Common Myths About the Medicare 8 Minute Rule

Common Myths About the Medicare 8 Minute Rule

There’s a lot of confusion about the Medicare 8 Minute Rule and how many units to bill. Calculating the correct number of units can be confusing without the proper training and understanding.

medical billingMany clinicians are unknowingly under billing and cheating their practice out of legitimate reimbursements.

The 8 Minute Rule is being used by Medicare and an increasing number of insurance companies.

Those that don’t follow the Medicare guideline typically bill in 15 minute increments.

For insurance companies that do follow the Medicare rule, each billable unit must be between eight and 22 minutes in duration, but it only applies to timed CPT codes.

The Total Is What Counts

Problems arise when an uneven number of minutes are dedicated to different tasks.

To bill accurately and ensure that they’re adequately reimbursed, clinicians must total all the minutes in the session for the maximum number of billable units.

To be included, only face-to-face time spent with the patient counts toward billable units.

The 8 Minute Rule applies as follows:

  • 1 unit is 6-22 minutes
  • 2 units is 23 to 37 minutes
  • 3 units is 38 to 52 minutes
  • 4 units is 53 to 67 minutes
  • 5 units is 68 to 82 minutes
  • 6 units is 83 to 98 minutes


Understanding Is Essential

Billing becomes more difficult when multiple procedures or services are provided.

When an uneven number of minutes occur, therapists should choose the code that best represents the majority of the treatment time.

To understand the 8 Minute Rule, therapists should talk with a professional biller. Without a full understanding of how the rule works, therapists will encounter errors and reimbursement denials.

Automatic Calculationsmedical billing

The In Touch EMR® automatically calculates the time for each CPT code.

The system knows if it’s a timed or untimed procedure and assigns the appropriate number of units.

Clinicians have full control and can change the claim before it’s sent.

Demonstrations can be scheduled to learn how the software works. It takes the guesswork out of calculations, increases efficiency, and ensures therapists are getting paid the full amount to which they’re entitled.

Common Myths About the KX Modifier and the Role of EMR

Common Myths About the KX Modifier and the Role of EMR

We get a lot of questions from billers, therapists and front desk people asking if the In Touch EMR™ system tracks the KX modifier and Medicare caps.

EMRThere’s no way any EMR system can do that.

The Medicare cap is shared with multiple professionals and the software has no way of knowing if a patient has seen another provider.

Tracking Medicare Caps

Clinicians can track the Medicare cap on a specific patient on the Medicare website. It’s the only accurate way of monitoring when a patient has neared his/her financial cap.

There’s no available EMR system that can track the Medicare cap, despite what vendors say. It’s not that they’re being deliberately misleading. It’s that they simply don’t know.

The In Touch EMR™ Difference

With the In Touch EMR, Medicare caps are handled differently. Clinicians monitor the caps of their patients to determine when it’s met or exceeded.

At that point, practitioners call In Touch EMR™ and the system is told to amend the KX modifier, which it does from that point going forward.

The KX Modifier

Medicare places an annual cap on the reimbursement amounts that it will pay for each patient’s physical therapy needs. That amount was $1,900 in 2013 for combined services of physical therapy and speech pathology.

Another $1,900 was allotted for occupational therapy.

The KX modifier is used for Part B claims when the cost for services exceeds Medicare’s financial cap, while meeting the exceptions process.

The KX modifier is also used when performing gender specific therapy. Its use notifies Medicare that it may need to examine a claim for editing.

EMRPayment is generally made, providing that clinicians have met and maintained the stringent documentation required to prove medical necessity.

It’s important to note that even with pre-approval, there’s no guarantee that reimbursements will be made.

It’s critical that clinicians understand the limitations and abilities of their EMR.

While no EMR can monitor the Medicare cap on a specific patient, Medicare maintains a running tab on each beneficiary and practitioners can use the site to ascertain the cap of any patient.

Once that information has been determined, the In Touch EMR™ can be told and the appropriate functions activated, making the billing process easier and more efficient for clinicians.

Billers Ethical Issues in Medical Billing and How to Avoid Them

Billers Ethical Issues in Medical Billing and How to Avoid Them

Professional medical insurance billers have access to patient information that’s protected by law. A career in the profession requires an individual with honesty, integrity and a highly developed sense of ethics.

Nitin Chhoda says that the professional life of an MIB contains multiple ways in which they can run afoul of ethical issues. An honest mistake can be corrected, but an ethical issue, either by commission or omission, can land a biller in trouble with the law. He explains further using the following factors which MIBs should be concerned about.

billersBreaking Confidentiality – The First Thing that Billers Should Avoid

Patient confidentiality is ensured by law. Violations by either word or deed will find clinicians and billers in trouble for a breach of HIPAA security regulations.

There are strict rules governing the sharing, release and transmission of health-related data and identity theft is a real concern.

The Blame Game

It takes only moments to obtain clarification for coding questions. Billers that submit inaccurate codes and try to shift the blame to others when the error comes to light won’t be employed for long and will earn the ire of their co-workers.

The billers’ job is to maintain the revenue stream by coding accurately and honestly.

They Should Not Ignore Errors

Billers are only human and an error is inevitable. However, when an error is uncovered, it’s imperative to bring it to the practitioner’s attention, correct it and submit a corrected claim immediately.

Failure to do so can result in a payment deficit, or an over payment that can have adverse financial ramifications for the clinician. The same ethics apply if an insurance carrier handles a claim incorrectly and inadvertently over or under pays the practitioner.

No More and No Less

Ambiguous information calls for clarification. Not every act performed by the clinician is billable. Eligibility for an increased level of payment requires additional skill or work by the practitioner.

IMPORTANT:  Code and bill only according to what the documentation indicates.

To Bundle or Not Unbundle: A Biller’s Concern Too

Each code is designed to include multiple actions within the treatment process. They’re billed as a whole rather than individually. There are times that billers should know when unbundling is appropriate, but the technique must be used with extreme caution.

Billers must also know that some codes aren’t compatible with others and documentation must support that extra time or expertise was required.

They Must Protect Patients

Many payers require patients to receive treatment from their network of physicians. Seeing an out-of-network provider may not be covered or the patient may have to pay additional out-of-pocket expenses.

Billers should endeavor to protect patients from this and explain the practice’s protocols for handling these types of situations.

medical billersTo reiterate, the billers must always consider the following factors during the process of medical billing:

  • Confidentiality of patients’ information
  • Avoid blaming others for errors they committed
  • Minimize errors as much as possible
  • Provide just coding – no more, no less
  • Awareness of bundling and unbundling codes

Protecting the patient includes verifying their coverage, obtaining a pre-authorization when needed and making referrals within the patient’s network.

Failure to do so can result in the patient being hit with an enormous bill they can’t afford. Following the dictates of the patient’s insurance also protects the clinician from non-payment.

Ethical issues for medical insurance billers can come in many guises and MIBs must be vigilant. They must code accurately, act honorably and perform ethically. Doing so will demonstrate their honesty, integrity and professionalism, while ensuring the best reimbursements for practitioners.


Flow Sheet and EMRs Increase Reimbursements

Flow Sheet and EMRs Increase Reimbursements

Flow sheet helps clinicians track what they did for a patient on previous and current visits, but they’re much more than a means of patient management. They hold the key to obtaining reimbursements.

Claim denials and delays result in fiscal hardships for practices and in a time of shrinking healthcare payments, and in this article, Nitin Chhoda explains how the flow sheet is a critical element in the reimbursement process.

flow sheetFlow Sheet and its Important Role to Claim Reimbursements

The flow sheet has to justify the billing amount and should be designed to reflect the CPT code in the reimbursement claim.

It forms the basis of the billing, streamlines the reimbursement process and supports medical necessity.

A properly designed flow sheet provides all the information needed for billing and supports each prior step.

The flow sheet provides a permanent record of care, supplies and products dispensed that are eligible for reimbursement. They’re essential for patient care and management, reimbursements, and can be used for research and quality improvement.

A flow sheet offers a birds-eye view and summary of changing factors that includes vital signs, diseases, treatments, medications and test results.

It’s used to document findings for each patient encounter, allowing practitioners to tell at a glance if the patient is being seen for a new condition or something that has occurred in the past.

No matter what type of practice is being operated, the flow sheet is one of the greatest assets available to determine when patients are due for check-ups and tests, and facilitates moving patients through the office in a timely manner.

 –> Clinicians don’t have to start from scratch when working with established patients.

The Value of an EMR in Creating Flow Sheet

Maintaining flow sheets to expedite reimbursements is much easier with an electronic medical record (EMR) system.

The In Touch EMR, which is also integrated with billing software called, In Touch Biller Pro, is an example of an “intelligent” EMR that advises and prompts users when information is entered to ensure each element of the reimbursement claim matches and all the necessary components support each other.

EMRs offer portability to help clinicians provide a superior level of care, while allowing practitioners to see more patients within the day.

flow sheet

Clinicians can move easily through the office without the need to find and retrieve paper records before patients can be seen. They also support the creation of custom forms and templates.

The systems encompass built in calendars, calculators and treatment reminders. Clinicians can pull up photos, videos and print information for patients to take with them.

It ensures patients have data from a reputable source instead of letting them surf the web and obtain erroneous information.

An EMR can be implemented on tablet technology, allowing practitioners to diversify the practices services. The systems can be updated by multiple healthcare professionals and utilizes electronic communication to save time, money and resources.

Data can be retrieved whenever needed, for printed reimbursement claims, RAC audits or litigation. Errors due to illegible handwriting are eliminated.

To file reimbursement claims that are paid quickly, the flow sheet must reflect the CPT codes used and all the documentation must support the billable expenses. EMRs are an essential component of the process, with prompts to ensure each step supports the next, for clean claims that are paid quickly.

Claim — How to Appeal and Handle When Denied

Claim — How to Appeal and Handle When Denied

When a reimbursement denial is received, medical insurance billers (MIBs) may need to initiate an appeal process to collect disputed funds for practitioners. In this informative article, Nitin Chhoda reveals the most common reasons for denials and the best strategies for handling claim disputes.

claimEach claim goes through an adjudication process at a clearinghouse to check the data for errors before forwarding it to the appropriate insurance carrier.

A claim examiner conducts another exploration of the claim and renders a decision. The examiner can choose to pay the billed expenses, reimburse at a reduced rate, or deny the claim.

Insurance carriers usually deny payment for one of seven typical reasons. Some of the factors are the following:

  1. Carrier’s procedures
  2. Medical necessity
  3. Inactive policies
  4. Out-of-network
  5. Level of care
  6. Pre-existing conditions
  7. Pre-authorization

Unknown Carrier’s Procedures

MIBs should be aware of each payer’s procedures and policies for handling claims. Each insurance company has its own hierarchy and protocols for reviewing a claim. MIBs should also check the contract between the clinician and the insurance company to determine that all conditions have been met.

Medical Documentation is Necessary

When a claim is denied on this basis, it’s up to the MIB to provide documentation that the appropriate diagnosis and procedural codes were employed. Sometimes a coding change and resubmitting the claim will result in a satisfactory resolution.

If the codes are accurate, a letter must be provided that clearly states why the treatment was necessary, along with any extenuating circumstances.

Patient’s Insurance Policy is Now Inactive

It’s essential that the MIB has proof that the patient has an active insurance policy at the time treatment was provided. This can be accomplished through a copy of the individual’s medical card, a letter from their employer, or a statement from the insurer.

Out-of-Companies-Network of Physicians

Some carriers require patients to only see practitioners within the company’s network of physicians, but situations arise when an in-network clinician isn’t available.

A simple letter explaining, in detail, why the patient didn’t have access to the carrier’s network of clinicians can easily turn a denial into a payment.

Having Too Much Level of Care

Claim examiners may determine the level of treatment that was billed exceeded the usual care for a particular ailment. The culprit in these situations is usually a lack of physical therapy documentation that fully explains why additional treatment or procedures were required. Providing supporting documentation usually takes care of the problem.

The Most Common – Having Pre-Existing Conditionsclaim

Most insurance policies won’t cover treatment for conditions and diseases that patients were afflicted with prior to when their policy became active.

If treatment can be linked to any prior health problem, the need for an appeal is negated.

If it wasn’t related to a previous health issue, MIBs should provide a written explanation as to why the ailment wasn’t related to a pre-existing condition.

Unable to Meet Pre-Authorization

A wide variety of treatments require pre-authorization for reimbursements. MIBs can reverse a denial if they provide proof the treatment would have been approved, as in the case of an emergency. A convincing argument can result in full payment and waiving of penalties for not obtaining the pre-authorization.

A denial doesn’t always result in an appeal. Providing documentation and a convincing argument as to why the denial was in error is essential when disputing reimbursement rejections. Clear and concise communications are critical elements of strategies to obtain payment for denied claims.


Billing:  The Importance of Keeping Records in Your MIB Business

Billing: The Importance of Keeping Records in Your MIB Business

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.

billingTools 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.billing software

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.