Medical Billing and Revenue Cycle Management

  A survey revealed that healthcare organizations anticipate that autonomous coding will accelerate the revenue cycle process and enhance coding accuracy. Although autonomous coding has the potential to streamline revenue cycle processes and alleviate administrative burdens, a majority of healthcare finance leaders surveyed either lack familiarity with it or harbor reservations about fully trusting this automated tool. A survey conducted by  Revenue cycle management company  in collaboration with the Healthcare Financial Management Association (HFMA) involved over 450 healthcare finance professionals, seeking to gauge their understanding and anticipated outcomes related to autonomous coding. Only 47.9 percent of healthcare organizations reported familiarity with automated claims coding, and among them, 18.6 percent had limited knowledge of its specifics. A majority of respondents, 52 percent, were unaware of autonomous coding altogether. The coding process stands out as t...

Regardless of whether you’re a newcomer to private practice or a seasoned professional, you’re aware that the healthcare landscape is ever-changing. What was effective for your practice in the past, be it last year or last month, may not hold true today. Staying updated on these shifts is essential for ensuring the prosperity and expansion of your practice. The  American Medical Association  produces a range of resources designed to enhance efficiency, foster engagement, and promote success. This way, you can devote your attention to your patients while maintaining the viability and sustainability of your practice. Business operations In this podcast mini-series, the AMA provides guidance on navigating the intricacies of business operations and efficiency challenges to foster the growth of your private practice. 1. Staffing and Human Resources Securing, hiring, and nurturing dedicated staff is pivotal for the success of a private practice. The AMA offers a comprehensive guide ...

  With Halloween right around the corner, be on the lookout for some of these incidents that may require new ICD-10 codes. ICD-10 CM Code W49.01 – HAIR CAUSING EXTERNAL CONSTRICTION W49 . 01XA  is a billable ICD  code  used to specify a diagnosis of hair causing external constriction, initial encounter. A ‘billable code’ is detailed enough to be used to specify a medical diagnosis. ICD-10 CM Code X99.2 – ASSAULT BY SWORD OR DAGGER X99.2 is a non-billable ICD-10 code for  Assault by sword or dagger . It should not be used for HIPAA-covered transactions as a more specific code is available to choose from below. More specific codes – 7th Character selection: The appropriate 7th character is to be added to each code from category X99 Use X99.2XXA for initial encounter Use X99.2XXD for subsequent encounter Use X99.2XXS for sequela ICD-10 CM Code R44.1 – Visual Hallucinations R44.1  is a billable ICD code use...

  Costly medical emergencies have the potential to impose a significant financial strain. It’s important to recognize that unexpected and expensive health issues can affect anyone. While we can’t predict when or if we’ll face an unforeseen health challenge, we can take steps to be financially ready. Below are some approaches to kick start your preparations. The Current Landscape of Medical Insurance First and foremost, ensuring you have the appropriate health insurance in place is crucial for managing the financial aftermath of a health crisis. Many individuals acquire coverage either through their employer, via an individual policy, or as part of a government program like Medicaid or Medicare. Irrespective of your insurance source, it has become increasingly common to encounter co-pays or deductibles when seeking medical attention. Hence, your financial responsibility extends beyond the premiums you may be accountable for. Depending on your policy, you might potentially face out-o...

  Uncertain about the details of Medicare Advantage? Here’s what you need to know. The Medicare open enrollment period, running from Oct. 15 to Dec. 7 annually, is now underway. This gives you the chance to make adjustments to your current Medicare coverage. One potential change worth considering is transitioning from original Medicare (Parts A and B, along with a Part D drug plan) to a  Medicare Advantage plan . This shift could provide you with enhanced coverage and potential savings on healthcare expenses. If you’re still unsure about how Medicare Advantage plans operate, here are some crucial points to consider: They must cover all the services included in original Medicare. When you sign up for a  Medicare Advantage plan , you’re guaranteed to receive, at minimum, the same level of coverage offered by original Medicare. While some may be enticed by the potential cost savings of an Advantage plan, it’s important not to compromise on essential services for the sake of ...

  According to a recent survey, eligibility and prior authorization issues were among the most prevalent causes of claim denials. Hospitals and healthcare systems are experiencing an uptick in claim rejections due to errors in front-end revenue cycle processes. The Healthcare Financial Management Association’s Pulse Survey program, conducted for a healthcare technology company, gathered responses from over 350 CFOs and revenue cycle leaders in hospitals and healthcare systems. Nearly half of these financial leaders (47 percent) reported an increase in claim denial rates compared to the previous year, with 37 percent noting a rise of at least 5 percent. While a majority of hospitals and healthcare systems saw a significant surge in claim denial rates, only 2 percent of respondents stated that their rates had decreased by 5 percent or more. Meanwhile, 27 percent observed no change, and 24 percent reported a decrease of less than 5 percent in claim denial rates. As claim denial rates ...

  The CPT code set for 2024  has recently been released. The modifications discussed below pertain specifically to urology and will become effective on January 1, 2024, across all payers. While pricing and coverage details will be finalized for certain procedure codes, primarily for Medicare, with the release of the Medicare Physician Fee Schedule in late October or early November, we will keep you updated on these determinations and their anticipated impact on urology. A notable portion of the new codes falls under the category of CPT Category III codes. These will necessitate additional investigation, particularly in terms of coverage and payment rates, especially when dealing with private payers. It’s crucial to bear in mind that CPT Category III codes are officially recognized as CPT codes and should be used to report services rendered, provided they most accurately describe the services offered, unless explicit instructions have been given by a payer (we strongly advise o...

  Preauthorization is a process in which a healthcare provider obtains approval from the patient’s insurance company before providing certain services or procedures. This process is important for both the patient and the provider, as it helps to ensure that the services are covered by the patient’s insurance plan and that the provider will be reimbursed. Preauthorization is also an important part of the  healthcare revenue cycle management (RCM) process . RCM is the process of managing all of the financial aspects of a healthcare practice, from billing and insurance to collections and payments. Preauthorization helps to reduce the risk of claims being denied or delayed, which can improve the practice’s overall cash flow. Benefits of Preauthorization Preauthorization offers a number of benefits for both patients and providers, including: •Reduced risk of denials and delays: Preauthorization helps to ensure that the patient’s insurance will cover the services or procedures being...

  The Centers for Disease Control and Prevention (CDC) has recently unveiled the   ICD-10-CM code updates   for the fiscal year 2024, effective since October 1, 2023. This comprehensive update encompasses a staggering 433 changes, including 395 additions, 25 deletions, and 13 revisions, resulting in a total of 78,044 codes within the ICD-10-CM set for FY 2024. Staying current with these annual alterations is imperative for coding professionals and relevant team members, ensuring proficient application and adherence to new documentation requisites. Noteworthy updates in the realm of medical coding encompass the following highlights: In Chapter 21, addressing Factors Influencing Health Status and Contact with Health Status: Introduction of fresh codes centered on social determinants of health (SDoH) and their influence on the well-being of children. Specifically, five additional codes have been incorporated into category Z62, enhancing the ability to identify upbringing-rel...

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is a coding system used to report medical diagnoses and procedures in the United States. It is updated annually to reflect changes in medical terminology and practice. In 2024, there are several new ICD-10-CM codes for breast cancer, including: C50.919: Malignant neoplasm of unspecified site of unspecified female breast C50.929: Malignant neoplasm of unspecified site of unspecified male breast These codes can be used when the specific site of the breast cancer is unknown or unspecified. This may be the case if the cancer is diagnosed based on a biopsy of a metastatic lesion, or if it is not possible to determine the primary site of the cancer. There are also several new ICD-10-CM codes for breast cancer by stage, including: C50.11: Malignant neoplasm of upper inner quadrant of breast (C50.11) C50.12: Malignant neoplasm of lower inner quadrant of breast (C50.12) These codes can...

  Ensuring effective denial management continues to be the foremost concern for revenue cycle leaders, emphasizing the increasing demand for streamlined processes and vigilant oversight. Over the recent months, there has been a notable surge in challenges related to denials management, presenting a multifaceted and costly issue for revenue cycle leaders. Seeking Cost-Effective Solutions? Explore the Option of Automating Your Denials Management Process According to a survey conducted by AKASA, 78.7% of financial and revenue leaders emphasized that denials management demands the highest level of expertise. Interestingly, the survey also revealed that only 38% of hospitals and health systems have presently implemented automated denials management systems. Considering the potential for inefficiencies and errors, adopting technologies like artificial intelligence or other advanced solutions holds the promise of significant time and cost savings for organizations, allowing them to optimi...

  The Centers for Medicare & Medicaid Services (CMS) have embarked on a decisive move by enforcing a standard for prior authorization. In a conversation with the Senior Director of Utilization Management, we discussed the potential implementation and impact of this proposed mandate, slated for enactment in January 2026 The Predicament of Prior Authorization The process of obtaining prior authorization, also referred to as pre-approval, instills apprehension in both patients and providers. According to a 2022 survey conducted by the American Medical Association, 88% of providers expressed that the demands of prior authorization were notably high. The Medical Group Management Association (MGMA) further underscored this sentiment by ranking prior authorization as the most significant regulatory challenge for doctors. In the traditional fee-for-service payment model, prior authorization by payers is undeniably vital. Without it, there would be a surge in over-treatment, leading to ...

  As the 2024 calendar year’s open enrollment period swiftly approaches, it is imperative for organizations to focus on ensuring compliance with the Affordable Care Act (ACA) in order to guarantee that their procedures for managing health plans are well-executed. Despite nearly a decade of ACA reporting, organizations still tend to make errors in Affordable Care Act compliance, particularly in relation to the ACA’s Employer Mandate. This mandate dictates that employers with 50 or more full-time or full-time-equivalent employees must furnish Minimum Essential Coverage (MEC) that also meets Minimum Value (MV) to at least 95% of their full-time workforce and their dependents. For businesses of all sizes, navigating the complexities of the ACA’s Employer Mandate can be a formidable task. Making mistakes in  ACA compliance  can lead to substantial financial penalties from the IRS, such as receiving Letter 226J. In this article, we spotlight the critical blunders that organizat...

  The Centers for Medicare and Medicaid Services have unveiled the premium rates, deductibles, and coinsurance figures for Medicare Part A and Part B in 2024, along with the income-based monthly adjustments for Medicare Part D in the same year. What is the Impact of Part B Premiums and Deductibles On Medicare Costs? Medicare Part B encompasses a range of essential services including physician visits, outpatient hospital care, specific home health services, durable medical equipment, and various other medical treatments not covered under Medicare Part A. In 2024, the standard monthly premium for Medicare Part B enrollees will be $174.70, reflecting a $9.80 increase from the 2023 rate of $164.90. Additionally, the annual deductible for all Medicare Part B beneficiaries will rise to $240 in 2024, up by $14 from the previous year’s deductible of $226. The rise in the 2024 Part B standard premium and deductible is primarily attributed to projected increases in healthcare expenditures, c...

  As we approach the year 2024, it is important for healthcare professionals to stay up-to-date on the latest coding updates for outpatient surgeries using the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10 PCS). These updates are crucial for accurate and efficient billing, reimbursement, and data analysis. The following is a summary of the most significant changes that will take effect on January 1, 2024, for outpatient surgery ICD-10 PCS coding. New Procedure Codes There will be a total of 1,227 new procedure codes added to the ICD-10 PCS code set for outpatient surgeries in 2024. These new codes will be used to describe a wide range of procedures, including: Minimally invasive surgical procedures Robotic-assisted surgeries Endoscopic procedures Percutaneous procedures Radiological procedures These new codes will provide greater specificity and accuracy in coding these procedures, which will facilitate more accurate billing and reimburse...

Advantages of Healthcare Workflow Automation Automation within healthcare workflows offers a host of valuable benefits, such as: 1. Enhanced Accuracy: In healthcare, even a minor error can lead to significant consequences. Human errors in manual data entry are always a possibility for healthcare providers. These errors cost healthcare providers $40 billion annually and can even pose life-threatening risks. Automating uploads, however, guarantees precise data entry without room for error.  2. Enhancing Communication and Patient Care: Ensuring effective communication between patients and physicians is paramount for achieving positive healthcare outcomes. Through automation, patients receive timely and consistent information, ultimately elevating the quality of care provided. Addressing the issue of no-shows is a common challenge. Occasionally, individuals may forget about their appointments, leading to missed opportunities for care. This challenge can be mitigated by proactively send...

In the intricate realm of healthcare, where patient well-being is closely entwined with administrative complexities, the cornerstones of success lie in effective revenue management and specialized  revenue cycle management services . This pivotal link between clinical operations and financial viability is established through the practice of healthcare revenue cycle management (RCM) and services offered by specialized firms. To grasp the true significance and comprehensive scope of RCM and its affiliated services within the healthcare landscape, one must comprehend their advantages and their transformative impact on medical practices. Let us explore the myriad benefits of revenue cycle management and its associated services in healthcare, understanding why they have now assumed unprecedented importance. Comprehending Health Care Revenue Cycle Management and Services Every component—be it clinical care, patient experience, or financial administration—plays a vital role in shaping the...

In the intricate realm of healthcare, where patient well-being is paramount, the financial dimension often receives less attention. Yet, it’s imperative to recognize that healthcare encompasses not only patient treatment but also ensuring fair compensation for healthcare providers. Precise medical coding is a cornerstone of this endeavor. This piece delves into the profound importance of  medical coding services  in healthcare reimbursement and its wide-ranging impacts on the healthcare sector. Understanding the Basics of Medical Coding Prior to delving into the significance of precise medical coding in healthcare reimbursement, it is essential to have a firm grasp on the fundamentals of this practice. Essentially, medical coding entails the translation of intricate medical diagnoses, treatments, and procedures into standardized alphanumeric codes. These codes function as a universal language, facilitating seamless communication between healthcare providers, insurance companie...