Demonstrating Skillful Decision-Making in Your Billing

When you’re treating patients, your clinical decisions may feel like second nature. Without any prodding or prompting, you know exactly what modalities to use, what exercises to prescribe, and how to approach each individual plan of care. But, outside of the clinical realm, some of your job duties might not come so naturally. For example: translating the efficacy of your care into billable codes and defensible documentation. Now, even if you don’t consider these tasks easy—or you simply dread them—it doesn’t mean you should brush them off as unvaluable. These processes affect more than just your payments. In fact, when you’ve got your documentation and billing on lock—and thus, are getting the bulk of your claims paid on first pass—you’re actually elevating the PT profession as a whole. That’s because you’re effectively proving the necessity of your services to your payers. If your claims-out-payments-in cycle isn’t spinning so smoothly, you might be wondering what you can do to improve. Well, I’d recommend starting by ensuring you are demonstrating skillful decision-making in your billing. How? To start, ask yourself the following questions:

What makes this treatment decision necessary?

If you’re struggling to come up with only one answer to this question, you’re not alone. After all, there’s a lot to consider with any clinical decision. As Mary R. Daulong, PT, CHC, CHP, explains in this PhysicalTherapy.com article: “We must know the national coverage determinations, local coverage determinations and therapy medical policies. We also have to make our decisions based on our standards of practice, our practice act and rules specifically looking at the areas such as the therapeutic benefit and abandonment issues. We also base decisions on our professional as well as personal ethics.” That’s a lot to think about—let alone document. So, how do you communicate—and justify—your thought process within the confines of the patient record? It all starts with adhering to the basic tenets of defensible documentation and accurate billing. When you’ve successfully done both, your patient records will:

• Support the need for rehab therapy services on a continual basis; the frequency and duration of visits; the necessity of treatment provided; and the number and type of charges submitted for reimbursement.
• Provide an accurate overall picture of the patient’s condition and plan of care—one that’ll stand up to strict third-party scrutiny.
• Corroborate the patient’s claim of injury.

If that’s not enough information to help you clean up your patient records, check out this post and download a free defensible documentation quick guide.

What are my billing code options?

After you’ve sufficiently documented your clinical decision-making process, it’s time to look at the billing code options that support your reasoning. On that note, it’s very important that you’re familiar with your contracted payers’ coverage, payment, and medical policies to ensure you’re acting within their guidelines as you make your selections. Now, if you already know those policies backwards and forwards—and you’ve got payable codes down pat—it can be easy to fall into the trap of coding solely to get paid. But, this is a serious billing no-no. Your code selection always should be as accurate as possible, which means your codes should only account for the services you provided—no more, no less. Here are two examples of billing practices that do your practice harm—regardless of your intentions:

• Overbilling: This occurs when a practice bills for more expensive or costly services than the provider actually provided, meaning the billing codes are incorrect.
• Misbilling: This 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.

The good news is that it’s not all that difficult to avoid these blunders in the first place. Simply make sure that when you—or your staff—make decisions about coding, you bill only for the services provided; include all billable codes; and affix any relevant modifiers. (For more information on modifiers, check out this resource.)

What are the consequences of poor billing practices?

Finally, as you’re making billing decisions, think about the consequences that eventually could follow your actions. For example, if you code accurately and bill properly, you’re more likely to get paid. But, if you fail to bill the proper codes—or you don’t support your codes with clear, defensible documentation—you risk:

• Failing to prove the medical necessity of your treatment,
• Receiving claim denials,
• Getting slapped with external audits, and
• Facing legal action.

Now, don’t let that list intimidate you. If you’re already making good clinical decisions—and I really hope you are—then you’ve already won half the battle. You just need to ensure you’re effectively proving it.

Above all else, demonstrating skillful decision-making in your billing is about clarity: being clear about why and how you decided to bill for certain services, and then having the defensible documentation to back up those choices. And while these tasks probably aren’t the best part of your day, with some practice, they just might become second nature, after all.