Medical Billing Training: 5 Skills That Get Claims Paid

“I pulled a hamstring during the New York City Marathon. An hour into the race, I jumped off the couch…” (David Letterman)

Train for it

A marathon is 26.2 miles. That is a long way. One early December morning, I was getting ready to find out how long. Up to then, my longest run was 13.1 miles. I had completed 3 or 4 events of that distance, the most recent about 3 weeks earlier. For those who do not know the recommended training plan for a marathon, by race day the runner should have completed more than one training run of 20 miles or more. I was not prepared.

You may wonder why I was there. I had to be. The person next to me, a long-time friend, had completed a three-part breast cancer treatment: mastectomy, chemotherapy and radiation therapy.

The year before, we had “agreed” that now that I was running, “I had to do a marathon.” Those were her words, as an accomplished and once very competitive runner. But after the “agreement,” the diagnosis came with all of the treatment that followed, so the plans to race were postponed.

Then the last piece of her treatment, reconstruction, was postponed until early the next year. At that point the race was still not back on. She did start training again, and at a wine tasting party in mid-October she told me she was already back up to 9-mile runs several times a week.

I mention the wine because challenges between good friends often start over a drink. I made the first challenge: “Then you can do the half marathon with me in 4 weeks.” She agreed on one condition: “I will do it, but then we have to do the marathon in December.”

There was no way I could refuse this strong, brave woman sitting in front of me. There was too little time to build up my training safely, so I would run a marathon with only 13.1 miles as my longest run.

Note: I do not recommend running a marathon under-trained. Luck, determination and encouragement got us to the finish line.

You cannot rely on any of that to do your medical billing well. Proper, complete and up-to-date training is necessary to get the best claim reimbursement for the medical practice.

Mile 0: Understanding insurance benefits, payer LCDs and medical policies

Front office staff should verify benefit and coverage information for all new patients on or before their first visit. Check established patients once a year in case their coverage has changed.

Insurance benefits. Staff members need to understand the terms deductible, coinsurance, copayment and out-of-pocket so they can give the patient accurate information about what the patient owes. Staff should also understand payer authorization requirements and protocols in case the physician orders any diagnostic or other treatment procedures.

Payer LCDs and medical policies. Medicare publishes Local Coverage Determinations (LCDs), which are guidelines that set the payment criteria for certain procedures. Commercial payers usually call the same type of guidelines medical policies. Teach staff that reviewing these documents is necessary to determine in advance whether a planned procedure meets the payer’s “medical necessity” coverage. These documents are updated periodically, so set a regular time to check for changes. This prevents unnecessary denials.

Mile 6.2: Verifying proper medical documentation

Documentation. EHR and EMR systems have tried to make documenting a procedure error-proof. But not all systems are equal. Some may be missing fields, or may let staff skip some of the requested details. Before any charges go to the payer, staff should review the medical records to verify that the proper codes are being submitted.

For evaluation and management services, CMS has an entire section of its website dedicated to these procedures. The Florida MAC, First Coast Service Options (FCSO), provides a free interactive E/M worksheet so staff can properly score the visit and determine the code. Audits and fraud investigations are a real concern, but careful documentation review before you submit charges protects you.

Mile 12.4: Knowledge of CCI edits

The Correct Coding Initiative (CCI). To understand and prevent denials that read “mutually exclusive,” staff need a thorough knowledge of CCI edits. Medical billing software with a built-in claim scrubber can automatically identify CCI code pair conflicts. Even with this technology, staff should know three basic things:

Where to find the most recent version of the edits. CMS publishes them quarterly in the Medicare section of the CMS website.
How to read the edit tables. There are 3 columns. Columns 1 and 2 show code pairs. If two codes you plan to bill appear as a code pair, in most cases they are not both paid. Only the code in column 1 is paid. If a medically indicated modifier, typically 59, can be added to the column 2 code to override the edit, column 3 shows a “1.” If column 3 shows a “0,” no modifier will override the edit.
The reason behind the edits. A code pair edit may represent two codes that should not be reported together unless an appropriate modifier is used. Or it may represent mutually exclusive procedures that cannot reasonably be performed at the same anatomic site or in the same encounter. Understanding the nature of the two procedures helps staff know whether they are mutually exclusive or whether adding a modifier is appropriate.

Mile 15.5: Using EDI transactions

Electronic Data Interchange (EDI) transactions. Medical billing uses numeric identifiers for many things. Procedures are reported as 5-digit codes. Diagnoses are reported as alphanumeric codes from 3 to 5 characters long. EDI transactions are no exception.

270/271 is the Health Care Eligibility Benefit Inquiry and Response, also known as Real Time Eligibility (RTE). With RTE, you can verify your patient’s eligibility and coverage within seconds and make fewer time-consuming phone calls to the payer.
276/277 is the Health Care Claim Status Request and Response.
278 is the Health Care Services Review Notification, used to request authorizations.
835 is the Health Care Electronic Remittance Advice, commonly called the ERA. The best practice management systems, like Iridium Suite, can post many ERAs automatically.
837 is the Health Care Electronic Claim Submission. It can nearly eliminate printing and mailing paper claim forms. Combined with the ERA, claim payments can arrive in less than 10 business days from many payers.

Mile 18.6: Investigating rejections and denials

Rejections and denials. In medical billing, unpaid claims typically fall into two categories: rejected or denied.

A rejection usually results from incorrect or missing data on the claim. When the biller receives a rejection notice, the biller is responsible for reviewing the rejection message and making the needed changes before resubmitting. For instance, if the payer says the claim contained an invalid policy identification number, the biller should use every available means to get the correct information. It is not appropriate to write off the charge or bill the patient automatically.
A denial is typically based on a coverage issue, either the patient’s policy or the payer’s general benefit guidelines for the denied service. This goes back to our first point, understanding insurance benefits, payer LCDs and medical policies. For example, a patient may have hospital-only benefits but was seen for an office visit. Or the procedure performed is not considered medically necessary for the patient’s diagnosis. There are many reasons for denials. A medical biller must have the skills to research the issue thoroughly and decide whether to appeal the claim before it is written off or the patient is billed.

Mile 24.8: Keep learning

Medical billing is a complex and varied job. Use every available resource to keep increasing your knowledge. Payer websites contain a great deal of information, and if you subscribe to their email newsletters and bulletins, you will be among the first to know about changes that could affect your practice.

I also recommend our other publications:

Mile 26.2: The finish line

With proper training, you and your office staff can set a personal record (PR) in medical billing.

What has changed since this was written

ICD-10 replaced ICD-9. ICD-10-CM took effect on October 1, 2015, and diagnosis codes are now 3 to 7 characters long, not 3 to 5. See 5 facts about ICD-10.
Modifier 59 has more specific alternatives. Since January 1, 2015, CMS accepts modifiers XE, XS, XP and XU to describe a distinct service more precisely than 59. See CMS says modifier 59 needs an assist.
E/M code selection changed. Since January 1, 2021, office and outpatient E/M levels are chosen by medical decision making or total time, so score sheets built for the older guidelines no longer apply to those visits.
LCDs are in one place. All Medicare contractors’ LCDs and articles are searchable in the CMS Medicare Coverage Database.

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