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Physical Therapy Billing Software | Scalability Is The Word

Physical Therapy Billing Software

Running a single clinic, several clinics, or many hundreds of clinics. Centralized or federated model. Options are many. Question is does your EMR and more specifically your physical therapy billing system scale to meet your needs?

In a federated setup, individual locations may bill a certain set of payers while the corporate office may bill some payers centrally. Does your billing software have the flexibility to handle the variations and complexity and automatically route claims appropriately?

Let us take a closer look at the physical therapy billing process itself.

Charge generation – where it all begins

Daily notes play a key role in charge generation. There are two parts, the flowsheet and the SOAP note.

  • The flowsheet itself would consist of a list of interventions and exercises along with the corresponding CPT codes. It would enable you to copy forward exercises, interventions, and charges from previous visits.
  • On the flowsheet, activities performed on the previous visit would be automatically checked off. Therapists could select/unselect exercises, increase/decrease sets/reps, or otherwise update exercises and interventions as well as the daily SOAP note.
  • The other component of the daily note is the SOAP note. The daily SOAP would enable you to roll forward the previous SOAP note.
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Charge generation would be a natural outcome of the documentation, therapists should not have to do that as an independent activity. The system would utilize the time at the activity level along with rules predefined for the payer.

  • All the provider would need to do is to select the intervention, note the time taken if it is a time based code, and other modalities if used (like hot pack/cold pack, for example).
  • When the flowsheet is saved, the system would automatically generate charges. While listing charges, the system would automatically itemize the correct number of units for time-based codes, along with modifiers like GP, KX, or 59 modifiers.
  • System warnings would help direct attention to items that need a fixing. Some codes may not be supported by the patient’s payer class. These could be documented but no charges would be generated.
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So, charge generation and rules would happen automatically at the point of documentation. The flowsheet and SOAP should empower you to make better decisions at the point of care.

Peeling back the layers in the billing system

The billing rule engine is structured like a pyramid. There are three layers.

Layer 1: Master Fee List

At the base is the master fee list, which is every CPT code available in the system. You could start with preloaded codes that were set up for your practice. These could be updated anytime while the system would get updated based on major changes with CPT codes that get released from payers. Properties at the fee level would include if the code is time-based or not, if the code would count in productivity, if reports would calculate units per visit/charges per visit, to name a few.

It is possible that some CPT codes being offered would not be billed on the insurance claim form. Examples would be selling over the counter goods and massage packages, these charges would go directly to the patient responsibility.

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Layer 2: Fee classes

Above the master list of CPT codes in the pyramid would be the master fee list or fee classes. Out of the master set of codes available in the system, fee classes would define the subset of codes that the payer class would reimburse and their applicable date ranges. Default modifiers in fee classes, number of units, and number of minutes would also be set. Besides the codes that are permitted by payers, the codes that are actually being charged would also be defined.

In the fee schedules, setting gross charge amounts and contracted charge amounts for a payer class would feed into reports like expected amounts for the payer class vs. gross amounts. When Medicare patients go over their therapy cap limit, the system would automatically apply KX modifiers. Contracted amounts would also be used in EOB and ERA postings that itemize charge amounts, contracted amounts, and what the payer paid. That would help verify if you are getting paid what you are supposed to be paid.

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Layer 3: Payer rules

At the top of the pyramid would be payer specific rules. Does the insurance require authorization? Or prescriptions? Which 8 minute rule does the payer follow? Other attributes could include per diem contract or not, enforcement of payment modifiers and progress notes, if certifications are required to lock the note, and when progress notes become due. Place of service code and modifiers for telehealth would complete the set. Hover over image to see more detailPhysical Therapy Billing Software

Ensuring clean claims that are not delayed or denied

Over to charge review and charge/claim scrubbing.

  • The charge review report would highlight things that could cause rejections like charges that are missing an appointment, authorizations, or diagnosis pointers, Medicare patients over the Medicare cap, and eval appointments missing eval codes.
  • Issues like missing diagnosis pointers could be fixed at the backend. Billers could also send charges back to the provider to have them correct data for the encounter. Anything over a typical 3-4 units per visit would be highlighted. The idea is to make sure that charges are as clean as possible before creating claims.
  • The create claims process would bill all unbilled charges based on filters that are set (by account type, by provider, by patients, charges for signed off documentation etc.) to create a batch of claims.
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The billing entity filter would play a key role in federated setups. Some contracts could be billed locally and some billed centrally in the case of a group of provider locations like owned clinics or franchises. If responsibilities for billing out claims are spread out between own billing teams at the location level and corporate billing teams, this filter would help specify which claims are being billed out where.

The next step would be to run claims through a final check before sending them to the clearing house.

  • Processing claims through a scrubbing rule would validate them and would turn up red or green flags. Greens and reds could be split into separate batches with the green claims being sent out, keeping cash flow healthy.
  • Issues in an individual claims batch like missing diagnosis pointers or missing authorization numbers could be analyzed.
  • While previewing how the claim looks like on a HIPAA form, you could make necessary changes that would change the flag from red to green. Eventually, turning the entire batch green.
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Turning claims into cash flows

This is where you would send claims to the clearing house and initiate collections follow-up.

  • Tasks could be added for billers or collection agents to follow up on claims if not paid in a certain amount of time. This would add work tickets for each individual claim in the batch to follow up on outstanding amounts at a set frequency.
  • Expected collection timeframes would appear in a specialized dashboard for billers to coordinate follow up on outstanding claims. Claims status information would be automatically pulled in from the clearing house, extracting all information needed by the biller to follow up in just one click.
  • Notes could be added each time a follow up action is performed like a phone call. This would provide a structured way to close out on outstanding claims while documenting the efforts and process.
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Posting monies, ERAs, and EOBs is where the rubber hits the road.

  • Most insurance carriers would provide automated ERA postings. These would be directly pulled into the system.
  • When posting or allocating the money, all transactions and adjustments could be read along with explanations. Essentially, the system would read the ERA file and provide a visualization of how it is transferring the money.
  • It would be possible to override amounts in the ERA like an insurance write-off along with notes on why the override was done before going ahead and posting selected payments and transfers. Updates could also be made after the fact in the future.
  • Patient payments would be automatically adjusted against an available patient balance pool that was collected upfront.
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When creating patient statements and invoices, there are several options. Handle them yourself. Send them to the patient portal. Or to a print service.

  • You could design how statements would look and control what types of patient statements or invoices are being created like statements for patients with unpaid patient responsibilities, for example.
  • Creating a batch of patient statements would follow a process similar to the claims process. Delivery methods could be set for each batch of patient statements like electronic (patient portal) or paper (print on paper).
  • Patients who have signed up for the patient portal would receive a text message and email notification informing them they have a balance available online. They can login to the portal and make payments.
  • Statements could be printed just for patients who have not signed up for the portal. The integration with the external print service would provide “one click” print capabilities.
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Reporting is where we would close the loop with several reporting tools and categories. Audit reports and logs. Billing reports. Reports by department: Owner (top level productivity), Marketing, Financial. Facility summary reports. Raw collections by posting. Provider level productivity reports that would only include charges that count in productivity. Reports added to favorites could be accessed from the dashboard. Inbuilt links would directly navigate to the patient’s ledger or claims pages. The ledger would present a detailed view of charges and transactions. Hover over image to see more detailPhysical Therapy Billing Software

Billing is clearly a complex process with several variables and tasks. You should be able to establish the processes and tasks that make sense for you. Flexibility and scalability would carry the day. How flexible and scalable is your current EMR?