Lyndsey: Hi and welcome to Nuesoft's Podcast Series. I'm Lyndsey Coates. Every year there are coding changes that can greatly impact reimbursement rates and 2012 is no different. And in fact there's several key changes on the horizon that every biller in medical practice should know and be on the look out for if they want to be assured maximum reimbursement.

And to share their vast experience and knowledge in medical billing, we've got to Jeff and Allen here. Hey guys.

Allen: Hi

Jeff: Hello

Lyndsey: Alright so let's just jump right in and Jeff I'll throw this first one at you. Broad change that affects all specialties is how to define new versus established patients. So what is a difference in 2012 and why does this even matter?

Jeff: I mean it's not a big difference for 2012. E&M codes have pretty much been the same for year after year. The difference is for a new patient. When a patient has never been to your practice then they're considered a brand new patient to your practice. If they return to practice then you'd mark them as a established patient.

If there's a lax in time, they haven't been to your practice in over three years then you can bill them as a new patient again. But within the three year period they're still considered an establish patient.

Lyndsey: Okay great. So is that different from the previous year?

Jeff: It actually is not. It actually really hasn't changed much other than if a physician is actually working in a hospital. If a physician actually sees a patient in the hospital versus in their office they would bill the patient as a brand new patient. Even though they are not in their office, but they are in the hospital you bill them as a new patient.

If the patient does a follow up in the physician's office then that patient will be billed as an established patient.

Part 2:

Lyndsey: Allen, the industry narrowly avoided these SGR cuts at the end of 2011 with the Congress passing a temporary stay. A two month bill that suspends all cuts went long with payroll tax cuts and unemployment benefits so a lot of people were hearing about more so that part of it.

But what are these SGR cuts and what should billers know about these if they get enacted at the end of February.

Allen: Essentially, what it is- it's a reduction in our reimbursement and so if it in fact
comes to light that indeed it is going to go through, you know, then there's going to be a significant cut. However, there's been many talks and articles stating that Congress is once again going to work on not allowing it to pass through as well.  

Lyndsey: It would be more I guess directed at doctors than billers for the most part?

Allen: Correct, correct.

Part 3:

Lyndsey: OK. Starting in 2011, Medicare reimbursements will be adjusted if you aren't an e-prescriber or using software that has e-prescribing. Can you give us some background on these penalties and what will happen over the course and the next few years if you don't start using or your clients don't start using a e-prescribing.

Allen: Yes, effective I believe this year, there's going to be a 1% cut in reimbursement for Medicare if you're not using e-prescribing. And I believe the following year it can go up to 1.5%. And ultimately in 2014 up to 2%.

Jeff: That would be a 2% reduction. That's a considerable amount of money.

Lyndsey: Right, you start noticing at that point. 

Part 4:

Lyndsey: The next question then is January 1st of 2012 marked an important date as far as electronic transmission goes. I know we were gearing up here and we covered this in depth in a previous podcast but can you just touch on what that change was? What this deadline was and what billers should be on the lookout for?

Jeff: Again the reason for the change from the 4010 to the 5010 was the ability to support new cases brought forward to the industry which is the 4010 or the 4010A could not handle. So that's one of them.

Another one too is the 4010 couldn't really support the NPI regulation whereas the 5010 can.

And the other is the removal of data allowed content that is no longer used by the 5010 that 4010 was using. So you have less of a confusion. It's more user friendly.

And the main thing with the 5010 is mostly on the part of the insurance companies and the clearinghouses that are processing these claims.

Lyndsey: Right so most people shouldn't even be seeing a difference. It's just going to be back end transmissions.

Jeff: Right, most billers or physician offices- they won't even see it. They won't even see it. Cause it's- most of the stuff is done at the back end. 

Part 5:

Lyndsey: This was the precursor-this 5010 change was a precursor to the implementation of ICD-10 and is there anything that billers should start doing this year before the massive overhaul in 2013?

Jeff, I'll start with you and then we'll throw it to Allen.

Jeff: Yeah absolutely, this is probably one of the biggest and most major changes that we're going to see in the industry for a long time.

Lyndsey: Let's hope so.

Jeff: The ICD-9s, if you know about it- actually only has 17,000 codes whereas the ICD-10s are going to have 140,000 codes. And the reason being the ICD-10 is going to be- you know have to be more specific in how you're diagnosing a patient. You're not to be able to use non-specific codes anymore. It's going to have a big impact on revenue if they're really not- if they're not ready for this change.

Lyndsey: So Allen any advice- is there something billers could start doing?

Allen: We should look at it two ways. First and foremost, I think physicians and the staff in the physician's offices need to be clearly aware that this change is coming in a year or so. Actually it's going to be two years or so.

But they need to learn their area of specialty- learn the changes that are coming to ensure proper coding.

Physicians need to be aware of changes well so that they can provide more specific documentation to allow their coders to be able to properly code.

From our side I think that if and when physicians and physicians' offices are not up to date with this, we will see the impact in the back-end in the sense that there's going to be a lot of bumps along the road with sending in those claims.

The billers are going to have to work harder at identifying these and circling back with the physicians' offices and resolving the issues and sending them back out  and getting paid.

But when you take a look at this you can clearly see that there's going to be an impact if things aren't coded correctly from the very beginning. It's going to take twice as long and billers and anybody else- who aren't at 100% all of the time- and so some can slip through the cracks and there may be three times as long. So then you can start to look and see that there could be an impact to your cash-flow.

Lyndsey:  So overall, just start familiarizing yourself.  

Jeff: Absolutely. Like Allen said, if the documentation is not precise, the insurance companies will not pay for the procedure that you're performing. 

Part 6:

Lyndsey: Is there a top resource or website or something that you guys are going to go ahead and start reviewing? Is there a book? Where should billers start getting knowledge?

Jeff: You're actually able to order books through AMA, through Ingenix, those types of  companies and there are actually conferences out there. I mean they're being held all over- in every state which they could attend. That's probably one of the best- is to actually attend the conferences.

Lyndsey: Alright, is there any other final thoughts? I mean I think we covered some large nuggets here but is there anything else you'd like to share about changes in 2012? What billers should look out for?

Jeff: Yup, it's actually training your staff what to look for and what to be cognizant about and then- getting those claims paid.

Lyndsey: Excellent guys. Well I do appreciate you joining us today. Thank you so much and thank you to our listeners.

Allen: Thank you for having us.

Lyndsey: Thanks again and we'll see you next month.