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Effectively Navigating Nephrology Billing Complexities for Practices

October 22, 2019

Nephrology Billing ServicesIf your practice seems to be having claims denials these days, you’re not alone. Thanks to complex billing and documentation requirements from the Centers for Medicare and Medicaid Services (CMS)  as well as private payers, nephrology practices are under pressure as never before to stay current with the latest changes and updated guidelines. Fortunately, there are some strategies available to keep your billing and revenue cycle running more smoothly.

Nephrology Documentation Fundamentals

With inpatient encounters, the “time” component includes all the time spent with the patient: interview, examination, and floor or unit time spent discussing with other clinicians.

According to a recent study, physicians spent an average of 26 percent  to 31 percent of their working hours on medical documentation, but the Department of Health and Human Services reports that as many as 55 percent of all submitted E/M claims were erroneously coded.  Twelve percent of claims had insufficient documentation, underscoring the need for better training of providers and billing staff.  The guidelines below are general; always refer to the latest CMS updates for the latest information.

Above all, remember that documentation is judged on the quality, not quantity of information.

Documenting Dialysis:
Since patients with kidney disease need dialysis (whether hemodialysis or peritoneal dialysis) for ESRD or AKI, dialysis procedures for both can be rendered and reimbursed with inpatient settings. When done on an outpatient basis, previously only dialysis treatments for ESRD were reimbursable, however, starting in 2017 Medicare will also began to reimburse AKI-indicated outpatient dialysis. Use CPT® code 90935 (for single evaluation during a hemodialysis procedure) and 90937 (repeat evaluations during a hemodialysis procedure). Codes 90947 and 90945 are listed as appropriate for single and repeated evaluation during dialysis procedures other than hemodialysis, such as renal replacement therapy or peritoneal dialysis. However, there are a few caveats with these codes, as we’ll see below.

Documenting Time-Based Encounters

Time component fulfillment isn’t typically required for coding purposes, unless the majority of encounter is spent on counseling  or coordination of care, in which case, time spent can determine service level.

The time requirements for level 3 (99213) and level 4 (99214) outpatient follow-up visits are 15 and 25 minutes respectively, for example. At least one face-to-face visit every three months is also required for in-center dialysis patients. 

CMS Adds to the Confusion

Sometimes where CMS is concerned, definitions and related Information are omitted or worded so vaguely as to create confusion when billing. PD is one of those “other” procedures – and instead of being given its own section in the CMS manual, it’s simply lumped in with hemofiltration and continuous renal therapies CPT codes, with the section listed as “Miscellaneous Dialysis Procedures.”

Example: CPT 90945 is “Dialysis procedure other than hemodialysis, with single evaluation by a physician or other qualified health care professional.” The CPT code 90947 has basically the same wording except it is used for “visits requiring repeated evaluation.” Because of the inclusion of physician components in both codes, it should be obvious that these are intended for billing physician services for inpatient ESRD and non-ESRD as well as outpatient non-ESRD services. That information, however, was omitted from the description of 90945 and 90947, stating only that they are for inpatient ESRD and outpatient non-ESRD care.

Lacking proper wording can lead billers and payers to believe that those codes are used for billing outpatient PD. This can result in centers billing for just technical components of dialysis, omitting physician services.

Protecting Practice from Nephrology Coding Errors

One of the big problems when billing for nephrology and differing forms of dialysis with CMS are their own coding guidelines. Review each of your commercial payer contracts, checking whether 90945 or 90947 are required as well as their reimbursement.

Be sure that home dialysis training is included and the reimbursement is higher than for standard treatments. Check to see which PD codes are required for Medicaid as well as military payers and their reimbursement amounts.

In states where the 20 percent co-insurance assigned by Medicare isn’t accepted by Medicaid, the physician needs to review Medicaid remittance advice for any paid claims secondary to Medicare to determine how much is allowed for home training as well as PD.

Additionally, nephrology practices need to review their reimbursement from commercial payers for professional services concerning home dialysis training to ensure that Medicare Advantage, PPO and HMO plans are reimbursing claims correctly.

Schedule Periodic Coding Reviews to Catch and Prevent Coding Errors

 Since the CMS is very focused on its acclaims abuse and fraud regulations, any incidence of over- or under-documentation are considered fraudulent and can increase the risk of audit. One of the most effective ways to determine if coding and related documentation are on track is to undergo periodic coding reviews, with subsequent monitoring and ongoing biller and clinician training. Those practices which schedule regular reviews, follow-up monitoring and continuing education for improved documentation and coding have been shown to have a higher accuracy profile than those which lack reviews, monitoring and ongoing training.

To reap the full benefits of reviews, they must be regular and frequent; one-time reviews, even if followed up with monitoring and additional training, have shown little impact on performance improvement.

Choose Nephrology Experienced Medical Billing Service to Improve Reimbursement Revenue

M-Scribe has the experience you need and trust from having been helping Nephrology practices of all sizes and specialties since 2002. Our highly trained medical claims professionals are available to provide the billing expertise needed for ensuring that the necessary documentation is present when sending your claims, whether to Medicare or other payers. We’re here to answer your billing inquiries and help your office staff avoid problems with nephrology billing as well as other types of claims, resulting in higher reimbursement rates and better control over your revenue cycle. Contact M-Scribe today by phone at 770-666-0470 or by email for a confidential assessment of your practice’s management needs and goals.


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