Chapter 09: Insurance and Billing

Medical Records, Insurance Billing and Coding Guidelines 

[Reflections on the New Reality] 

By Patricia A. Trites 

It’s like a game: Get the doctor to add the word “sepsis” to the chart as opposed to “urinary tract infection,” and the hospital can bill for a higher-paying DRG. Or, prompt the doctor to write down “acute respiratory failure”, instead of “chronic obstructive pulmonary disease exacerbation,” and the hospital can once again charge for a more lucrative DRG – Report on Medicare Compliance 

Physicians of all persuasions are having trouble adjusting to the radically new use of medical records in the present era of managed care and new reviews of billing practices, like the Medicare Recovery Audit Contractor [RAC] hospital initiatives [Diversified Collection Services of Livermore, CA; CGI Technologies and Solutions of Fairfax, VA; Connolly Consulting Assoc. of Wilton, CT, and Health Data Insights of Las Vegas]. 

And, doctors worry this “bounty hunter” approach – the second for CMS after medical practice audits – will create a bias to focus only on collecting government overpayments, 


So, more than ever, inadequately documented medical chart can mean civil and criminal liability to the sloppy and/or unwary practitioner. Medical records were previously used to aid in the quality of medical care. Now they are also the basis for payment for services, not as a record or reflection of the care that was actually provided, but as a separate justification for billing.  The lack of appropriate documentation now no longer threatens just non-payment for services but risks civil money penalties and criminal charges. 

More here: BOOK ORDERS [Pre-Release]: 

Dictionary of Health Insurance and Managed Care:


14 thoughts on “Chapter 09: Insurance and Billing

  1. The New Year 2010 has brought some changes in the Medicare Physicians Fee Schedule

    For many specialists, the most significant change is the elimination of consultation codes, 99241-99245 in the outpatient setting and 99251-99255 for inpatient care.

    Physicians can still provide consultations and bill for these services – using codes for routine new or established patient visits (99201-99205 and 99211-99215).

    Reported Revenue Neutrality

    It has been reported that this change has been made in a revenue neutral manner. Reimbursement for all E/M codes has been increased in order to make up for the removal of consultation codes. The increase is approximately 6% in the outpatient setting and about 2% for inpatient codes.

    Of Averages and Outliers

    The result of these changes might be revenue neutral overall, but the outlier effect on many specialties and individual physicians can be significant. Specialists who obtain most of their income from procedures will see less of an effect on their income. This includes dermatologists, surgeons, and gastroenterologists. Less procedurally-oriented specialists, particularly those who rely upon Medicare as a primary payor, are seeing the most significant effect. For example, neurologists and hematologists will likely see double-digit declines in revenue.

    Private Payers

    While private payers have not yet adopted these changes, billing codes must be adjusted when filing a claim with a commercial insurer when Medicare is the secondary insurer. If a consultation code is used in these instances, the primary payer will pay their portion of the bill, but Medicare will deny secondary coverage. There is no indication yet that commercial insurers are dropping the consultation codes altogether, but if history is any indication, they will likely eventually follow the lead of Medicare.


    Physicians can take certain measures to decrease the impact of these changes on their revenue stream. It is increasingly important to understand how the complexity of a patient visit affects the appropriate level to be billed. Prolonged service codes are also available (99356 and 99357) to enable physicians to bill appropriately for more complex and time-consuming evaluations.

    Brian J. Knabe; MD, CFP
    [Savant Capital Management]

  2. Cross Over Claims

    The Centers for Medicare & Medicaid Services (CMS) has identified a problem where claims were not automatically crossing over to supplemental payers even though the provider remittance advice indicated otherwise.

    This problem began January 5, 2010 and impacted Part B professional claims.

    Action is required on behalf of Part B professional providers where a remittance advice with an issue date between January 5, 2010 and February 12, 2010 has two or more service lines for a beneficiary where both of the following apply:

    • One service line is 100 percent reimbursable (i.e., the approved amount and amount to be paid are equal,) AND

    • One service line where part of or the entire Medicare approved amount is applied to the Part B deductible and/or carries co-insurance amounts.

    CMS is not able to forward these beneficiary claims to supplemental payers even though the remittance advice may indicate otherwise. Providers will need to identify these claims by reviewing their remittance advice with an issue date between January 5, 2010, and February 12, 2010, that contain the criteria noted above.

    Once identified, providers will need to take action to balance bill the beneficiary’s supplemental payer.

    As of February 12, 2010, this system problem was fixed and all claims are crossing over.


  3. I don’t want to sound like an “old guy” …. but

    Things have really changed in the era of Health 2.0.

    Today, most physicians accept patients whose insurance is supplied by one of the over three-hundred federal healthcare programs. This, in essence, makes physicians “Government Contractors”. The American people, physicians included, become a little more than slightly aggravated when they hear about government contractors charging ridiculous amounts for hammers and toilet seats.

    Physicians and other healthcare providers are now being asked to comply with the government contracting rules regarding documentation of services for appropriate payment.

    Why do physicians have to follow these complicated DRG and time-consuming CPT® rules when they have more important duties to complete?

    It all boils down to the “Golden Rule.” “He who has the Gold—Makes the Rules.” This applies to both Federal insurance programs, private insurers, and whatever health reform political machination may evolve going forward.

    Dr. David Edward Marcinko; MBA

  4. How to get paid for online e-Health Consults

    A growing number of insurers are paying for online communication between physicians and patients. And when insurers don’t cover it, many patients are willing to pay out of pocket for the convenience.

    But, either way, expert say, a clear plan and set of procedures can help ensure that physicians get paid for their online consultations.


  5. The current reality is that medical records perform a billing function.

    It can even be argued that this function takes precedence over the original purpose – to record the medical care and thought process of the physician. My personal experience reinforces this argument.

    In my first experience with an EMR system, we were taught to record the appropriate number of bullet points with the acceptable wording to justify the level of care being billed. We learned to link tests to diagnoses in order receive payment, and we were given the proper language to use in order to bill for a consultation or a procedure.

    I recall a conversation with a colleague several weeks into the implementation process. He suggested that we all make a point to type a sentence or two at the end of the “canned” EMR bullet points – a short statement describing our thoughts about the patient and their disease, so that the next physician will understand the first provider’s thought process.

    Physicians still provide excellent quality of care, but when it comes to the medical record, we have taken over the functions of transcriptionists, unit clerks, and billing departments!

    Brian J. Knabe, MD
    Savant Capital Management, Inc®.
    190 Buckley Drive
    Rockford, IL 61107
    Tel 815-227-0300
    Fax 815-226-2195

  6. HI Claims Mistakes

    Health insurers make mistakes processing 20 percent (one in five) of medical claims, according to the 2010 National Health Insurer Report Card from the American Medical Association (AMA) in Chicago.

    As Dr. Gary Bode, a CPA stated elsewhere in this book, a one percent improvement in that error rate could cut unnecessary administrative costs by $776 million a year estimates the AMA. (A perfect 100 percent accuracy rate could generate $15.5 billion in annual savings.)

    So, keep em’ clean.


  7. Moving paper – a hard way to make a dishonest living

    For those who might be wondering, the paper value of 33,000 medical records is about $40 – or 0.12 cents each (less the gas it takes to haul them to the recycler).

    The more I hear about the following, mysterious California data breach, the more entertainiing it becomes. And I’m not alone. This morning, Dom Nicastro, writing for HealthLeadersMedia posted “Janitor Sells Patient Records for $40”. He quotes Frank Ruelas, a compliance and risk management expert and principal of HIPAA College in Casa Grande, AZ. who says, “This incident is a bit of a head scratcher…”

    The privacy breach was first noticed in late July when an official discovered files were missing from a Los Angeles County medical facility, according to a LA Times article that was posted on Friday in response to an official press release.

    To me, stealing paper medical records to sell to a recycler just doesn’t seem profitable enough for the amount of work compared to stripping A/C units for copper or even stealing hubcaps.

    Here’s my take on a story that still hasn’t been adequately revealed if you ask me: I think a janitor named Robert Sanders who was employed by Martin Luther King, Jr. Multi-Service Ambulatory Care Center in Willowbrook, California was told by his supervisor to clean a bunch of junk out of a cluttered storage closet and that’s exactly what the hard-working man did.

    But instead of moving the 14 boxes to the dumpster a few yards away, it sounds like the 55 year old county employee might have backed his pickup up to the delivery entrance and piled all 14 boxes in the back. Then, instead of chucking them to the dumpster where the paper wouldn’t have been recycled for hundreds of years, he unloaded all 14 boxes at the recycler and picked up some beer money for the same amount of effort. So far, so good, right? Nope. I bet the janitor didn’t know the difference between a HIPAA and a hippo until a few months ago.

    According to the LA Times story (no byline): “An investigation into the missing files led authorities to Sanders, who was among the custodians questioned about where the files had gone.” It’s not like someone could “sneak” 14 heavy boxes without being noticed. And according to the press release, “One such employee confessed that he had personally taken the files to a recycling company for its paper value.” That would be Robert Sanders.

    Now the janitor is facing felony charges. Think about it: 14 boxes, $40 and a felony.

    “So what are you in prison for, old man?”

    “I moved a lot of paper in my time, son.”

    Carol Meyer, head of operations for the Department of Health said “We take patient privacy in this department very seriously.”

    I know what you’re thinking, and nope – this isn’t out of the “Onion.” This is the LA Times… wait, I see your point. But nevertheless, even Dom Nicastro offers: “One HIPAA privacy and security expert said hospitals can avoid records falling in the wrong hands by having an officer account for [14 boxes in a closet] at all times.

    Thanks, HIPAA. I couldn’t make this stuff up.

    Darrell K. Pruitt DDS

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s