The Ten Must Have Medical Billing Tools!
After a decade of serving many thousands of medical billers, I‘ve learned that every biller has an assortment of resources they rely upon daily, and the best of them live by these tools religiously, and trust them implicitly. These tradecraft tools are always on hand, and never too far away to easily grab and refer to.
Great medical billers also have an almost photographic memory (their most important tool by far), and an almost psychic ability to read a payer rule once and remember it forever (or at least until it changes). I think it was Albert Einstein that said you don’t have to remember what you understand. And in a nutshell, great medical billers ‘get it’, so remembering arcane payer rules comes to them naturally.
Over the years, I have learned that in order to avoid rejections and denials (and get paid) billers consistently rely on an arsenal of tools. This article covers the most important “must have” medical billing tools that every biller needs to have at their disposal.
#1. Anatomy & Physiology 101
Many billers start out in a credentialing program and are amazed that 99% of their education in medical billing involves little to no coding whatsoever. In fact most medical billers don’t get exposed to actual coding until after they graduate and begin their Internship at some practice or medical billing company. I was always astounded that you can pay thousands of dollars on a medical billing certificate and learn zero about medical billing. What you learn is medical terminology from a big thick intimidating book called Anatomy & Physiology, (which btw, you could have taken for free at your local community college and saved your parents the moolah) (but to be fair, you wouldn’t get the certificate).
#2. The Big Book, The Medical Billing Bible
The paper version of the ICD-10 coding book from Ingenix (now Optum) is the undisputed bible of medical coding; and like tax-codes, it’s updated each year. This large book is the primary reference guide for Medicare, Medicaid, and many other payers, and it sets the tone for the entire insurance industry. And while each payer has their own payer specific claim-payment rules (10,000 edits/rules alone for Medicare), the guidelines set down by CMS are reliable and learnable, so that if they are applied, your Medicare claim will get paid without hassle.
#3. Coding Cross-Walk
We are still in the transition from ICD-9 (30 years of history) to ICD-10, and barely a day goes by for any biller when some new diagnosis and procedure makes its way across their desk; one that they billed before, but now have to bill in ICD-10.
This is where a convenient tool called a diagnosis code cross walk comes in handy. Most of these tools are versions of the 3M GEM (General Equivalence Mapping) tool that allows you to type in your “old reliable” and peruse the applicable new ICD-10 code that somewhat matches the old ICD-9 code. The problem here is that only slightly over than half the old codes have a new 1-1 equivalent. The other half have a 2-3 to 1, or worse, a 20-1 equivalent, or much worse, some ICD-10 codes have 2500 to 1 equivalent codes to trudge through and decipher which is closest to the condition treated. And even worse, many payers haven’t learned what diagnosis they require for reimbursement. It’s a black box.
That’s why I like the ICD-10 coding tool from PracticeSuite. It offers a “tabular” function that allows you to quickly zero in on the right family of codes, and then smartly allows you to only select a “billable” code from the proper family. This tool is indispensable for any medical practitioner or coder. By coding from the right family of codes, you’ll at least get a payer rejection pointing out the right payer code.
#4. Medical Coding Software
The Big Book from Ingenix (now Optum) has its electronic angel-twin (opposite of evil-twin) named coding software. These tools may or may not have GEM crosswalks in them, but most of them do, due to the transition to ICD-10. There are different software for each medical specialty such as radiology or neurosurgery, but in general med and family medicine, a few electronic tools are more popular than others. To name a few, 3M, SuperCoder, and Ingenix would probably be the most common.
Superbills are a biller’s best friend and are supplied by the doctor. Typically every doctor has their own and some have two or three suited to the type of patient visit, or condition they are treating. A superbill is a cheat-sheet of the most common 20-50 diagnosis codes the doctor uses and the 20-50 most frequent procedures they perform. Superbills contain the patient’s demographics, insurance info, co-pay amounts, co-insurance info, diagnosis, procedures, patient balances, insurance balances, and a place for physician notes at the bottom. Superbills are typically created by the office software system and generated either the night before or before the day starts from the appointment calendar. And this brings us to medical billing tool number six. Medical billing software.
#6. Medical billing software
If the cheat-sheet-superbill is a biller’s best friend, their Medical billing system can be either a best friend or worst enemy. When the billing software does everything it’s supposed to and does it fast, then things are fine. But when it cannot do something that’s needed to get a claim to pass, then it’s not fine (translated hell).
Medical billing is different from medical coding in the sense that a coder’s role is to read the clinical note, say that of a surgery, and assign the right procedural codes (CPT codes) to the treatment(s) the provider performed. While the medical billing function is more of making certain that all the necessary elements needed to get reimbursed from the insurance payer are on the claim form (CMS-1500 claim form, or UB-04 facility, or Workers Compensation claim form).
Some medical billing software are standalone systems (like medisoft or lytec) that only do scheduling and billing, while others are an integrated part of large enterprise systems like Centricity, Epic, or PracticeSuite.
The thing about billing software is that it needs to be able to bill for your medical specialty, bill your insurances properly, and be easy to use. There are many other considerations as well, like creating labels, receipts, posting payments and sending out statements, but it all starts with our next primary tool without which no biller can do their job, the HCFA claim form.
#7. The CMS-1500 Claim Form (aka Hic-Fa)
This little bad boy is the source of more woes and consternation than can be imagined. Who would think that 35 little data fields could produce so much trouble. The electronic version of the 35 field paper claim contains over 3000 lines of potential trouble, any one of which can get a claim rejected or denied. Over the years this endearing insurance claim form has changed but every medical biller knows it like the back of their hand, and has learned the hard way (in medical billing there is only the hard way) what each payer requires, in each field, in order to get a claim paid.
Just to sort everything out properly, there is the Medicare Part A non-ambulatory claim form for facility billing (UB-04), and the Part B claim form for ambulatory medicine like physician practices––contrasted to a hospital where one is admitted and given a bed. If you visit your doctor and have insurance, the biller files the CMS-1500 claim for professional services. If you’re admitted to the hospital, the biller files a claim for the facility and its services on the UB-04. If you’re hurt at work, a WorkComp claim is filed––usually on the 1500 form, but in some states like NY, on it’s own state-form.
#8, A Good Clearinghouse
Having a good clearinghouse is indispensable to every medical biller, and having a good one makes life bearable, but having a bad one makes life unbearable. A clearinghouse for medical billing makes possible to one-stop-shop file insurance claims. The clearinghouse account keeps track of every claims and its current status as payments are pending. Without a clearinghouse, claims have to be submitted directly to each payer, which would be impossible in a typical family practice that can easily have over 200 different insurances to file medical claims to.
Reports are to the medical biller like water is to a fish, or daylight is to someone walking over treacherous terrain. Billing Managers live by their reports. And while there are too many reports to mention, there are some that are absolutely necessary to medical billing.
- Charges Report. The charges report tell you every claim that was created. This is reconciled against the scheduler report which show everyone who came in that day.
- Payments Report, which shows every penny that came into the practice that day, cash, credit card, EFT, or check. This is balanced against the Adjustments report.
- Adjustments report. A medical practice is the only business on earth where you charge one price for a service and get paid another. When a service technician comes out to repair my fridge, he charges me $85 for the visit. The doctor also charges $85 for a visit, but only gets $65 from the insurance company. After co-pays and insurance are entered into the accounting/billing system, the leftover amount still owed is then “adjusted” off of the patient’s balance, to zero, and simply lost. Makes you want to become a Doc, right?
- Aging Reports. You need two of these. One showing aging claims so you can follow up with the insurance carrier, and Aging Receivables, which show your total past due in increments of 30 days, 60 days, 90 days, and over 120 days after which, statically the past due amount is unrecoverable and lost.
That being said there are hundreds of daily and weekly reports, but one particular report gets an honorable mention: The Month End Close and Reconciliation report where the entire billing system reconciles every penny owed, every penny paid, everything that was written down, and the exact balances left to patient or insurance. Without the month-end close report, a practice has no idea where it is financially.
Running a billing department for even a single Doc requires a team. Without a team, eligibility may go unchecked, benefits overlooked, co-pays uncollected, claims not filed in a timely manner, claim rejections not worked, denials not appealed, aging claims not followed up with insurances, and patient balances not collected. Every billing manager’s task is to put together an A-Team of competent players who each do their assigned task on a daily basis, diligently, religiously, and systematically.
With these ten tools at your disposal, you can get the job done.
Please leave a comment about what medical billing tools you can’t live without!