We understand how to do medical billing for the specialties you serve, let us build your business.
Multispecialty Practice are often riddled with complications when billing out charges for various encounter types.
The ongoing changes in the healthcare environment have necessitated that a billing team have dedicated and prompt follow through on denials and no claim responses. The range of patient care issues provided by Multispecialty Practices is wide and varied. Even though our focus is on medical billing and accounts receivable management, our broad experience across the entire Revenue Cycle Management process in a Multispecialty practice is why we can give you an advantage compared to in-house billing.
Our team at Etransmedia has the knowledge and skills necessary to successfully work denials and provide our Multispecialty clients with valuable feedback to assist in managing and decreasing the most frequently seen denial types, while streamlining revenue and increasing your practice’s collection rates. Getting you paid fast!
What we know…
Most of the billing errors & questions related to Multispecialty groups have to do with the Global Surgery Package & modifiers:
There are three types of global surgical packages based on the number of postoperative days:
Zero Day Post-operative Period, (endoscopies and some minor procedures).
No pre-operative period
No post-operative days • Visit on day of procedure is generally not payable as a separate service
10-Day Post-operative Period, (other minor procedures).
No pre-operative period
Visit on day of the procedure is generally not payable as a separate service • Total global period is 11 days. Count the day of the surgery and 10 days following the day of the surgery.
90-day Post-operative Period, (major procedures)
One day pre-operative included
Day of the procedure is generally not payable as a separate service
Total global period is 92 days. Count 1 day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery.
Services that are included in the Global Surgery Payment are:
Pre-operative visits after the decision is made to operate.
For major procedures, this includes preoperative visits the day before the day of surgery.
For minor procedures, this includes pre-operative visits the day of surgery.
Intra-operative services that are normally a usual and necessary part of a surgical procedure;
All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room;
Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery;
Post-surgical pain management by the surgeon;
Supplies, except for those identified as exclusions: and
Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or a note in the discharge summary, hospital record, or ASC record;
Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;
Diagnostic tests and procedures, including diagnostic radiological procedures;
Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications;
*Note: The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier -25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure.
Services that are not included in the Global Surgery Payment are:
Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries (90 global period). This is billed separately using the modifier -57 (Decision for Surgery).To be used only for major surgical procedures
*Note: A new post-operative period begins with the subsequent procedure. This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure.
Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR);
If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
Immunosuppressive therapy for organ transplants; and
Critical care services (CPT) codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
Modifiers: Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure:
Modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and postoperative care associated with the procedure or service.
Use modifier -25 with the appropriate level of E/M service.
Use modifiers -24 (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated, procedure.
*Note: Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and
the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician
practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.
Modifiers: Post-Operative Period Billing:
Modifier -79 (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a postoperative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.
Modifier -78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the post-operative period). The physician may also need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier 78 to the related procedure.
Modifier -24 (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the postoperative period of an unrelated procedure. An E/M service billed with modifier 24 must be accompanied by documentation that supports that the service is not related to the postoperative care of the procedure.
Modifier -58 (Staged or related procedure or service by the same physician during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. Modifier “-58” indicates that the performance of a procedure or service during the post-operative period was:
Planned prospectively or at the time of the original procedure;
More extensive than the original procedure; or
For therapy following a diagnostic surgical procedure.
*Note: Modifier 58 may be reported with the staged procedure’s CPT. A new post-operative period begins when the next procedure in the series is billed.
Modifier: Pre-Operative Period Billing:
Modifier -57 (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. Evaluation/Management (E/M) services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, these services may be billed and paid separately.
*Note: The modifier 57 is not used with minor surgeries, (0-10 global), because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure.
Modifiers: Co-Surgeons and Team Surgeons:
Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedures and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. The following billing procedures apply when billing for a surgical procedure or procedures that require the use of two surgeons or a team of surgeons:
Modifier -62 (Two Surgeons) If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier-62. Co- surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements.
*Note: Some procedures require modifier 62 and will be returned without payment if it is not used by both surgeons.
Modifier -66 (Surgical team). If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier 66 Certain services submitted with modifier 66 must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”
*Note: If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services
Modifiers: for Assistant-at-Surgery Services:
Modifier -80 (Assistant Surgeon)
Modifier -81 (Minimum Assistant Surgeon)
Modifier -82 (Assistant surgeon – when qualified resident surgeon not available)
Modifier -AS (the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery policy. Accordingly, pay claims for procedures with these modifiers only if the services of an assistant-at surgery are authorized).
*Note: For assistant-at-surgery services performed by physicians, the fee schedule amount equals 16 -20 percent of the amount otherwise applicable for the surgical payment. (Reimbursement varies contingent on the insurance carrier).
On October 1, 2016 the Centers for Medicare and Medicaid Services (CMS) will no longer accept unspecified codes in most cases.
Starting in October, CMS requires greater specificity for claims filed in ICD-10-CM/PCS. The 12-month grace period originally introduced in 2015 said they would not deny claims for lack of ICD-10 specificity. That all changes on October 1, 2016. Payors will most likely follow suit if they haven't already.
First Pass Clean Claim Rate
Boost in Revenue*
Reduction in Cost*
We’re always on top of all the latest coding and billing updates for Multispecialty practices. Additionally, to make sure all claims are reimbursed on the first claim submission, our system is able to pre-edit claims prior to the initial submission for possible billing/coding errors. Our detailed end of month reports keep our clients up-to-date on what is happening in their practice so any issues can be addressed quickly. Having an experienced medical billing team, with visibility into performance, is vital to your practice’s financial health.
Although the new industry standards can be confusing and difficult to navigate, our dedicated team here at Etransmedia can assist in guiding you and helping to make your practice grow successfully.
*Please Note: Results are not guaranteed, implicitly or explicitly, and will vary based on several factors such as individual practice demographics, specialty, payer mix, operations, and management among others
Service and Technology Packages
Our customizable revenue cycle management service and technology solution packages allow you to outsource based on the specific needs of your practice
Silver RCM Service
This package has the core service and technology needed for revenue management allowing you maintain the responsibility of patient billing.
Gold RCM Service
This package includes the core RCM services with added denials, A/R management services, and full service patient billing
Ancillary RCM Services & Technology
Available to enhance any package