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Addressing Medical Billing Challenges in Public Health. CPT Code 96372 ICD-9 Code V25.49 HCPCS Code J1055. Northwest Partnership for Public Health. Also called the Northwest Incubator Group of 10 county health departments Innovative projects for the betterment of public health
CPT Code 96372 ICD-9 Code V25.49 HCPCS Code J1055
Lack of emphasis on revenue generation
Increases in numbers of patients/decreases in funding
Correct coding and medical billing practices a must for Health Departments
Ashe County Health Department
Alleghany County Health Department
Pt had a Pap smear
Pt was charged for a Pap smear
Procedure codes charged
Procedure codes were correctly used
Pap smear charged & also performed
Additional codes that could have been charged including codes missing from the encounter form
A Pap smear was done but it was not on the encounter form and the provider did not write it in
Companion codes and modifiers that could have been charged and would increasereimbursement
A Pap smear was done & sent to an outside lab but the additional specimen handling code was not charged
A Pap Smear was done but the physician’s order wasn’t documented
*Limited number of patients served
*Cuts in programs and services
*Decreased monies from Federal, State and Local Agencies.
*Increase Medicaid, third party insurance and private dollars
*Outdated CPT Codes and/or Encounter Forms
*Pay-back of Medicaid/Insurance dollars
*Improperly trained staff
“Fees shall be based upon a plan
Recommended by the local Health
Director and approved by the local
Board of Health and the appropriate
County Board or Boards of
Mike Reavis, Yadkin CountyHealthDirector
The healthcare industry in the US:
$2 trillion industry
Third party insurers pay out $700 billion
Medicare and Medicaid make annual payments of $1 trillion
Annual revenue of $1.5 trillion for care providers
Information provided by First Research, a sales consulting firm.
Thus, medical coding may be said to be the biggest success factor for any medical office. Doing it correctly can mean the stability of your business. Doing it incorrectly could mean the downfall of your practice.
Hundreds of millions of dollars are lost annually due to medical billing errors.
The national trend for fixing these issues consists of:
Having a coding/billing specialist in house that stays up to date with current changes in Medicare, Medicaid and third party billing requirements.
Larger corporations hire a regional coder that is responsible for training and billing compliance for more than one office.
Outsourcing to a medical billing and coding company that are often located offshore.
Currently there are 3 Health Departments close to the Northwest that have “coders”: Cabarrus, Guilford and Mecklenburg
Otherwise, NC health departments use state consultants. Each consultant has anywhere from twenty to twenty-five counties and are responsible for:
Accreditation Policy and Procedures
CPT coding audits and training
Support in improving efficiencies
Generalized nursing consultations
Clinical experts for the new HIS system
They are extremely valuable resource. However, they have limited time to help with individual health departments.
Not as able to help with third party billing and insurance credentialing.
Are diverse and cross over county and state lines and even into the private sector
Partners take the form of local, regional and state level personnel, primarily in public service agencies
Health Directors, health department staff, Boards of Health and County Commissioners form the backbone of our support
Their support helps:
The medical billing consultant provide valuable coding training;
Health departments will provide public health training
Our of state partners who are a valuable asset to the LHD will be the Nurse and Administrative Consultants
The medical billing consultant will share the burden for coding questions
Our partners would be interested in participating in this plan because:
We offer a trained and knowledgeable professional
Work loads are decreased
Potential payback situations are decreased
Creates less dependency on grant monies
Numerous competitors in our business:
Other consulting firms
Using only the “Goggle” search engine for organizations in NC:
1,170,00 hits for Public Health Medical Billing Consultant
73,700 hits for Public Health Medical Coder Consultant
1,180,000 hits for Public Health Medical Coder
Five Organizations offering services similar to project:
TCN, The Coding Network in Beverly Hills, CA
Medical Coding Services, LLC in Pendleton, IN
Healthcare Business Consultants in Asheville, NC
Healthcare Management & Consulting in Bay Shore, NY
Health Care Economics in Indianapolis, IN
Of these five organizations, Healthcare Business Consultants offers consulting advice but it does not have public health expertise nor does it list it’s prices.
Make initial contacts; NWPPH will vote to approve business plan
March 2009—July 2009
Collect information, write job description
Obtain approval of job description
Conduct interview; make offer to qualified candidate
Initiate hiring process and public health orientation
Audits of pilot counties
Conduct 1 to 2 pre- & post-evaluations
December 2009—February 2010
Audit results to counties and formulate strategy
Contracts, technical assistance, evaluations and other services would be added as needed
$51,000 - $28,000 = $23,000
(Projected Operating Expenses) - (Base Rate) = (Amount needed)
Surry County = $3,394,072 Northwest Counties = $7,683,968
$3,394,072 / $7,683,968 = 44%
44% x $23,000 = $10,120
Surry County pays: $4,000 + $10,120 = $14,120
Front Row (L-R): Jan White (Surry), Trish Belton (Yadkin), Candice DuVernois (NWPPH)
Back Row (L-R): Inge Leonard (Davidson), Samantha Ange (Surry), Debbie Widener (NWPPH)