The best approach to appropriate maximization of reimbursements from billings – is by having administrators with the core knowledge required - keeping your office legally compliant at all times.
Although many thriving ophthalmology practices may prefer to train billing staff “in-house” there is much to be gained by hiring a professional who has the ability to “hit the ground running” with legal delivery of increased billing revenue.
Design the “Billing Specialist” Interview
We know that even though a billing administrator might have experience – this doesn’t necessarily mean they have not adopted non-compliant ideas and practices from a previous office.
For a new ophthalmologist founding a new start-up practice – that person may seem like a veteran to billing processes. To avoid this potentially damaging situation – you can adopt specific questions to use in your interview process when choosing a new billing professional.
Interview for Legal Compliance in Office Billing
Asking your candidate to answer situation-specific questions is the fastest approach to testing the knowledge of your billing office candidate.
These questions should include:
Explain the difference between evaluation management codes and eye codes for office visits
Tell us the difference between a procedure and a diagnosis
Explain the documentation requirements for the coding of a consultation
How should a unilateral procedure get coded?
Please define 66982
Please explain just what “bundling” means to you
CPT code 99213 – is this paid by all payers equally?
Please explain “upcoding”
Who bears ultimate responsibility for coding selection for procedures and diagnosis?
Explain when or if a practice can have more than one fee schedule
Validate and Investigate Compliance Rules
It is no mystery that bad habits can become ingrained – especially when correct approaches and rules have been erroneously applied over time.
Often long-time billing staff can miss new rulings or even bring false ideas of how to manage coding needs with them from previous offices.
A few correct responses to the questions posed above are as follows – use these answers to check your own understanding of some of these issues, and to discover if your office needs to focus more on compliance:
Both a diagnosis (ICD-9) code as well as a procedure (CPT) code are required for filing a claim. An example should be given: ie; the ICD-9 correlates to procedure, such as 92083 (visual-field and 365.XX glaucoma)
It’s best to submit a written request for the consult - (ideally a provider with a UPIN number). A consultant’s letter needs to be sent back to the referring source – a specific outcome and tests or surgery can be recommended.
Every payer recognizes E and M documentation and the eye codes are very specific to date and payer. Some have local documentation requirements (LMRP) while others rely on the CPT descriptor. Commercial rules are also more varied.
Never Worth the Risk
Billing compliance violations are never worth the risk. Always be sure you have knowledgeable administrators in your billing department.