physical therapy documentation

EMR Software System — Transforming Patients into Referral Sources

by Nitin Chhoda PT, DPT | Jan 21, 2014 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Software

It’s important for physical therapists to keep in touch with their patients throughout the year and not just when they make an appointment. Nitin Chhoda elaborates on how electronic medical record (EMR) software provides the tools to build and maintain an ongoing relationship with patients and transform them into a primary source of referrals.

Familiarity Breeds Referrals

Patients want to know that their business is appreciated. They’re busy and have dozens of options available when choosing a healthcare professional.

They want to feel that they’re more than just an insurance card or a paycheck. Clinicians must reach out to them.

An electronic medical record makes it easy, simple and streamlines the process.

Practitioners must strive to create an improved relationship with patients to increase the chances of referrals. They have to like, trust and be familiar with the therapist before they feel comfortable enough to refer them to friends and family.

Practitioners must keep their names in front of patients and an EMR provides the means to do that.

Modern Communications

An integrated solution, such as the In Touch EMR™, offers multiple methods of connecting with patients in traditional and modern ways to form and maintain long-term relationships. Practitioners can use the abilities of an EMR to provide patients with gentle reminders without being invasive.

Communication is the key to creating a long-term relationship between patients and practitioners.

Note: An EMR contains multiple mechanisms to communicate with patients.

When patient information is entered into an EMR, it provides clinicians with eight pieces of data that can be used to inform, educate and connect with their clientele.

Therapists should automatically collect the needed patient information, including their email address and cell phone number. Practitioners can take advantage of the built-in abilities and data residing in the EMR to send clients offers, announcements and eBooks, along with voice and text messages. Patients must give permission for the contact, with the option of ending the communication when they desire.

An EMR Facilitates Communication in a Variety of Ways

Clinicians can keep in touch with patients through mail, email, phone and cell phones, and voice and text messages.

All those methods can be used to mark the client’s anniversary with the practice, the patient’s birthday, and send a variety of patient reminders.

Most text messages are read within five minutes of receipt, making them a reliable vehicle of communication.

Electronic medical records provide practice owners with automated options that can be used to deliver newsletters, greeting cards and special offers. Clinicians should endeavor to use at least two or three of the available communication options. With the metrics contained in an EMR, practitioners can also track patients who make a large number of referrals.

Integrated EMRs will soon be the standard in private practices, hospitals, labs and pharmacies across the nation. They streamline all facets of the office and reimbursement process, and provide automated methods of connecting with patients to build relationships that generate referrals.

EMRs have the necessary tools to help practitioners expand their reach and transform patients into an ongoing source of referrals.

Billing: The Importance of Keeping Records in Your MIB Business

by Nitin Chhoda PT, DPT | Jan 15, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Software

Documentation is the backbone of a medical insurance billing (MIB) business. It’s essential to file claims for clients and interacting with the IRS at tax time. In this informative article, Nitin Chhoda reveals the many reasons for maintaining proper documentation within an MIB business.

Tools of the Trade

Billing software is designed to handle virtually any billing related task an MIB chooses to offer, but MIBs should consider the option of employing electronic medical record (EMR) technology in their business.

Fully functional EMR software is available for free and only requires a modest monthly user fee.

EMRs are in compliance with HIPAA privacy standards and submit claims electronically. They have the ability to maintain multiple databases for any number of patients, providers and payers. The billing software maintains a comprehensive array of information digitally or in the cloud, eliminating the need for paper medical records.

Avoiding the Litigation

Perhaps the greatest need for documentation in a biller’s arsenal is to avoid running afoul of litigation on behalf of their clients. It offers protection against accusations of billing for services and procedures that weren’t provided, altering or falsifying claims, misrepresentation, and billing for non-covered services.

Daily Documentation

Armed with a medical provider’s day sheet, MIBs are tasked with submitting a client’s current claims, complete with the necessary patient data. Documentation must be kept that supports the medical provider’s diagnosis, treatment and procedures performed when claims for billing are sent.

It’s a simple matter to import written records into an EMR for storage and easy retrieval should a claim be denied, rejected or need correction.

Billing software provides a running account for each client that documents which claims have been paid, patent balances owed and payments posted to a clinician’s practice. Billers can quickly refer to their software when dealing with clearinghouses, payers or recalcitrant patients.

Patient IDs and Coverage

A patient must provide a photo ID and a copy of their insurance card for a claim to be filed. All that information can be kept securely within billing software, allowing billers to update the data as needed. Copies of all those insurance cards provide billers with necessary information to submit claims that get paid in a timely manner.

The billing documentation provides essential information about the client’s medical coverage, insurance exclusions, co-insurance, deductibles and co-pays, and who is covered, along with any financial maximums or caps. The documentation contained within the software allows billers to ascertain if the patient’s coverage requires pre-approvals or referrals.

Contracts and Databases

To deal with clearinghouses with authority, billers need a copy of the contract between clients and their clearinghouse. Digital documentation puts the necessary information at their fingertips.

Multiple databases can also be created to provide an array of information that billers have agreed to track for their clients, from referral sources and revenues to the number of procedures performed each month.

Operating Costs

Documentation and receipts are critical for billers at tax time. The data allows MIBs to claim the cost of operating expenses, from equipment replacement and depreciation to loan payments, office supplies and coding updates. Don’t forget to document income.

With the elimination of paper forms, digital documentation becomes a critical element in business, especially in the medical billing industry. Billers who want an affordable full management system that will grow with their business should consider an EMR for comprehensive documentation, storage and retrieval.

Understanding the RAC Audit Process

by Nitin Chhoda PT, DPT | Jan 11, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Software

One of the greatest challenges facing practitioners is a potential investigation by a Medicare Recovery Audit Contractor (RAC). Medicare estimates that there is a sixty two percent error rate among reimbursement claims in which documentation doesn’t match the billed expenses.

Private practice marketing expert, Nitin Chhoda, says that when services, fees and documentation don’t match, it increases the possibility of a RAC audit. The good news is that there are concrete steps clinicians can take to reduce the risk. And he shares that information in this article.

Even with the best coders and billers, errors can occur and it’s ultimately the responsibility of the practitioner to ensure that records match.

Knowing how the RAC process works allows clinicians to develop measures and install appropriate software systems to minimize risk factors that lead to an audit.

Medicare RAC auditors examine reimbursement claims after payment has been made, using methods similar to those employed by commercial healthcare insurance carriers.

The practice is known as pay and chase among industry officials. They look for inconsistencies in the billable services and submitted documentation.

RAC auditors utilize methods that comply with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.

Determining the Two types of Audits

There are two types of audits – automatic and complex.

An automatic audit seeks easily identifiable errors in payments, but doesn’t require human intervention or medical records to determine a problem exists.
A complex audit addresses improper payments through a manual evaluation and a request for extensive supporting documentation. Medical providers have strict and definite timelines in which to request an extension, comply with producing the appropriate records, and make appeals.

The process doesn’t stop there. Practitioners singled out for a RAC will be reported to CMS for potential fraud. If the RAC determines the problem is a potential quality issue, they report the provider to the state’s Quality Improvement Organization.

Initiate Self-Audits in order to Minimize RAC Interventions

Conducting self-audits will help minimize RAC interventions, but the best way clinicians have of avoiding an audit is to ensure their flow sheet, plan of care and billed expenses all match. If they don’t, it’s a problem and the responsibility of the practitioner.

Integrated electronic medical record (EMR) software is a critical element and provides the first line of defense toward that goal of avoiding an audit.

Each EMR differs slightly, but systems such as the In Touch EMR, and In Touch Biller Pro, have capabilities specifically designed to assist coders and billers.

When data is entered, it prompts and advises the user for information and data to ensure all the components match and support each other.

It’s a crucial feature that offers a greater level of compliance and minimizes the probability of an audit.

Knowing how and why a RAC audit is conducted provides clinicians with the necessary information to help them avoid the experience. Confirming that the flow sheet, plan of treatment and documentation are all in agreement is the first step. The second is implementation of an “intelligent” integrated EMR physical therapy software system.

An audit isn’t desirable, but instead of living in dread practitioners should look upon a RAC audit as an additional way to maintain compliance.

Healthcare Coding Basics

by Nitin Chhoda PT, DPT | Oct 31, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

In the 21^st century, paying for visits to healthcare providers is a simple process for patients. They simply present their insurance cards, make a copay and go on their way.

The system can be a nightmare for medical insurance billers (MIBs), who complete hundreds of reimbursement claims each week covering a wide spectrum of treatment. In the following article, Nitin Chhoda examines what MIBs need to know about healthcare coding basics.

MIBs will encounter a multitude of technical terms in healthcare coding that will affect the codes used when preparing a claim for reimbursement.

Billers will need to be fluent in medical terminology and healthcare coding procedures to accurately code claims.

The knowledge enables them to submit claims that are reimbursed quickly, meet the demanding standards required by insurance carriers, and maintain compliance with federal and state standards.

Documentation

Billers will be working with multiple and disparate healthcare coding documentation that provides substantiation to payers that the services, procedures and treatments provided were needful and appropriate to the practitioner’s diagnosis.

Each piece of documentation is the evidence that carriers will utilize for reimbursements and a single omission will result in a denial.

CPT Codes

The acronym CPT stands for current procedural terminology. CPT codes will be used on claims to describe the medical services and procedures provided by the practitioner.

CPT codes must match the services they represent to avoid denials and payment interruptions. This is very important.

ICD-9 Codes

The International Classification of Diseases (ICD) codes will soon be updated to CPT-10 to encompass new diseases and technology. The alpha-numeric healthcare coding is the primary diagnostic tool used to document and explain the signs, symptoms, illnesses and diseases clinicians will encounter.

The codes provide insurance companies with essential information about a patient’s condition and resulting treatment.

Some billers will encounter alpha-numeric C codes and V codes:

C codes are used to identify the external causes of poisonings and injuries.
V codes are utilized to categorize factors that have a direct influence on a patient’s health status, along with encounters that aren’t due to an illness or injury.

Modifiers

There are times when a procedure is altered from its original description. Healthcare coding modifiers are used when a procedure requires additional time and expertise, or has extenuating circumstances.

Billers will use the two-digit modifiers in the CPT healthcare coding to report such occurrences. They provide MIBs with the means to bill very specifically and obtain additional revenues to compensate practitioners.

Modifiers are also appropriate when a technical component (TC) is involved.

Sometimes a clinician will need the use of equipment, labor and/or supplies to perform a procedure that is maintained by another specialist or medical facility.

Modifiers in healthcare coding are used to explain that those items are billable by entities other than the practitioner.

MIBs will encounter a host of different codes and medical terminology that must be entered on claims accurately to facilitate quick reimbursements and avoid costly denials and delays.

Medical billing staff who are familiar with the healthcare coding basics are well on their way to becoming masters in their profession.

The Typical Insurance Claim Cycle

by Nitin Chhoda PT, DPT | Oct 27, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing

The demand for medical insurance billers (MIBs) continues to grow and many individuals are eager to launch a career in the field.

The popularity of medical billing has given rise to a multitude of unfounded claims by scam artists who insist it’s a career path with minimal work and quick rewards. In this informative article, Nitin Chhoda explores the claim cycle and the MIB’s responsibilities.

The insurance claim cycle is the process of billing a third party entity that pays for the medical care of one of its subscribers.

The claim cycle begins the moment a patient makes an appointment with a provider and doesn’t end until the full amount has been deposited in the practitioner’s bank account.

Patient Paperwork

Medical histories, questionnaires and other forms impart necessary data about the patient’s past and current ailments, complaints, procedures and treatments.

A release of information is required so MIBs can file a claim and obtain payment from the patient’s healthcare insurance carrier. During the claim cycle, a release is critical, as MIBs can’t share the needed information with an insurance company without the patient’s permission.

Essential paperwork also includes a copy of the patient’s photo identification and their insurance card. Health insurance fraud is a very real crime for which MIBs must be wary. The insurance card contains information on who is eligible for services, along with exclusions, restrictions, limitations and prerequisites that must be met for payments to be dispersed.

Patients may also have coverage under multiple policies. Each insurance plan will have established deductibles and co-pays that constitute the patient’s portion of the final bill. Make sure that these are all reviewed during the claim cycle process. Always attempt to collect these fees before the patient sees the provider, or have the patient make alternative arrangements for paying.

Computing Power

All of the data must be entered into the MIBs billing software program or electronic medical records (EMRs) system where it can be accessed and retrieved for transmitting, tracking and monitoring reimbursement claims. Care must always be exercised in the claim cycle process to ensure the information is entered correctly to avoid delays and denials.

EMR technology is especially helpful, as it can identify users of potential claim problems.

A patient encounter form must be created and the appropriate ICD and CPT codes entered to substantiate the provider’s diagnosis and subsequent treatment. Any referrals, diagnostic tests and pre-authorizations must be documented, along with follow up visits if needed. The claim cycle process contains a full accounting of medical fees which must be entered and a claim form is always created that will be transmitted electronically to a clearinghouse.

Claims and Follow Ups

Once the claim arrives at the clearinghouse, MIBs will receive electronic verification. Clean claims that are free of errors are forwarded to the payer for remittance. Those with problems will be denied and returned. Clearinghouses and insurance companies are experts at finding even the smallest reason to justify delaying payments. So the billers must not end the claim cycle when they submitted the claims but rather when every claim has been reviewed and accounted for.

Once the claim is approved, it’s the task of the MIB to track the payment, see it securely deposited at the clinician’s chosen banking institution and recorded in the patient’s account.

Overdue payments must be investigated and appealed when appropriate. Billers will need to contact patients about any outstanding balance, be prepared to send unpaid accounts to collections, or write it off as a loss at the provider’s discretion.

The insurance claim cycle is completed when each portion of the payment is collected from the insurance carrier and the patient.

With EMR technology, receiving remittance from commercial payers can take as little as 10 days, and 30 days for government operated plans. MIBs are a crucial element in the claim cycle process, working to ensure that the practices of their clients receive the funds to which they’re entitled.

Reimbursement Claims: How Can to Make Sure I Get It the First Time Around?

by Nitin Chhoda PT, DPT | Oct 21, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Clean reimbursement claims are the bread and butter of the medical billing industry. They pass the scrubbing process at clearinghouses quickly and generate revenues faster. Billers can take a variety of precautions to avoid denied claims and in this telling article, Nitin Chhoda reveals the most common billing mistakes.

The first rule of medical billing is never assume anything. If a medical insurance biller (MIB) has any doubt due to a practitioner’s illegible scrawls, the type of treatment received or procedure performed, it’s imperative to contact the clinician for clarification.

Coding Errors

Mistakes and oversights in coding represent the number one reason that reimbursement claims are denied. Electronic medical record (EMR) technology can identify potential claim problems and notify the user. Insurance carriers are constantly seeking ways to avoid paying reimbursement claims and examine coding closely for the following items:

Mismatched coding that creates inconsistencies in the claims. A good example is gender specific ailments.
Truncated coding doesn’t address all three levels of the practitioner’s diagnosis is suspect.
Up and down coding is a red flag for carriers. Trying to obtain higher reimbursement claims or coding at a lower level in an effort to avoid denials can result in penalties, or the carrier may decide not to do business with the clinician.

Document Everything

Clean claims provide the appropriate documentation for every item, from the patient’s identity to the treatment provided. MIBs must ensure that reimbursement claims contain complete and accurate information on all facets of the patient’s visit.

When claims are returned with a request for supporting data, insurance carriers can become suspicious and suspect the medical provider or the MIB of altering or recreating documents to support a claim.

Billing Blunders

Unbundling is the act of billing separately for elements that should have been claimed as a whole. Insurance carriers allow for unbundling under very specific circumstances, but MIBs should utilize caution when doing so. Coding is designed to cover an entire treatment or procedure and will single out a claim for closer inspection.

Complying with Carriers

There’s no standard procedure when dealing with insurance carriers. Each company establishes its own rules for reimbursement claims submissions. MIBs who don’t adhere to the carrier’s specifications will be deemed non-compliant and the reimbursement claims will be denied. That can also encompass failure to obtain a pre-approval prior to the patient’s treatment.

Clerical Oversights

Correct coding and detailed documentation won’t avoid a denial if the reimbursement claims contain omissions, data entered in the wrong location or typographical errors.

Even simple items, such as misaligned paper in a printer, can pose sufficient reason for a clearinghouse to reject a claim.

Most mistakes can be identified and corrected prior to transmission to the clearinghouse. It takes only moments to double check a claim before it’s sent, but correcting and resubmitting reimbursement claims can take hours of work and severely disrupts the flow of revenue. Knowing where the most common errors occur is the first step toward filing clean claims.