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Do you make these common charge mistakes?
How you fill out a billing sheet has a lot to do with how much you’re paid

Keywords: ICD-9 coding - Seven tips to help physicians avoid billing problems and maximize payment


by Kristy Welker, CPC



Published in the March 2009 issue of Today's Hospitalist

FILLING OUT YOUR BILLING SHEET seems fairly straightforward. You simply list a patient’s diagnoses, write in the appropriate code that corresponds to your level of decision-making and submit the charge, right?

Not exactly. In reality, physicians often make mistakes when filling out billing sheets that affect when— and whether—they are paid. Those errors may cause your billing staff undue frustration or, even worse, billing delays or denials.

Here’s a look at the most common errors I see on charge sheets, along with advice on how to avoid them.

#1. Pay attention to your diagnosis
Most insurers allow you to submit only four diagnoses on a billing claim form.

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Did you know that most insurers allow you to submit only four diagnoses on a billing claim form? I often see physicians list more than 10 for one patient stay.

Even worse, some physicians list a chronic diagnosis, such as hypertension, first on the billing sheet, while the acute medical problem being treated—such as acute renal failure—is way down the list. There’s a good chance that if the patient’s most serious medical issue is listed as the fifth (or lower) diagnosis, it won’t even be submitted for payment!

You may want to have your group adopt a billing form that lists a daily charge and diagnoses or allows you to number the diagnoses. That way, you can assign a number to each of the diagnoses that you treat on any given day.

And always list diagnoses in order of their relevance to your patient care, from the most serious through the less so. The diagnoses you bill for should correspond to the medical problems you address.

#2. Provide supporting documentation
When you list service codes for diagnoses, you are claiming that those diagnoses are the reasons why your services were medically necessary. Unfortunately, physician documentation doesn’t always support those claims.

When submitting a diagnosis, make sure your documentation clearly references your care and treatment of that specific condition. Otherwise, an insurer may consider it to be a false claim.

Let’s go back to the patient with acute renal failure and chronic hypertension. Say the patient’s hypertension on one day of the hospital stay is stable; you don’t need to adjust medications or direct any form of treatment that day for the hypertension.

Your documentation for that visit shouldn’t mention hypertension. When filling out your charge sheet for that visit, you should likewise not mention hypertension as a diagnosis. Otherwise, you’d be listing the diagnosis without any documentation of treatment on that day to back it up.

#3. Don’t confuse current condition with history
Don’t list a diagnosis as a current condition when you should be designating it instead with “a history of.”

Say a patient has had a transient ischemic attack (TIA) in the past. List that diagnosis as “a history of TIA”; otherwise, it will end up in the patient’s medical history as the current condition. That will put you in the same bind that we just talked about in No. 2, where you’re listing a condition without providing any documentation on treatment.

On the other hand, if a patient has a history of a disease that is relevant to your treatment, list it as a supporting diagnosis. Also, avoid using rule-out or possible diagnoses. Include those in the differential diagnoses you note in the patient chart, but not as part of your diagnoses on the billing sheet.

#4. Use only standard abbreviations
I’ve said it before in previous articles, but it bears repeating: Abbreviations pose problems when you deviate from the standard, not only for patient safety reasons but for billing purposes.

Imagine a coder trying to figure out if “ARF” means acute renal failure or acute respiratory failure or if “PE” stands for pleural effusion, pulmonary edema or pulmonary emboli. To avoid such confusion, be sure your group establishes a list of abbreviations that everyone agrees to use. That way, your documentation will always support the right diagnosis code.

#5. Pay attention to the date
This is particularly important when you’re working a late night shift. Often, physicians see patients past midnight, but they fail to use a new date of service. I often see claims denied due to the fact that a charge document has the wrong date of service or the documentation is dated incorrectly.

Keep in mind that insurers look to the hospital’s information when determining payment. If the date you give is inconsistent with what the hospital says is the date of admission, discharge or death, your claim will be denied.

#6. Submit only one charge per day
Make sure you’re the only person in your group submitting a bill for services on a patient on any given day, or fold your charges into another physician’s bill for that date and that patient.

As you probably know by now, a group can bill only one hospital visit per day per patient. But that doesn’t stop many groups from submitting multiple bills for patients visited by more than one group physician that day.

The solution? Set a billing protocol within your group for which doctor gets billing credit when more than one physician per day treats a patient. That way, you can avoid duplicate billing—which leads to denials—and unnecessary work for you and your billing staff.

# 7. Submit your charges promptly
Many insurers limit how long claims can be submitted. In general, those limits are up after 30 or 60 days, although Medicare accepts claims for a longer period. Make sure you turn your charges in on time.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.
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