, range of motion, and flexibility.
97530: Therapeutic activities to improve functional performance.
36415: Collection of venous blood by venipuncture.
97140: Manual therapy techniques (e.g., mobilization/manipulation) one or more regions.
97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception.
85025: Complete blood count (CBC) with automated differential white blood cell count.
80053: Comprehensive metabolic panel.
90837: Psychotherapy, 60 minutes with patient.
Most Common Medical Claim Denials: Causes and Impacts
Here are the most common reasons for claim denials in a primary care practice that require the most oversight and attention. Denied claims not only mean lost income for your practice, but they also create a ripple effect of administrative headaches. Staff time is wasted tracking down missing information or appealing denials, which can lead to bottlenecks and delays in getting patients the care they need. Additionally, denials can erode patient satisfaction if they’re left with unexpected bills for services their insurance supposedly covered.
Most Common Denials in Primary Care
- Missing or Inaccurate Data: Errors in patient information, such as incorrect names, dates of birth, or insurance details, can lead to denials.
- Prior Authorization Issues: Failure to obtain prior authorization for certain treatments or medications can result in claim denials.
- Coding Errors: Incorrect or incomplete coding of procedures and diagnoses can cause claims to be denied.
- Incomplete Documentation: Insufficient or missing documentation to support the services billed can lead to denials.
- Eligibility Issues: Claims can be denied if the patient is not eligible for the services under their insurance plan.
- Duplicate Claims: Submitting duplicate claims for the same service can result in denials.
- Timely Filing: Claims submitted after the payer’s deadline can be denied.
- Medical Necessity: Claims may be denied if the payer determines that the services provided were not medically necessary.
- Coordination of Benefits: Issues with determining the primary payer when a patient has multiple insurance plans can lead to denials.
- Service Not Covered: Claims for services that are not covered under the patient’s insurance plan can be denied.
Relevant Regulations Require Persistent Attention
Here are relevant regulations for primary care providers and those that should receive attention in the revenue cycle management and billing departments.
Relevant Regulations for Primary Care
- Health Insurance Portability and Accountability Act (HIPAA): Ensures the privacy and security of patient health information.
- Affordable Care Act (ACA): Expands access to healthcare and includes provisions that affect primary care, such as preventive services and Medicaid expansion.
- Medicare Access and CHIP Reauthorization Act (MACRA): Introduces the Quality Payment Program, which includes the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
Stark Law: Prohibits physician self-referral for certain designated health services paid for by Medicare or Medicaid. - Anti-Kickback Statute: Prevents the exchange of remuneration for referrals of services covered by federal healthcare programs.
Emergency Medical Treatment and Labor Act (EMTALA): Requires hospitals to provide emergency medical treatment to patients regardless of their insurance status or ability to pay. - Controlled Substances Act (CSA): Regulates the prescribing and dispensing of controlled substances.
- Patient Protection and Affordable Care Act (PPACA): Includes provisions for patient protection and healthcare affordability.
- Telehealth Regulations: Governs the provision of telehealth services, including licensing, reimbursement, and patient privacy.
- Prescription Drug Monitoring Programs (PDMPs): Requires physicians to monitor and report controlled substance prescriptions to prevent abuse and diversion.
- The No Surprises Act: Effective January 1, 2022, this act aims to protect patients from unexpected medical bills, particularly from out-of-network providers.
- Balance Billing Prohibitions: Primary care physicians cannot balance bill patients for emergency services or for non-emergency services provided by out-of-network providers at in-network facilities, unless specific notice and consent requirements are met.
- Good Faith Estimates: Physicians must provide good faith estimates of expected charges to uninsured and self-pay patients at least three business days before a scheduled service or upon request.
- Notice and Consent Requirements: When providing care at in-network facilities, out-of-network providers must obtain patient consent and provide clear notices about potential out-of-network charges.
- Public Disclosure: Physicians are required to publicly disclose patient protections against balance billing, ensuring that patients are aware of their rights under the No Surprises Act.
- Independent Dispute Resolution: The Act establishes an independent dispute resolution process for resolving payment disputes between providers and insurers, which can impact how primary care physicians negotiate and receive payments for out-of-network services.
- Non-compliance: The exact percentage of physicians not complying with the No Surprises Act isn’t readily available. However, it’s known that there have been over 12,000 complaints regarding noncompliance from both insurers and providers. This indicates that while many are adhering to the regulations, there are still significant instances of noncompliance.
The most common complaints against providers include surprise billing for both emergent and non-emergent care. This suggests that a notable portion of providers are struggling with or not fully implementing the requirements of the Act.
https://www.healthcaredive.com/news/no-surprises-noncompliance-restitution-cms-insurers-providers/724901/
UnisLink: Your Partner in Revenue Cycle Management
UnisLink offers a comprehensive revenue cycle management solution designed to minimize your overhead headaches and optimize your practice’s financial performance. By combining advanced technology, expert insight, and unparalleled analytics, we streamline your operations and billing processes while optimizing your revenue and profits.
We’re Experts in Primary Care RCM and Can Deliver:
- Increased Revenue: Our solutions identify and capture every dollar you’ve earned.
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- Enhanced Efficiency: Automate routine tasks and reduce administrative burdens.
- Seamless Integration with Your Existing Systems: UnisLink works seamlessly with the most popular EMR/EHR and PM platforms, integrating with your existing systems to ensure a smooth transition with minimal disruption to your workflow.
- Unparalleled Revenue Intelligence: Our advanced analytics provide deep insights into your revenue cycle, enabling you to make data-driven decisions that drive positive financial outcomes.
Ready to elevate your practice’s financial health? Get a free RCM services quote today.
Article References:
American Academy of Family Physicians (AAFP): https://www.aafp.org/
American College of Physicians (ACP): https://www.acponline.org/
American Medical Association (AMA): https://www.ama-assn.org/
Family Practice Management (FPM): https://www.aafp.org/pubs/fpm.html
Primary Care Collaborative (PCC): https://thepcc.org/