What’s the simplest way to ensure prompt payment for your claims? Ensure that the insurance payer has no reason to deny them. Submitting a “clean claim” from the start can have a more significant impact on your net collections than any other step in your billing workflow. Net collections and accounts receivable (AR) can improve significantly when claims are clean from the start.
I frequently encounter offices seeking help to resolve their AR issues, yet they insist that their claim submission process is already optimal. This highlights a common problem in our field: Many reimbursement issues stem from preventable errors made during the initial claim submission.
While it may seem tedious to meet strict insurance criteria, filing clean claims from the start is far more cost-effective and efficient than dealing with denials, corrected claims, appeals and follow-up calls later on.
Although insurers do make mistakes, a significant portion of the challenges we face are self-inflicted. The goal of this article is to provide best practices for submitting clean claims, ensuring you’re reimbursed correctly the first time.
The Foundations
Before diving into applying best practices, let’s establish a foundation by discussing modifiers, diagnosis pointers, diagnosis exclusions, documentation, and patient eligibility. Mastery of these elements is crucial for clean claim submission.
Modifiers: Conveying the Details
Modifiers inform the insurance company about specific details regarding how a service was performed. It is a best practice not to apply modifiers by default, but only when necessary.
Modifier 25: Use this modifier when an evaluation and management (E/M) service is performed on the same day as other procedures. This indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre- and post-procedure care.
Modifier 59: Use this modifier when multiple services that might be considered overlapping are performed, such as chiropractic manipulative therapy (CMT, 98940-98943) in conjunction with manual therapy (97140) or therapeutic exercise (97110) with group exercise (97150). Modifier 59 indicates that these are distinct procedural services and should be reimbursed separately.
Modifier GP: This modifier denotes that a service is part of a physical therapy plan of care. Some insurers require the GP modifier on therapy codes to indicate they are provided under a physical therapy plan, even when performed by a chiropractor. Only some payors require this modifier.
Modifier AT: Use this modifier to indicate active treatment, rather than maintenance care. Medicare requires AT for chiropractic manipulative treatments to distinguish active treatment. Other payors may also require it, depending on geographic region and payer policies.
Modifier NU: This modifier indicates the purchase of new durable medical equipment (DME). If you provide DME to a patient, use modifier NU to show that the equipment is new and being purchased rather than rented.
Note that this list is not exhaustive. Your unique payor mix may require additional modifiers not listed here, and your biller can help research the individual payor policies. Applying the correct modifiers ensures that you are properly reimbursed for the services you provide.
Diagnosis Pointers: Linking Services Provided to Diagnoses
Diagnosis pointers link each CPT code to the appropriate diagnosis code(s). While you may list multiple diagnoses, most EHR systems default to using the first four diagnoses for pointers and list any additional diagnoses without pointers. Contact your software provider to understand how to use diagnosis pointers effectively.
For instance, if your CMT codes point only to cervical, thoracic and lumbar diagnoses, but an extraspinal adjustment was also performed, the extraspinal adjustment may be denied due to the absence of an extraspinal diagnosis. Similarly, for code 98941 (3-4 region manipulation), ensure you have at least three regions listed in your diagnosis pointers to match the code’s description. Even if you adjusted three regions, when only two regions appear on your diagnosis pointers, the code will be denied.
Note: The regions documented should match the diagnosis pointers for the CPT code. Consistency between your documentation and claim submission is vital.
Diagnosis Exclusions: Avoid Conflicts
Be cautious of using mutually exclusive diagnoses. Diagnosis exclusions occur when two diagnosis codes used together are considered conflicting or illogical. Always ensure that your chosen diagnoses are compatible and accurately reflect the patient’s condition. (See Table for examples.) Using a free resource like ICD10Data.com can help verify whether a diagnosis code is sufficiently specific and identify any exclusions.
Documentation: Support Your Claims
Documentation is crucial, especially for motor-vehicle accident (MVA) and worker’s compensation (WC) cases, but it impacts all claims when documentation is requested.
Timed codes: For time-based services (e.g., therapeutic exercises), always document the exact amount of time spent. A time range (e.g., “8-15 minutes”) is insufficient. You must note the precise duration, such as “Therapeutic exercises performed for 12 minutes.”
Purpose of procedures: Clearly document the purpose of each procedure performed. For example: “Performed therapeutic exercises to improve lumbar spine flexibility and reduce low back pain.”
Comprehensive exams: Ensure that exams include a full physical evaluation when billed as such. If there is no additional documentation compared to a typical daily visit, insurers may recoup exam payments during audits. Remember, you can use either time or complexity to justify exam codes. If using time, follow the precise time documentation rules.
Adjusters are looking for incomplete documents to save money for the insurance company. Either time or complexity can be used for exam codes now. If you choose to use time, then the time requirements we discussed above apply.
Patient Eligibility and Benefits
Verifying patient eligibility and understanding their benefits before rendering services is a critical step in the claim submission process. This ensures that the services you provide are covered and you are aware of any limitations or requirements.
Verify insurance information: Confirm the patient’s insurance details, including the insurance carrier, plan type and policy number. Errors in this information can lead to immediate claim denials/rejections.
Understand coverage limitations: Check for any coverage limitations, such as the number of allowed visits, specific exclusions, or services that require preauthorization.
Determine patient responsibility: Be aware of the patient’s financial responsibilities, including co-pays, co-insurance and deductibles. Collecting these amounts at the time of service reduces the risk of non-payment later.
Check for preauthorization requirements: Some services may require prior authorization or referrals. Failing to obtain these can result in claim denials.
Document eligibility verification: Keep a record of the eligibility verification, including the date, time and details of the information obtained. This documentation can be useful for showing your patients you’ve done everything you could for them.
By thoroughly verifying patient eligibility and benefits, you reduce the risk of claim denials due to coverage issues and improve patient satisfaction by setting correct expectations.
Implementing Best Practices
With the foundations in place, best practices are remarkably simple. In a majority of the offices I work with, the front desk sees the patients first, the doctor sees them second, and the biller sees them (or their documents) third. As a result, these three individuals create a three-legged table. Each leg of the metaphorical table must be strong, or else everything on the table is at risk.
- Train the front desk on eligibility and benefits. Since staff start this revenue cycle, it is imperative that the information they collect is accurate and represented accordingly to the patient. Without this step, patients may end up owing more than they expected and have a poor experience, despite receiving great care.
- Train yourself / any other doctors in the documentation each code requires. That way, all doctors in the practice can communicate the medical necessity of the services they rendered. If the doctor selects proper pointers and diagnoses, it will save many hours for your billing team.
- Train billers to identify and correct errors from all previous steps. Recognizing patterns in undercoded exams, missing modifiers for specific payors or incorrect diagnosis pointers can save significant revenue.
Implementing regular training for your staff on these billing practices can also be beneficial. Conduct periodic audits of your claims to identify common errors and address them promptly. Utilizing billing software that flags potential issues before claims are submitted can save time and resources.
Remember, the goal is to give insurance companies no reason to deny your claims. Clean claim submission is the key to a healthy revenue cycle.
