Is Your Medical Biller Using Modifier 25?

To understand modifier 25, let’s define what it is.  Modifier 25 is Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

This modifier can only be used with an Evaluation and Management service.  It has to be above and beyond the usual preoperative and postoperative encounter with the procedure.  Using this modifier does not require you to use another diagnosis to bill.  It is most important that the Evaluation and Management level should meet its key components.  Make sure that when using this modifier that it meets medical necessity.  Below is an example of when this modifier would be used.

A patient comes in for a follow up for chronic neck pain, and then the patient then complains of having severe allergies.  A pain management procedure was administered at the same time of service.  This would call for the modifier 25 being used for the Evaluation and Management code to indicate that both services were rendered on the same day.

It is important that a medical insurance biller use this code when appropriate.  Otherwise you will receive many claims that will have unpaid codes that could have been paid for.  Keeping up to date on changes with this modifier is important to ensure efficiency when billing.

An example of not using modifier 25 is when an ear nose and throat physician has seen a patient with Medicare, for a routine office visit and the physician decides that the patient needs a hearing test which can be done in their office by a certified Audiologist.  The physician determines that the patient has hearing loss from the results of the hearing test.  The physician now can bill for an office visit, most likely a 99213 or 99214 and a hearing test, which is a procedure using CPT code 92557.  Now if the modifier 25 was not attached to the Evaluation and Management code, the hearing test 92557 would not receive payment.  So if the E/M code has the modifier 25 billed along with it and then the procedure code for the hearing test 92557 both will be paid.

So many physicians have missed out on payment of minor procedures or testing performed in the office because of the fact that the biller did not attach the modifier 25 to the Evaluation and Management code.  What a costly mistake for the physician.  Some insurance companies may allow you to re-bill a corrected claim to re-submit for payment on claims that did not have the modifier attached.  It would serve the physician well to investigate if this is being done.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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Etiquette For Your Medical Practice

Giving Medical Advice

Current patients and even new patients to the office often call the office for medical advice over the phone.  The receptionist does not have the medical authority to answer these types of questions.  The receptionist should never give suggestions or advice for medical care to a patient.  The best way to handle this situation is to let the caller know that you are not qualified to give out medical advice.  They can then ask the patient to make an appointment so that the physician can recommend treatment.  Or the patient can be transferred to the nurse, nurse practitioner or physician who can give them further medical advice. When given to the proper person who can give medical advice, this should always be out of earshot of other patients so as to keep that patient’s confidentiality private.  Usually a medical practice has a private office that an appropriate staff member can give results to patients without the possibility of other people hearing them.

Patient Confidentiality

Making sure patient confidentiality is enforced is the one of the most important things when communicating with them.  This falls under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  This law forbids medical staff from releasing any information about their patient unless specified by the patient themselves.  If a family member of a patient calls the medical office for any type of medical history or want results of tests that have been performed on the patient, this is not allowable under the HIPAA regulations.  The staff member should inform them that they are not allowed by law to give out medical or personal information from the patient’s chart.  When requesting records whether it be another medical office, law office or even the patient themselves, a signed medical records release form should be signed and dated by the patient giving the appropriate person the right to view their records.

Switchboard Operation

Some medical offices operate a switchboard in their offices.  When doing this there are a few things to keep in mind.  Keeping track of what patients are on hold will keep the lines of communication open.  Most medical practices have multiple lines that can accommodate several lines at one time.  Make sure that the receptionist asks the caller for their name and phone number, then place them on hold and refer the line to the appropriate person.  The tone of voice of the staff member should always be polite and professional. If the person is not available then they should take a message along with the patients name, phone number, alternate phone number, reason for calling, date and time that the call was received and then give the message right away to the appropriate person.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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How to Handle a Problem Patient

Most patients are easy to work with.  They call ahead for an appointment, they arrive at their scheduled time, they pay their bill on time, but there is always that one patient that defies all of the above.  On occasion, however, things can go very wrong and patients become angry, stubborn, manipulative and even abusive.  Some people are ready for confrontation while others avoid it at all costs by hiding, giving in to strong demands, or finding someone else to handle the problem.

If you communicate in ways that show you care and have empathy for the patient this could diffuse a situation or at least calm the situation down.  You could simply say that you wish you could help them but the physician’s policy is very clear in this manner.  You can also agree with the patient on principal.  Rather than go back and forth and try to prove your point, you can acknowledge that the patient has a valid point of view and you can present to the patient what you are willing or able to do.  You may say things like “I can understand how you might see it that way…”  By saying those simple words shows that you care for the patient and also validates your understanding of the complaint.

When patients continue to ask and demand what they want it is best to stay firm, talk with the patient in a calm voice, make sure that they know what you are willing and able to do.  If you keep coming up with new reasons or excuses why you can’t do something this will only prolong the situation and make it seem as though the policy can be changed in some manner. 

Keeping your tone of voice low, soothing but yet firm should help to calm a situation and help the patient to regain their composure.

Keep direct eye contact with the patient and a straight posture.  This adds to your credibility.  If the patient is standing, stand up, if the patient is sitting down, sit down.  If a patient is in the waiting room with other patients or in an area where others can hear the confrontation, move the conversation into a private office if possible, so that other patient’s or staff are not disrupted.  Ask the office manager to join you in the conversation, or it might get to the point where the physician may need to step in.  The bottom line is you want to keep the office in a peaceful state and have the ability to handle patient complaints in a professional dignified manner so not to disrupt the entire office staff and patients that are waiting to be seen.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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Secrets to Boost Your Practice Profits

Secrets to Boost Your Practice Profits

Some key steps to make your practice a success are simpler than you think.  There are a few easy ways to cut costs and boost your profits.

1. Pay as little rent as possible

Besides payroll, paying rent is the biggest expense in your practice.  You don’t necessarily need a medical office building for your practice or the most luxurious location.  Consider sites such as a residential unit.  One physician bought a fourplex and he turned one of the apartments into his office and rented out the other 3 units to other medical practices.  By owning your property you don’t have to answer to anyone as to how you want to manage your space.

2.  Hire only a few employees

It’s always good to have a few good core employees.  Assign positions to each employee along with having them multitask and share responsibilities.  Have them all work as a team and back each other up when needed.  Treat these employees well because they set the tone of the office and you want them to be satisfied in their job which makes for a better work environment for everyone.

3.  Send ALL claims electronically

This should be the ONLY way to send a claim for processing.  Sending claims on a “claim form” is the old way and not efficient.  You can receive payment from some insurers within 5 working days, and few take no longer than 2 weeks.  This keeps a good flow of payments coming in.

4.  Good Service

Make sure you offer good care and service to your patients.  This keeps your patients coming back and recommending you to their friends and family.  Don’t make your patients wait.  If they do have to wait, apologize to them.  Call the next day and see how they are doing.  Also report back to them with any test results promptly.  In addition leave room for same day appointments to accommodate patients that need to be seen right away.

5.  Cultivate relationships to generate referrals

Making friends and relationships with your medical community is also a good way to generate referrals.  Consulting with them will result in more patient referrals.  As discussed before, offering good service will eventually get back to the physician that referred them and in turn this will make the physician more comfortable in referring more patients to you. 

6.  Create a Niche

Consider doing wellness medicine, which widens the scope of potential patients to include everyone. Develop a subspecialty such as geriatrics, thyroid disorders or diabetes.  Get into occupational health, offer driver’s physicals, and worker’s compensation for minor injuries, drug screening or pre-employment physicals.  Spend the money to advertise for these services and you will see your practice grow along with your profits.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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Keys To Keeping Good Medical Records

Medical records are an important part of any medical practice.  Keeping good records is essential in avoiding an audit or possibly not getting payment from an insurance company.  Several auditing groups include, licensing boards, payers, litigants, accreditation organizations, each one is looking for specific things in the documentation.  Licensing boards want to find out if the doctor acted within his or her scope of practice or if they were grossly negligent.  Payers want to determine if a claim is justified for reimbursement.  Litigants want to know whether a breach happened during care.  Accreditation organizations want to determine if their standards and elements of performance have been met by the doctor.

These are some general requirements for documentation.

  1. Medical Records should be complete and are legible.
  2. Documentation of each patient that is being seen should include a reason for the visit and a history that is relevant to the complaint, physical examination findings and any prior diagnostic test results, a full assessment and clinical impression and diagnosis, a plan for care and date the record along with signature of attending physician, nurse etc.
  3. Reason for ordering tests.  If this is not recorded, it can be easily proved that it was not necessary.
  4. Past and present diagnoses whether it be from the patient or other past office visits from other physicians.
  5. Appropriate health risk factors should be identified and noted.
  6. Patient’s progress, response to changes in treatment, and a change of diagnosis should be clearly documented.
  7. The CPT and ICD-9 codes reported on the insurance claim form should always be supported by the documentation in the medical record.

Meeting the standard of care medical records must:

  1. Document any details regarding a patient’s history during the exam
  2. Document referrals
  3. Document refusals of treatment and the reason the patient has refused treatment
  4. Document that the physician has clearly reviewed the possible consequences of refusing a specified treatment to the patient
  5. Document encouragement of the physician of healthcare maintenance and risk reduction (example: weight loss or smoking)
  6. Document advice that has been given to the patient (example: pink eye can spread to others in the family)
  7. Document patient noncompliance with treatment regimen or referral, including the patient’s reason for not complying and advice to the patient about the risk of failing to take the advice given.

Good medical record keeping is an important part of good business.  The consequences of errors can result in a denial of payment, audit, loss of contracts, accreditation or possible lawsuit brought on by a patient.  It may take longer to do but in the end it benefits you, your practice and most important of all your patients.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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How Do You Know If Your Practice Is On Target?

Many physicians are overwhelmed with their day-to-day activities and are not aware if their practice is doing well or is in need of some fine tuning.  Below are five key areas of concern that should be looked into and followed up on to see how the practice is flowing.

1. Overhead

Calculate your overhead rate which includes staff and general operating costs by the total revenue the practice is bringing in.  Do some research on other practices similar to yours and see if they are comparable.  If your overhead rate is higher than the average for your specialty, consider reviewing all the cost that are involved within your practice and see if there are areas where you can reduce expenses.

2.  How productive is your practice

It’s a good idea from time to time to check the amount of referrals you are getting every month.  Make a spreadsheet of all referring doctors and see where possibly there is a drop in referrals or you are seeing an increase in referrals for a specific doctor.  By a physician taking 10 minutes out of their day to call a physician to remind them of your practice and also thank them for referring patients in the past, this could generate future referrals for the practice.

3.  Access the practices financial situation

Start by calculating a net collection rate.  When you enter into a contract with an insurance company, you agree to take a contractual adjustment from your submitted charges.  The net collection rate tells you whether you are collecting the remainder of your submitted charges once the adjustment has been made.  Calculate your net collection rate.  It should be 97% or greater to ensure a healthy bottom line.

4.  Avoid unnecessary hospital admissions or ER Visits

Evaluate a one month period and calculate the number of ER visits and admissions that were avoidable or potentially avoidable.  If your practice has a high level of preventable visits and admissions, create a quality plan to expand continuity of care, transition management, and care outreach.  Track this over time by checking it on a quarterly basis, with the goal of reducing your practice’s rate to zero.

5.  Survey referring physicians and patients

Many offices now use a patient survey or referring physician survey to evaluate their practice better.  This could be something that could be e-mailed or mailed with a return postage envelope to patients and referring doctors.  It can be done unanimously to protect their privacy as well.  This is an excellent tool to use to find out what’s really going on with the practice.  This data can be analyzed and put into good use to further make changes within the practice to help it run better.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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Commonly Asked Medicare Q & A

As an outsourced medical billing company I get many questions regarding Medicare.  I will keep track of these questions and publish some of them periodically on my blog.  Below are answers to three commonly asked questions.

Do Medicare rules apply to patients who don’t have Medicare?

Medicare has rules called “conditions of participation” regarding facilities and home care agencies and these rules apply whether or not the patient has Medicare.  In order for the facility to maintain its Medicare provider status, it must meet the conditions of participation.  On the other hand, Medicare only stipulates that these rules only apply to Medicare patients and do not have any connection with other payers.  So if there is a patient that comes in for an office visit and they do not have Medicare or any other type of insurance and will be paying for the visit themselves, the provider does not have to accept Medicare’s rates and does not have to meet Medicare’s required documentation or disclosure requirements or Medicare’s performance measures.

What constitutes an “Initial Visit” for Medicare billing?

For example, if a patient comes into the office to receive results of a sleep study can this be billed as an initial visit?  An initial visit or a “new patient” visit is a face-to-face visit.  If you are going over and giving the results of the sleep study with the patient present and have given further instruction and have a treatment plan, this is an initial visit.  If the patient is not present when giving the results, then this is not a visit.  According to Medicare, a patient qualifies as a new patient when they have not been seen in over 3 years.  If the patient has not been seen for over 3 years, an initial visit can be billed.  If a patient visits the hospital, then one initial visit per patient per hospitalization is allowed.  All other visits while the patient is hospitalized are to be billed as subsequent visits.

Can more than one Nurse Practitioner bill a Medicare patient on the same day?

In some cases this is allowed.  For example, if there are two Nurse Practioners one being the primary care nurse that bills Medicare one diagnosis and the other Nurse Practioner being in a specialty practice bills for a different diagnoses on the same day.  Will the bills for these visits through two separate practices and two separate provider numbers be paid by Medicare?  Yes. According to Medicare rules, both claims would be paid.  The reason they will be both paid is due to their being two different diagnoses on each claim and the bills are being generated by two separate providers.  However, when there are cases of two Nurse Practitioners who have billed for the same day with the same diagnosis, it is likely that one of these claims will be rejected by Medicare.  In this case, it is extremely important that the Nurse Practitioner has justification through their progress notes to back up their claim.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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