Clinical, Financial and Administrative Insights For Physicians

8 Hidden Revenue Opportunities for Physician Practices

Posted by Alok Prasad


Even despite auditor scrutiny, decreasing reimbursements, and more stringent regulatory requirements, physician practices do have opportunities to enhance revenue if they look hard enough to find them, according to a recent article published in Medical Economics. Rather than lament the regulations and requirements that physicians can’t likely change, they should instead focus their attention on how to make the most of new opportunities that could yield additional revenue. This article highlights eight revenue-generating areas to which physicians should devote more time and consideration.

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1. Chronic care management (CCM)

New Current Procedural Terminology (CPT) code 99490 allows physicians to bill for the time they spend developing a plan for, and managing the care of, patients with two or more chronic, potentially Save_Money_with_EHRlife-threatening conditions. CMS will allow approximately $42 for code 99490. To bill this code, physicians or their clinical staff members must spend at least 20 minutes performing the CCM service. For CCM payment in 2015, physicians must use EHR technology certified to either the 2011 or 2014 edition(s) of certification criteria.

2. Telemedicine

Coverage for telemedicine services continues to expand, and practices that haven’t yet ventured into this realm of medicine may want to consider doing so. The 2015 Physician Fee Schedule now includes the following codes to capture these services:

  • Psychoanalysis (CPT codes 90485, 90846 and 90847)
  • Prolonged evaluation and management services requiring direct patient contact (CPT codes 99354)
  • Annual wellness visit (HCPCS codes G0438 and GO439)

3. Digital mammography

Medicare now pays for 3D mammography when providers reporting it using add-on codes in addition to the 2D mammography codes when 3D mammography is furnished.

According to Medlearn Matters article MM8874, “Effective January 1, 2015, HCPCS code 77063 (Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)), must be billed in conjunction with the screening mammography HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views, 2D imaging only.”

Providers must bill code 77063 with ICD-9-CM code V76.11 or V76.12. When ICD-10-CM goes into effect on October 1, 2015, providers must report ICD-10-CM code Z12.31 to ensure payment.

4. Transition care management

Many physicians don’t realize that they’re able to bill for face-to-face visits with patients within 14 days of discharge from an inpatient facility. The appropriate code is either 99495 (transition care management with moderate complexity medical decision making) or 99496 (transition care management with high complexity medical decision making). Providers must also communicate via phone call, email exchange, or face-to-face visit) with the patient or caregiver within two business days of discharge. The American Academy of Family Physicians provides a helpful Q&A about transition care management. It also provides a transition care management 30-day worksheet.

5. Prolonged services

Providers may also not realize that they can bill for prolonged services in the office or other outpatient setting. These services require direct contact and must go beyond the usual service. Report code 99354 for the first hour and 99355 for each additional 30 minutes. These codes must be reported in additional to the code for the office or other outpatient evaluation and management service.

6. Labs and ancillary services

These services are frequently overlooked and often missed in terms of revenue capture. Many physicians give verbal orders for patients who require onsite labs and other ancillary services. As a result, the order may not be documented appropriately or at all. Ensure that lab technicians maintain a detailed record of all lab services performed so coders can capture charges appropriately.

7. Injections

Injections may also be overlooked and thus under-reimbursed. Coders must report a CPT code for the administration/injection itself as well as a HCPCS code for the drug/medication. Units of service are important when determining the correct codes.

8. Modifiers

Modifiers can often make or break a payment, and it’s important to append them correctly. Ensure that coders understand when and how to report the following modifiers:

  • -24: Unrelated evaluation and management service by the same physician during a postoperative period
  • -25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
  • -53: Discontinued procedure
  • -59: Distinct procedural service

Note that Appendix A of the CPT Manual includes detailed descriptions of these an all other modifiers.


Thinking positively

It’s important for practices to take advantage of new and existing revenue opportunities as well as ensure closer oversight of their billing practices in general. By doing so, practices may be pleasantly surprised at the efficiencies they can gain, and the amount of revenue that they can recover.


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RevenueXL Inc. provides best value comprehensive solutions to medical practices. Our solutions include affordable Electronic Medical Records Software (a.k.a. EMR or EHR Software), Patient Portal, and Practice Management or Medical Billing software and revenue cycle services including medical billing, medical coding, coding audits and account receivables management services. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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