How to Optimize Your Claims

Billing. Everyone loves delving into their claim submission practices to optimize their billing. Amirite? Okay, so that statement might be a bit of a stretch. But, whether you love it—or not—this process could directly influence your clinic’s financial success. That’s why we’ve covered such a vast array of billing topics in our blog posts this month; we want to help you get your clinic’s billing practices into tip-top shape. If you’ve been following along, I hope you’ve found new ways to spruce up some of your own billing processes.

Beyond analyzing your clinic’s practices as a whole, you might want to get a bit more granular and dig into your individual providers’ habits. After all, you could be missing out on potential revenue if you—or your staff—have fallen victim to coding bad habits. One way of breaking those habits: examining your go-to CPT codes and determining whether there are higher value—but still accurate and appropriate—codes that you could be using instead. Now, I’m not talking about upcoding. I’m talking about taking a hard look at the purpose behind your code selection and submission—and adjusting accordingly. Here’s how to optimize your claims to increase your reimbursements:

Shake up Your Habits

Although a particular CPT code might be commonly used, it may not be the most appropriate code for the treatment provided. For example, 97110 (therapeutic procedure) and 97140 (manual therapy) might be your go-to codes. And after some time, these codes might transition from “go-to” to “only-billed.” If you’ve pigeon-holed your code selection into a only handful of options, you might be missing out on additional revenue from higher-paying codes. Keep in mind that, while higher dollar amounts should never be your sole justification for using different codes, you should always strive for coding accuracy. Speaking of accuracy, let’s go through a quick refresher of 97110 and 97140 and their definitions, courtesy of the PT Compliance Group:

• 97110 (therapeutic procedure) is exercise to develop strength, endurance, range of motion, and flexibility.
• 97140 (manual therapy) includes manual techniques such as soft tissue and joint mobilizations, manipulations, manual lymphatic drainage, and manual traction.

Now that we’ve covered the definitions, we can ask ourselves, “Are these common codes valid?” The answer? Absolutely. However, depending on your patient’s treatment plan, they might not be the most accurate. So, now what? You’ll need to evaluate the purpose behind your treatment to determine the proper codes. Let’s look at an example adapted from this article:

Patient A is performing an abdominal sit-up. Sit-ups are great for working on increasing abdominal strength (97110 therapeutic procedure), but you must ask yourself whether that benefit was what drove you to prescribe this exercise.

If you prescribed sit-ups to help your patient gain strength in his or her abdominals, you’d want to bill 97110 (therapeutic procedure). However, if that wasn’t the case, a different code might be more appropriate. Maybe you worked on sit-ups with Patient A to help him or her get out of bed. If so, you could bill 97530 (therapeutic activity). Why? Because you were working on improving the patient’s functional ability through this particular exercise. But wait—there’s more: 97112 (neuromuscular re-education) might be most appropriate if you prescribed sit-ups to improve the patient’s balance by helping him or her with dissociative movements.

As the aforementioned example shows, one exercise could have a variety of code options beyond the common 97110 (therapeutic procedure). Just remember that the code you bill should reflect the logic behind the treatment. Thus, you’ll need to really think about the procedures you performed and how you can code for them in the most accurate way possible. Instead of sticking to your coding go-tos, investigate whether there’s a more appropriate code available. But again, I want to make it very clear that I’m not talking about upcoding (i.e., using a higher-paying code when you know it does not accurately reflect the treatment you provided). This post is about knowing your value, examining your treatment, and getting paid for the services you provided.

Face Your Fears

Maybe you’re stuck in habitual billing patterns because you’re afraid of receiving claim denials. You might be dead-set on sticking with what works—in other words, continuing to bill the codes for which you know you’ll get paid—and if so, you’re probably hesitant to step outside of that box. Here’s the problem with that way of thinking: Although you might believe a common code just about covers a particular visit, there’s a chance you’re missing out on further reimbursement opportunities.

Now, I know what you’re thinking: Everything I’ve been doing has worked. I bill codes; payers pay ’em. Why run the risk of rocking the boat, especially if that rocking causes payers to scrutinize you more thoroughly? Here’s the thing: You shouldn’t be afraid of that scrutiny as long as you’re billing specifically and accurately—and your documentation supports your coding choices. That means making sure your evaluations and objective measures align with your coding methods: “For example, if you are using neuromuscular re-ed there should be an impairment for which neuromuscular is appropriate. In your treatment note for the visit include your clinical rationale for the treatment,” says this article. If your documentation supports your codes, then there’s no need to fear the reaper—er, the payer.

Here’s another example of a situation in which there’s an opportunity for more accurate coding, as adapted from this PT Compliance Group article:

Let’s say you’re seeing a patient who requires manual therapy to reduce swelling at the injury site—a treatment that would require billing 97140 (manual therapy). Additionally, the patient requires exercise to improve his or her range of motion (97110 therapeutic procedure) as well as movements that improve muscle efficiency for better balance (97112 neuromuscular re-education). To top it off, in this same visit, your patient has shown difficulty moving from seated to standing position, so you work on sit-to-stand exercise with equal weight distribution (97530 therapeutic activity). All of these codes accurately describe what treatments you completed with the patient during this visit. On the documentation side, just be sure to accurately document your patients’ needs and the purpose behind your treatment. If this patient’s chart were to undergo an audit, it would be crucial for your documentation to justify the services you provided. An added bonus to refreshing your approach to coding? You ensure that your patient receives the full range of treatments that would benefit them. Additionally, you have the potential for receiving reimbursement for four codes, as opposed to one. (Note: If you’re billing Medicare, make sure you take into account the 8-minute rule and bundled code/59 modifier requirements.)

See More Patients

Choosing more accurate codes is only part of the payment puzzle. You also have an opportunity to bill for more units by treating more than one patient at a time—as long as the patients are not Medicare beneficiaries and do not have insurance plans that follow Medicare guidelines (that’s important). However, when you’re treating patients with commercial plans, you typically can provide treatment in a group setting. Furthermore, you don’t need to apply other Medicare regulations to non-Medicare patients (unless their insurances specify that they follow certain Medicare rules). For example, you do not need to apply the 8-minute rule to all your patients, but rather only to those patients who have Medicare or an insurance that has timed coding requirements. We may treat Medicare like the law of the land, but really, it’s only the law for Medicare. So, know the rules for each and every one of your payers, and follow them as closely as possible. That way, you’ll know when you can treat more patients—and bill more units. With tech or trainer assistance, you have the potential to maximize the number of patients you see—while providing quality and individualized treatment, to boot.

As you review your coding habits, remember to keep compliance top of mind, code accurately, and ditch your fears to optimize your claims.