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PubMed2003

National Academy of Neuropsychology/Division 40 of the American Psychological Association Practice Survey of Clinical Neuropsychology in the United States. Part II: Reimbursement experiences, practice economics, billing practices, and incomes.

Leaders of the National Academy of Neuropsychology and Division 40 (Clinical Neuropsychology) of the American Psychological Association determined that current information on the professional practice of clinical neuropsychology within the United States was needed. These two organizations co-sponsored a national survey of U.S. clinical neuropsychologists that was conducted in September 2000. The primary goal of the survey was to gather information on such topics as: practitioner and practice characteristics, economic variables (e.g., experience with major third party payors, such as Medicare and managed care), practice expenses, billing methods, experiences with Current Procedural Terminology (CPT) codes, time spent on various clinical tasks, use of assistants, and income. In this second of two articles describing the survey results, reimbursement experiences, practice economics, billing practices, and incomes are highlighted. Survey results indicate that neuropsychologists frequently have difficulty gaining access to membership on managed care panels. For those who gain access, managed care companies often limit provision of services; this is quite often perceived as negatively affecting quality of patient care. It is very common for neuropsychologists to feel obligated to provide more services to managed care and Medicare patients than are allowed to be billed to the insurance carrier; these hours are typically "written off." Numerous CPT codes are used to bill the same clinical service. Awareness of Medicare practice and billing expectations is variable among practitioners, as is awareness of public aid/Medicaid billing status. Professional income is influenced by years of licensed practice, practice setting, gender, types and amounts of non-clinical professional activities, and types and amounts of reimbursement sources within one's clinical practice. Income of neuropsychologists has only a minimal relationship to percentage of clinical practice per week. Within the context of prior surveys, neuropsychologists are engaging in more clinical hours per week and, nevertheless, compared to data from 1993, are reporting decreased income. These and other findings are presented and discussed.

Academies and Institutes↗

PubMedDate not supplied

Clinical laboratory billing: superfluous requirements without justification?

Congress occasionally passes new laws that affect how clinical laboratories handle test orders from physicians and, subsequently, process the billing for tests. Once a bill is signed into law, it is forwarded to administrative agencies, which draft regulations and administrative procedures, under which the intentions of Congress are carried out. In the case of laboratory test ordering and billing, the Centers for Medicare and Medicaid Services (CMS) has the greatest influence over how these regulations and procedures are defined. Unfortunately, in many cases, billing rules have been promulgated in ways that create the need for hospitals and commercial laboratories to expend huge sums of money to bill within the confines of the administrative rules; cause clinical laboratories to suffer from omissions and mistakes of other parties who are part of the patient care process but are not accountable for the billing information they provide to laboratories; and, frankly, in some respects, simply defy common sense.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2000

Current issues in billing and coding in interventional pain medicine.

Interventional pain management is a dynamic field with changes occurring on a daily basis, not only with technology but also with regulations that have a substantial financial impact on practices. Regulations are imposed not only by the federal government and other regulatory agencies, and also by a multitude of other payors, state governments and medical boards. Documentation of medical necessity with coding that correlates with multiple components of the patient's medical record, operative report, and billing statement is extremely important. Numerous changes which have occurred in the practice of interventional pain management in the new millennium continue to impact the financial viability of interventional pain practices along with patient access to these services. Thus, while complying with regulations of billing, coding and proper, effective, and ethical practice of pain management, it is also essential for physicians to understand financial aspects and the impact of various practice patterns. This article provides guidelines which are meant to provide practical considerations for billing and coding of interventional techniques in the management of chronic pain based on the current state of the art and science of interventional pain management. Hence, these guidelines do not constitute inflexible treatment, coding, billing or documentation recommendations. It is expected that a provider will establish a plan of care on a case-by-case basis taking into account an individual patient's medical condition, personal needs, and preferences, along with physician's experience and in a similar manner, billing and coding practices will be developed. Based on an individual patient's needs, treatment, billing and coding, different from what is outlined here is not only warranted but essential.

Journal Article↗

PubMed2000

Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.

OBJECTIVE: To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation. DESIGN: Multi-method, cross-sectional observation study. SETTING: Eighty-four family practices in northeast Ohio. PARTICIPANTS: Four thousand fifty-four outpatients visiting 138 family physicians. MAIN OUTCOME MEASURE: The degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits. RESULTS: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients. CONCLUSIONS: Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies should be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.

Cross-Sectional Studies↗

PubMed2005

Lymphocyte-expressed BILL-cadherin/cadherin-17 contributes to the development of B cells at two stages.

The gene encoding BILL-cadherin/cadherin-17, a nonclassical cadherin expressed on B lymphocytes in a stage-and-site-specific manner, was inactivated by targeted disruption of its transmembrane/cytoplasmic portion-encoding parts. BILL-cadherin deficiency caused a threefold proB cell accumulation, as well as a reduction to half of the numbers of immature B cells in bone marrow. In spleen, CD21(hi)CD23(lo) marginal zone B cells were found reduced and the structure of the marginal zone was impaired. In addition, the size and number of germinal center as well as the number of PNA(+) cells were significantly reduced in BILL-cadherin-deficient mice. In the peritoneal cavity of mutant mice IgM(+)Mac-1(+)CD5(+) B1a cell, that express high BILL-cadherin in wild-type mice, was also reduced in number. The IgG1 and IgG3 antibody response to the T-independent antigen, TNP-Ficoll, was impaired in the mutant mice. These results indicate that BILL-cadherin participates in B lymphocyte development at least at two stages, first at the transition of pro/preB-I cells to preB-II cells possibly in association with surrogate light chain in bone marrow, and later at the point of development, accumulation and reactiveness of immature B cells in spleen.

Animals↗

PubMed1993

Constraints on the evolution of attractive traits: genetic (co)variance of zebra finch bill colour.

We estimated the heritability and genetic correlation between male and female bill colour in a laboratory population of zebra finches (Taeniopygia guttata) in order to examine the potential genetic constraints on the evolution of a sexually dimorphic trait. The heritability estimates of bill colour from regressions of offspring on single parents ranged from h2 = 0.34 to 0.73 and all but one of these estimates were significantly greater than zero. The restricted maximum likelihood heritability estimates for full- and half-siblings were significant for females (h2 = 0.48) but not significant for males (h2 = 0.45). The maximum likelihood estimates indicate that there is little dominance genetic variance for bill colour. The large genetic correlation between male and female bill colour (rg = 0.91) combined with opposing selection on male and female bill colour indicates that the evolution to sex-specific optima may proceed very slowly.

Animals↗

PubMed2001

Effects of billing and documentation requirements on the quantity and quality of teaching by attending physicians.

PURPOSE: The Health Care Financing Administration's guidelines for billing and documentation by attending physicians have increased the amount of time that attending physicians spend documenting the services that they provide for patients. This study assessed the impact of these guidelines on attending physicians' teaching of housestaff on inpatient medical wards. METHOD: A survey of 92 housestaff from the department of medicine at one teaching hospital was conducted in 1998 to determine how attending physicians' billing and documentation requirements, clinic responsibilities, teaching styles, and inpatient census affected the quantity and quality of their teaching. The questionnaire included a rank-order analysis of factors affecting quantity and quality of attending physicians' teaching, as well as a five-point Likert scale assessing the quality of attending physicians' teaching. RESULTS: All housestaff responded. A total of 39% of housestaff perceived billing and documentation requirements to be the major detriment to quantity of teaching by attending physicians, and 30% perceived these requirements to be the major detriment to quality of teaching by attending physicians. Housestaff perceived more teaching and higher-quality teaching on services where attending physicians did not perform billing and documentation during teaching rounds. CONCLUSION: Billing and documentation requirements are a major detriment to the quantity of teaching on inpatient services, especially when faculty attempt to meet these requirements during teaching rounds.

Attitude of Health Personnel↗

PubMed2006

Can Medicare billing claims data be used to assess mammography utilization among women ages 65 and older?

BACKGROUND: Medicare data may be a useful source for determining the utilization of mammography among elderly women, but the accuracy of these data has not been established. OBJECTIVE: We determined whether Medicare physician billing claims are an accurate reflection of mammography utilization among women ages 65 and older and whether they can be used to assess the use of screening as compared with diagnostic mammography. DATA SOURCES: Mammography use was assessed using Medicare billing claims and radiology reports from 2 mammography registries; the San Francisco Mammography Registry and the New Mexico Mammography Registry. METHODS: Completeness of the Medicare data was assessed by comparing mammography use based on Medicare, with radiology reports from the mammography registries, which served as the referent standard. Capture rates for Medicare claims for individual mammograms were examined, and women were characterized as having undergone at least 1 mammogram within each 2-year period based on the Medicare data, and these rates were compared with the referent standard. To determine whether Medicare data can distinguish between screening and diagnostic mammography, we performed a classification analysis using the mammography registries screening/diagnostic designation as the referent standard (dependent variable) and Medicare claim information as the independent/predictor variable. On the basis of the mammogram level classification analysis, women were categorized as having been frequently screened (at least 2 screening mammograms spaced by 12 to 36 months), screened (at least 1 screening mammogram), or not screened. SUBJECTS: Women ages 65 and older, diagnosed with breast cancer between 1992-1999, who had at least 1 mammogram between 1992-1999 were examined. RESULTS: A total of 3340 mammograms were obtained in 1371 women between 1992 and 1999. Overall, 83% of mammograms obtained by these women had a corresponding billing claim in Medicare. This increased from 65% in 1992 to 90% in 1999. Of women who underwent at least 1 mammogram during each 2-year period per the referent standard, 94% of women were accurately classified by Medicare claims as also having undergone mammography during the same 2-year period. In multivariable analysis, a mammogram was more likely to be associated with a billing claim over time, for women 80 years or older, and for white and Asian as compared with Hispanic women. Neither socioeconomic status nor screening/diagnostic designation affected the likelihood that a mammogram would be associated with a billing claim. The Medicare data accurately categorized a given mammogram as screening or diagnostic for 87.5% of mammograms. Lastly, there was moderate to substantial agreement in the categorization of women as frequently screened, screened or not screened between the 2 data sets (weighted kappa 0.74, 95% confidence interval 0.70-0.78). CONCLUSION: Medicare administrative claims are reliable for assessment of mammography utilization and have become more accurate over time. Medicare claims data also provide a mechanism for designating mammography as screening or diagnostic, which subsequently may allow accurate description of a woman's screening history.

Age Distribution↗

PubMed2005

Does the use of standardized history and physical forms improve billable income and resident physician awareness of billing codes?

OBJECTIVES: Resident physician knowledge of financial reimbursement guidelines for patient encounters is limited. We determined whether the use of standardized history and physical examination forms by residents for hospital admissions plus a brief lecture would increase the level of billing codes, increase billable income, and increase resident awareness of billing guidelines. METHODS: Residents used history and physical examination forms after a brief documentation lecture. Pretrial and posttrial surveys measured awareness of billing guidelines. The admission billing codes for a 6-month period were obtained, and the percentages were compared with a control 6-month period. RESULTS: There was an absolute increase of 14.5% in the highest code between the two study periods (P < 0.0001). Billable income increased by $10,385. Resident documentation awareness also increased (P < 0.001). CONCLUSIONS: The use of history and physical examination forms, combined with a brief lecture, significantly increased the percentage of highest billing codes, which increased billable income. Resident awareness of documentation requirements significantly improved.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2003

Reducing trauma payment denials with computerized collaborative billing.

BACKGROUND: Trauma care demands constant physician availability, resulting in rotational coverage systems. Third-party payors consider separate trauma surgeon bills as originating from the same individual. Trauma surgeons may be unaware of their colleagues' billing history on jointly managed patients. Not all postoperative procedures and evaluation and management services are denied by global surgical package rules. We investigated whether a networked billing program designed to crosscheck for global package coding concerns would reduce payment denials. METHODS: A networked relational database was created for trauma surgeons to enter billable encounters, displaying global periods and operative diagnoses while prompting for postoperative modifiers. Denials were compared for equivalent time periods before and after program initiation. RESULTS: Payment denials fell from 361 to 16 for "bundled" evaluation and management services and from 55 to 13 for bundled postoperative procedures. Time spent on billing decreased and legibility improved. Overall savings totaled $183,404. CONCLUSION: Collaborative billing can improve payments for professional trauma care.

Forms and Records Control↗

PubMed2001

Bill morphology reflects female independence from male parental help.

The study of territorial polygyny in birds has been influential in the development of the theory of social mating systems. Alternative female mating options have been studied within the framework of the polygyny-threshold model and later as the outcome of conflicts of interest between individuals. However, little attention has been given to variations between individual females, and how this affects their mating behaviour. Here, we test the hypothesis that some females are better adapted to raise nestlings without male assistance, and thus to mate polygynously. Specifically, we investigate whether intraspecific variation in female bill morphology is related to mating behaviour. This hypothesis is derived from earlier studies showing that, in both intra- and interspecific comparisons, uniparental care by females is correlated with the catching of larger prey items than when both parents provision the young. Using the polygynous dusky warbler (Phylloscopus fuscatus) as a model species, we found that, in accordance with our prediction, females with deep bills were more likely to mate as a secondary female. Moreover, regardless of mating status, females with deep bills settled in territories with more food and they received less male assistance in feeding their offspring. We argue that females with stronger bills are better adapted to exploit the abundance of large food items in rich territories and thus to raise young on their own. Our results demonstrate the importance of studying variations between individual females, and provide evidence for an extended version of the 'constrained-female hypothesis'. As bill depth is a highly heritable trait, our study strongly suggests that variation in female mating behaviour is not only related to ecological factors and female condition (as shown elsewhere) but also to heritable morphological traits.

Animals↗

PubMed2005

Is there value in using physician billing claims along with other administrative health care data to document the burden of adolescent injury? An exploratory investigation with comparison to self-reports in Ontario, Canada.

BACKGROUND: Administrative health care databases may be particularly useful for injury surveillance, given that they are population-based, readily available, and relatively complete. Surveillance based on administrative data, though, is often restricted to injuries that result in hospitalization. Adding physician billing data to administrative data-based surveillance efforts may improve comprehensiveness, but the feasibility of such an approach has rarely been examined. It is also not clear how injury surveillance information obtained using administrative health care databases compares with that obtained using self-report surveys. This study explored the value of using physician billing data along with hospitalization data for the surveillance of adolescent injuries in Ontario, Canada. We aimed i) to document the burden of adolescent injury using administrative health care data, focusing on the relative contribution of physician billing information; and ii) to explore data quality issues by directly comparing adolescent injuries identified in administrative and self-report data. METHODS: The sample included adolescents aged 12 to 19 years who participated in the 1996-1997 cross-sectional Ontario Health Survey, and whose survey responses were linked to administrative health care datasets (N = 2067). Descriptive analysis was used to document the burden of injuries as a proportion of all physician care by gender and location of care, and to examine the distribution of both administratively-defined and self-reported activity-limiting injuries according to demographic characteristics. Administratively-defined and self-reported injuries were also directly compared at the individual level. RESULTS: Approximately 10% of physician care for the sample was identified as injury-related. While 18.8% of adolescents had self-reported injury in the previous year, 25.0% had documented administratively-defined injury. The distribution of injuries according to demographic characteristics was similar across data sources, but congruence was low at the individual level. Possible reasons for discrepancies between the data sources included recall errors in the survey data and errors in the physician billing data algorithm. CONCLUSION: If further validated, physician billing data could be used along with hospital inpatient data to make an important and unique contribution to adolescent injury surveillance. The limitations inherent in different datasets highlight the need to continue rely on multiple information sources for complete injury surveillance information.

Activities of Daily Living↗

PubMed2001

What if pediatric residents could bill for their outpatient services?

OBJECTIVE: We prospectively studied the potential of billing and coding practices of pediatric residents in outpatient clinics and extrapolated our results to assess the financial implications of billing inaccuracies. Using Medicare as a common measure of "currency," we also used the relative value unit (RVU) and ambulatory payment class methodologies as means of assessing the productivity and financial value of resident-staffed pediatric clinics. METHODS: Residents were asked to submit voluntarily shadow billing forms and documentation of outpatient clinic visits. Documentation of work was assessed by a blinded reviewer, and current procedure terminology evaluation and management codes were assigned. Comparisons between resident codes and calculated codes were made. Financial implications of physician productivity were calculated in terms of dollar amounts and RVUs. Resource intensity was measured using the ambulatory payment class methodology. RESULTS: A total of 344 charts were reviewed. Coding agreement for health maintenance visits was 86%, whereas agreement for acute care visits was 38%. Eighty-three percent of coding disagreement in the latter group was resulting from undercoding by residents. Errors accounted for a 4.79% difference in potential reimbursement for all visit types and a 19.10% difference for acute care visits. No significant differences in shadow billing discrepancies were found between different levels of training. Residents were predicted to generate $67 230, $87 593, and $96 072 in Medicare revenue in the outpatient clinic setting during each successive year of training. On average, residents generated 1.17 +/- 0.01 and 0.81 +/- 0.02 work RVUs for each health maintenance visit and office visit, respectively. Annual productivity from outpatient clinic settings was estimated at 548, 735, and 893 work RVUs in the postgraduate levels 1, 2, and 3, respectively. CONCLUSION: When pediatric residents are not trained adequately in proper coding practices, the potential for billing discrepancies is high and potential reimbursement differences may be substantial. Discussion of financial issues should be considered in curriculum development.

Accounting↗

PubMed2006

Using billing data to describe patterns in asthma-related emergency department visits in children.

OBJECTIVES: To describe the development and evaluation of a pilot emergency department (ED)-based asthma surveillance system for childhood asthma visits based on billing data and to illustrate how the data can be used to document trends and patterns in ED visits for asthma in children. METHODS: During 2001 and 2002, aggregate reports based on ED billing data from 3 hospitals in western Michigan were obtained from a single physician billing company. Data were tabulated and graphed to show trends in the monthly number of ED visits for asthma in children. Comparisons were made by age, gender, and site. We evaluated the system by using established guidelines. RESULTS: The data illustrated strong seasonal trends, as well as marked differences in ED use according to age and gender. The total numbers of asthma ED visits were remarkably similar between the 2 years evaluated; however, the timing and duration of the seasonal peaks differed. Our evaluation of the system found that it met many of the characteristics that define successful surveillance systems, including simplicity, flexibility, acceptability, sensitivity and positive predictive value, timeliness, and stability. However, the surveillance system's representativeness was limited by the inability to calculate valid population-based ED-visit rates. Despite this limitation, the data provided useful information by documenting the burden and demographic profile of children who use the ED for asthma care and in identifying seasonal and time-related trends. CONCLUSIONS: We were able to successfully implement a pilot ED-based surveillance system for childhood asthma visits by using billing data. This system promotes the understanding of the burden of asthma among children visiting the ED. The development of an ED-based surveillance system for childhood asthma visits using billing data is recommended, particularly when there is a desire to understand the characteristics of children with asthma who use the ED and/or a need to understand the impact of local asthma quality-improvement programs.

Adolescent↗

PubMed2004

Gun control law (Bill C-17), suicide, and homicide in Canada.

Canadian Bill C-17 was implemented in 1991 to restrict the use of firearms, providing a chance to investigate the effect of firearm control laws in the use of firearms for suicide and homicide. Following Lester and Leenaars' comprehensive studies, the present study examined the use of firearms for suicide and homicide during the period prior to the bill and during the period after the passing of Bill C-17 to assess the association of the bill with rates of suicide and homicide by method. Analysis showed a significant decrease after passage of Bill C-17 in the rates of suicides and homicides involving firearms and the percentage of suicides using firearms. The analysis provides support for the position that restricting the availability of firearms as a lethal means of committing suicide and homicide may help reduce the numbers of suicides and homicides.

Canada↗

PubMed1989

Focus groups improve billing practices, patient relations.

The billing process plays a key role in maintaining good patient relations. Recognizing this, one California hospital conducted focus groups to discover how recently discharged patients viewed its billing process. The former patients gave patient accounts staff high marks, but found the bills themselves difficult to understand. Another source of irritation was receiving separate bills from outside specialists for treatment provided in-house. The hospital is using the participants' suggestions to enhance its billing process.

Accounting↗

PubMed2003

The decline in bulk-billing and increase in out-of-pocket costs for general practice consultations in rural areas of Australia, 1995-2001.

OBJECTIVE: To describe the changes in bulk-billing and out-of-pocket costs for Australian general practice consultations over the period 1995-2001. DESIGN: Retrospective analysis of 1996-2001 survey data from the Australian Longitudinal Study on Women's Health (ALSWH), linked with Medicare and Department of Veterans' Affairs (DVA) data on general practice consultations from 1995 to 2001. PARTICIPANTS: 22 633 women who gave consent to linkage of their ALSWH data with Medicare/DVA records. In 1996, women in the "young" cohort (n = 6219) were aged 18-23 years, those in the "mid-age" cohort (n = 8883) were aged 45-50 years, and those in the "older" cohort (n = 7531) were aged 70-75 years. OUTCOME MEASURES: Out-of-pocket costs paid by patients for general practice consultations, by calendar year, urban/rural area of residence, age, frequency of attendance, self-rated health, and education level. RESULTS: For each age group and year studied, the use of bulk-billing was lower in rural areas than in urban areas. For example, in 2000, the percentage of women in rural and urban areas, respectively, who had all their general practice consultations bulk-billed was 31% v 52% (young women), 24% v 45% (mid-age women) and 58% v 79% (older women). There has been a steady decline in bulk-billing for general practice consultations in rural areas since 1995. The average out-of-pocket cost per consultation for women in rural areas was higher than the cost for women living in urban areas. After adjusting for age, health and socioeconomic factors, women living in urban areas were more than twice as likely to have all their consultations bulk-billed as women living in rural areas: odds ratio (OR), 2.4 (95% CI, 2.1-2.7) (young women); OR, 2.5 (95% CI, 2.3-2.8) (mid-age women); OR, 2.6 (95% CI, 2.3-2.9) (older women). CONCLUSIONS: In Australia, the geographic differential in the cost of general practice consultations is widening. Policy changes are required to enable women in rural and remote areas to have access to affordable healthcare services.

Adult↗

PubMed2004

Tough trade-offs: medical bills, family finances and access to care.

About 20 million American families-representing 43 million people-reported problems paying medical bills in 2003, according to a new study by the Center for Studying Health System Change (HSC). While uninsured families are more likely to have medical bill problems, two-thirds of families with problems paying medical bills have health insurance coverage. Of all families with medical bill problems, almost two-thirds reported difficulty paying for other basic necessities-rent, mortgage payments, transportation or food-as a result of medical debt. People in families with medical bill problems also reported much greater trouble getting care because of cost concerns-one in three did not get a prescription drug, one in four delayed care and one in eight went without needed care.

Bankruptcy↗