Physiatry sits at the nexus of several medical specialties, interweaving neurology, orthopedics, and pain management to recover function and improve quality of life. It is the specialty’s most significant advantage, yet it also produces a vexingly difficult environment for billing.
In contrast to more linear specialties, physiatrist practices must navigate a complex maze of codes, document intricate care plans, and defend treatments that often combine therapies, procedures, and durable medical equipment. An AMA study even found that physicians end up spending 12 hours a week on prior authorization alone.
Mastering physiatry medical billing‘s subtle complexity is a crucial aspect of your practice’s sustainability. Inefficiencies or inaccuracies can result in claim denials, revenue loss, and risk of non-compliance, which ultimately take attention and resources away from patient care. For physiatrist practices to succeed, they need to craft a solid plan to overcome these intrinsic complexities.
The Challenge of Coding a Holistic Treatment Plan
A physiatrist does not address a single, discrete problem; a patient with a stroke, for example, may need diagnostic testing, therapeutic injection, management of spasticity, and a prescription for an appliance, all managed under one physician. This all-encompassing treatment poses a considerable challenge to medical billing.
The fundamental problem is to accurately capture the entire range of care through standardized CPT and ICD-10 codes. It calls for a profound knowledge of not only the codes themselves but also their context.
Coders should be aware of when it’s the right time to apply modifiers and how to tie specific diagnosis codes to a particular procedure to create clear medical necessity. A mistake in this complicated step can easily lead to a denial, with payers doubting the legitimacy of delivering various services in the same visit.
Interventional Procedures: A High-Stakes Environment
Most physiatrist practices provide a wide range of interventional services, including epidural steroid injections, facet joint injections, nerve blocks, and radiofrequency ablation. These are high reimbursements but, in turn, are reviewed very aggressively by payers.
The intricacy in this instance is two-fold. One, coding needs to be accurate. The accurate code for the correct anatomical site, the imaging guidance used (fluoroscopy or ultrasound), and the agent injected are of the utmost importance. One little error, like typing lumbar when the procedure was cervical, for instance, is a red flag right away.
Second, and no less significant, is the documentation. Payers have stringent and sometimes complex policies around the medical necessity of these procedures. Your documentation needs to put it all together and provide a clear picture of the patient’s history, including treatments tried and failed, the functional impairment the patient is experiencing, and a thorough procedural report. Without this solid supporting documentation, even a flawlessly coded claim is apt to be denied upon examination.
Medical Billing for Therapy Services and DME
Physiatry is linked inseparably to occupational and physical therapy. Although these services are essential to patient recovery, they also have their own rules regarding medical billing. Therapy is often billed with timed codes, which means that close monitoring of the minutes devoted to each particular modality is necessary. In addition, payers often place restrictions or “caps” on the number of therapy visits for which they will pay, requiring an active process to monitor authorizations and inform patients about their benefits.
Adding yet another layer of complexity is the supply of Durable Medical Equipment (DME) like braces, orthotics, and TENS units. Billed under its own group of HCPCS (Healthcare Common Procedure Coding System) codes, DME billing in many jurisdictions demands the practice comply with certain supplier standards. Policies for payers of DME are famously strict, with specific documentation needed to justify the use of the prescribed equipment.
The Cornerstone of Success: Fastidious Documentation
If there is one golden principle in dealing with the medical billing intricacies of physiatrist practices, it is this: if it wasn’t written down, it wasn’t done. Documentation is the final defense against audits and the solution to turning denials around.
A complete, readable, and prompt note should document each patient visit. This note should simply state the patient’s subjective complaints, the physician’s objective findings, a complete assessment, and a concise plan of care.
For physiatry, it’s essential to emphasize functional improvement. Tracking improvement in a patient’s pain level, range of motion, and capacity to perform activities of daily living offers the tangible proof payers require to observe the value and necessity of continued treatment.
Proactive Strategies for Financial Health
It takes more than a reactive strategy to thrive in this complicated environment. Proactive strategies are key to success.
- Continuous Education: Did you know that the global medical billing outsourcing market is predicted to expand from $2.17 billion in 2021 to $13.56 billion in 2022 and $20.98 billion by 2026 and it is constantly evolving? Invest in continuous training of your providers and healthcare billing services staff so they will be up to date on current coding changes and payer policy revisions.
- Internal Audits: Don’t wait for a payor to audit you. Routinely perform internal chart audits to find areas of potential weakness in your coding and documentation. This gives you a chance to fix problems before they result in expensive denials or take-backs.
- Strong Payer Relationships: Establish open communication lines with your large payers. Knowing their specific policies and having assigned contacts can facilitate the resolution of issues more quickly.
Finally, the ultimate aim of streamlining your medical billing process is to develop a system as strong and well-orchestrated as your physiatry clinical care. Through investment in expertise, in-house or outsourcing to skilled billing professionals, making documentation a priority, and taking a proactive approach, physiatrist practices can safely cope with these complexities, securing their financial integrity and enabling them to stay focused on the all-critical work of restoring patient function and hope.
