5 Ways PTs Can Beat Payers at Their Own Game

When it comes to billing, even the smallest mistakes can cost a practice—big time. And when I say “big time,” I mean it. Because as this Healthcare Business & Technology article explains, “It’s estimated that providers leave $125 billion on the table each year due to poor billing practices.” Ouch. And the reason this number is so high? Well, the article goes on to note that up to 80% of medical bills contain errors. So, if payers profit from providers’ mistakes up to 80% of the time, how can you avoid leaving cash on the table? To get your practice on the winning side of the game, keep these five tips in mind:

1. Know Your Modifiers

Improper use—or failure to use—modifier 59 can cause claim denials, rejections, and incomplete reimbursements. But, luckily for you, this mistake isn’t too difficult to avoid. When you’re thinking about using modifier 59, ask yourself the following questions:

Are you billing for two services that form an NCCI edit pair?

To know when it’s appropriate to use modifier 59, you have to be able to spot NCCI edit pairs. These so-called “linked” procedure codes designate sets of services that therapists often perform together. Essentially, the way Medicare sees it, one service is “built into” the other. So, if you submit a claim containing codes that form an edit pair, you’ll only receive payment for one—not both.

Did you perform those two services separately and independently of one another?

So, if you’ve spotted an edit pair—but you didn’t perform the two services together—what do you do? You use modifier 59: when you add this modifier to one of the CPT codes in an NCCI edit pair, it notifies the payer that you provided the services separately and independently of one another. Thus, you’ll receive payment for each individual service.

This coding mechanism is great for ensuring you receive the full amount of payment you deserve. However, keep in mind that you should never:

  • Use modifier 59 solely to guarantee more payment.
  • Intentionally leave out portions of your documentation or use vague or misleading information.
  • Routinely affix modifier 59 to re-eval codes (97002). When you do this on a regular basis, payers see it as a “red flag.”
  • Use modifier 59 if a better modifier option is available.

Does your documentation support your assertion that you performed the two services separately and independently of one another?

Now, modifiers only go so far in the way of justifying your billing decisions. So, you’ll want to make sure you have detailed, defensible documentation to back up your use of modifier 59.

One more thing to keep in mind: new modifiers—XE, XP, XS, and XU—that basically serve as subsets of modifier 59 were announced on January 1, 2015. However, therapists aren’t required to use them—at least not yet. So, keep an eye out for more news, because you may need to be familiar with them in the future.

2. Avoid Misbilling

As Courtney Lefferts explains in this WebPT article, misbilling “occurs when a practice fails to code to the highest level of specificity, doesn’t account for all billable codes, or isn’t able to create a clean claim.” These mistakes might be easy to make, but in reality, it’s not all that difficult to avoid them. How? First and foremost, you should always code for the services you’ve provided—no more, no less. And when you do, make sure you include:

  • Correct places of service,
  • Updated CPT codes, and
  • Accurate demographic information.

Now, if you ever receive a denial even though all of your claim information is accurate and complete, I recommend that you inspect the claim thoroughly. You may find payer errors that you can contest through an appeal for payment.

3. Understand Timed Codes

To ensure accurate billing, you must understand the difference between service-based (untimed) and time-based codes. Remember, when you bill for untimed codes, you can only bill for one unit of one code—regardless of how long you spent providing treatment. When you bill for time-based codes, on the other hand, the duration of treatment matters: each unit of a timed code represents 15 minutes spent providing one-on-one service. Examples of timed-code services include:

  • therapeutic exercise,
  • manual therapy,
  • neuromuscular re-education,
  • therapeutic activities,
  • gait training,
  • ultrasound,
  • iontophoresis, and
  • electrical stimulation.

Now, to ensure correct use of timed codes, you must understand the 8-minute rule. According to this rule, you have to provide direct, one-on-one treatment for at least eight minutes to get Medicare to reimburse for that service. To calculate the number of billable units for a particular date of service, this WebPT resource explains that you should add up “the total minutes of skilled, one-on-one therapy and divides that total by 15. If eight or more minutes are left over, you can bill for one more unit; if seven or fewer minutes remain, you cannot bill an additional unit.”

Confused yet? I get it; it can be hard to calculate billable units on your own. That’s why I had our team at WebPT build logic right into our application—to take guesswork out of the equation. All you have to do is record the time you spend on each modality—along with the number of units you wish to bill—as part of your normal documentation process. If the numbers don’t add up, WebPT will not only let you know something’s wrong, but the system also will tell you whether you overbilled or underbilled. So, if your EMR isn’t helping you stick to the 8-minute rule, then you should start researching your options—especially because there’s a good chance your current system is dropping the ball on other important rules and regulations that you can’t afford to flub up.

4. Prevent Overpayments

If you’ve been overpaid, it can be seriously tempting to keep the extra cash. But, it’s imperative that you resist that temptation, because the consequences can be dire. Overpayments not only give you an inaccurate view of your total revenue, but they also could encourage embezzlement. And I don’t need to tell you twice that these are things you want to avoid. Plus, if you don’t pay back the extra cash within 60 days of discovering the overpayment, you’re putting yourself at risk for legal action, fines, and even jail time. And the worst part? You could be held liable—and thus, penalized—for payments that are identified as overages up to six years following the receipt of funds.

My advice: the best way to address overpayment is to prevent it from happening in the first place. This WebPT article covers the following five claim errors that can cause overpayment:

  1. Plan of care requirements not met.
  2. Treatment notes requirements not met.
  3. Progress reports untimely or not contained in the medical record.
  4. Medical necessity requirements not met.
  5. Physician certification requirements not met.

Because these errors are so common, you’ll want to ensure you’re double-checking your documentation and claims for them. And if you find that you’re frequently receiving overpayments, it’s time to do a billing audit and review your processes.

5. Decode Your Contracts

Finally, you have to devote some time to assessing and understanding your payer contracts. Now, this is no easy task—especially because they’re jam-packed with legal jargon. But, that doesn’t mean you shouldn’t understand exactly what you’ve already agreed to—or what you’re about to sign. Here’s my list of top payer contract to-dos:

  • Understand the rules—including those governing submission and benefits. It can be easy to miss a timely filing window if you aren’t organized. Plus, when you know the timely filing limit, you’ll be able to spot when payers are wrongly denying your claims.
  • Get help from a lawyer to translate legalese into easy-to-understand terms. If you can’t afford legal assistance, look out for phrases like:
    • “Industry-accepted.” This is especially important if it’s used as a determining factor for your reimbursements. Don’t let that happen; it allows payers to use their discretion about payment—and you know which way they’re going to lean with their interpretations.
    • “Except as otherwise indicated herein,” means there’s an exception hidden somewhere within the contract—and chances are good that it is not in your favor.
    • If the contract mentions “affiliates and assignments,” be sure sure those entities are clearly defined and that the contract specifies what would happen in the event of a merger or acquisition.
  • Review the percentage paid, because some plans pay based on a percentage of the Medicare fee schedule. If that’s the case, shoot for a rate of more than 100% (Medicare reimbursements are low enough as it is).
  • Know the terms of the treatment authorization process; length of claim submission and denied claim appeal periods; late payment interest accrual rates; requirements for adding new services and providers; and cancellation terms and associated penalties.

Now, believe it or not, there’s much more I could cover when it comes to contracts. The point I want to drive home is that you need to inspect your contracts so you can hold payers accountable to the terms. Want more advice on how to negotiate better contracts? Be sure to check out part one and part two of a contract negotiation series we posted on the WebPT Blog.

Although working with payers can feel like a terribly one-sided game, it is possible to have the upper hand when it comes to payments. Your practice doesn’t have to contribute to the $125 billion left on the table each year. Simply keep these five pointers in mind, and you’ll be well on your way to beating the payers at their own game.

About the Author

Heidi Jannenga is co-founder and president of WebPT, the leading electronic medical record solution for physical therapists and a three-time Inc. 5000 honoree. She has more than 15 years of experience as a physical therapist and clinic director, and she’s an active member of the sports and private practice sections of the APTA as well as the PT-PAC Board of Trustees.