February 15, 2024 by AMS Solutions 0 Comments

Key Performance Indicators (KPIs) within the healthcare revenue cycle play a vital role in monitoring financial well-being and optimizing revenue capture for physician practices, clinics, hospitals, integrated health systems and other entities when the goal is to provide financially sustainable, high-quality, cost-effective care—especially in rural America. 

The most valuable insight provided when monitoring your revenue cycle KPIs frequently is to find opportunities for improvement, whether it is investing in education for your team, or — if KPIs are severely underperforming — identify that you urgently need professional revenue cycle management services

In our day to day, we use industry-standard metrics from the Healthcare Financial Management Association’s (HFMA’s) MAP Keys, which serve as benchmarks for excellence in the healthcare industry’s revenue cycle. Here are the top 5 KPIs that help us identify bottlenecks, make informed decisions, and implement effective strategies for continuous improvement in each one of our clients: 

Duration of Net Accounts Receivable 

The KPI focusing on net days in accounts receivable (A/R), stands as a barometer of efficiency within the revenue cycle. According to HFMA, providers calculate this KPI by dividing the net A/R by the average daily net patient service revenue.  

Determining the average daily net patient service revenue involves examining the most recent three-month daily average from the organization’s income statement.  

The higher the net days in A/R, the more unstable the revenue cycle. Industry leaders suggest keeping days in A/R below 50 days at a minimum, with 30 to 40 days being a more favorable range.

Expense of Collection

Another crucial metric in financial management is the cost-to-collect ratio. Which results from dividing the total revenue cycle cost, reflected in the income statement, by the total cash collected from patient services on the balance sheet and the results show the efficiency and effectiveness of revenue-related operations

The total patient service cash collected should comprise all payments posted to patient accounts for services rendered, including undistributed payments, bad debt recoveries, Medicare and Medicare payments. However, it excludes patient-related payments and settlements like capitation, DGME, Medicaid DSH, along with specific reporting requirements for net days in A/R. 

Industry benchmarks suggest that the standard cost-to-collect ratio typically ranges between 2 to 4% of net patient revenue. 

Clean Claim Rate

The clean claim rate represents the percentage of claims that successfully pass without requiring manual intervention, including all claims accepted into your claims processing tool for billing, with primary, secondary, and tertiary claims or all relevant 837 types.  

A high clean claim rate is vital for reducing claim denials and identifying areas for enhancement in claims management. It serves as an indicator of potential issues in patient data collection, timely claim submission, and coding accuracy within the revenue cycle. 

Healthcare organizations are encouraged to target a clean claim rate of 90% or higher, with some industry sources advocating for a standard of 95%. Achieving and maintaining such rates is fundamental for an efficient revenue cycle management and minimizing financial losses associated with claim denials.

Unrecoverable Debt

Healthcare organizations encounter bad debt when they are unable to secure payment for the care they provide. This is an affliction we see increasing, as higher levels of debt continue to rise with shifts in insurance dynamics and out-of-pocket expenses for medical services in underserved areas with low-income population. 

By dividing the bad debt by the gross patient service revenue, providers can gain insights into their ability to collect accounts and pinpoint payer sources contributing to revenue loss. Acceptable levels of bad debt vary based on the type of organization, with hospitals typically reporting higher levels compared to physician practices.

Percentage of Net Patient Service Revenue Collected in Cash

This KPI evaluates cash collection as a percentage of net patient services revenue measuring your organization’s financial well-being by assessing its revenue cycle’s efficiency in converting revenue to cash

This financial management KPI involves dividing the total cash collected from patient services by the average monthly net patient service revenue statement, offering valuable insights into an organization’s fiscal robustness. 

Ideally, if this metric reaches 100%, shows strong financial health and integrity in your organization. However, values falling within the range of 90 to 95% might indicate potential revenue leakage, requiring a further assessment.

AMS: Your Revenue Cycle Manager 

When your Revenue is on the line, AMS Solutions  can help. With over 30 years of experience, we are your full-service healthcare revenue cycle management partner. Schedule a Free Consultation with our team now! 

February 2, 2024 by AMS Solutions 0 Comments

We’re in the middle of deductible season: The time of year when most insurance plans reset deductibles back to $0 and in the meantime, patients are responsible for the full contracted rate of their sessions until they have finally met their set amounts. So, what exactly does this mean to your practice?

Deductible season lasts typically the first three to five months of the year, depending on your location, medical specialty and the patient volume you support. This can be really tough on medical providers for a couple of reasons: First, without insurance payments coming in, your practice’s income can take a hit at the beginning of the year. Second, patients will be receiving higher bills than usual and not all of them will feel prepared to pay these amounts, which can become a financial burden for your business if they go overdue on their balances.

Every healthcare provider can implement targeted strategies to navigate their unique challenges and the financial landscape of the season effectively, especially when you partner with a team that knows the ins and outs of Revenue cycle management to keep your practice in good financial health through these months. 

How to avoid delayed income during this time?

Up-to-date Documentation

As a medical provider, you must ensure that all chart notes and other paperwork requested are completed and sent to insurance companies on time, typically before the end of the previous year. This proactive approach ensures steady payments at the beginning of the deductible season and help your medical billing team keep a steady revenue flow more effectively.

Eligibility Check

Always check insurance eligibility for every patient, and this includes Medicare! Look for the following items when checking eligibility and verifying benefits:

  1. Does the patient have an active policy? What is the effective date of that policy?
  2. Does the patient have a co-pay, deductible, coinsurance, or an out-of-pocket maximum?
  3. Does the service you provide require a prior authorization or a referral?
  4. Does the patient have any secondary insurance?

Payment Collection

The easiest and most effective way to minimize the impact of deductible season, is to collect payments as accurately as possible at the time of service. Unless an insurer bars you from billing a patient (such as Medicaid).

Chances of collecting payments for deductible and co-insurance that apply to your service or co-pay balances drops 62% as soon as the patient walks out the front door according to the National Association of Healthcare Access.

Remember to always remind patients (verbally, in writing, or online) of their financial responsibility. Whether it is keeping insurance updated, patient contact information updated, and a friendly reminder that most insurers require the patient to pay the provider some portion of their bill – even Medicare.

Accessible Patient Support

One efficient solution is to offer patients the option to pay balances and submit billing questions online in real time, on their terms and not be limited by business hours or staff availability. This action not only modernizes and improves the patient’s experience but increases patient collection speeds, reduces paper statements and staffing costs while improving operational efficiency.

These strategies will help your medical practice keep a better cash flow during this deductible season. If you find yourself seeking a reliable partner to navigate these challenging times, contact us today for all-inclusive medical billing solutions tailored to your practice.

December 23, 2023 by AMS Solutions 0 Comments

An efficient revenue cycle process is the financial lifeline of any healthcare practice. It encompasses everything from patient registration to the final payment of a balance. In today’s rapidly evolving healthcare landscape, it’s crucial for medical practices to periodically review and refine this process. 

An effective review can identify inefficiencies, streamline operations, and ultimately lead to enhanced financial performance. Understanding and continuously improving the revenue cycle process is key to the success of healthcare providers. Let’s take a closer look at the revenue cycle process, and how it can be improved for your practice.

Understanding the Importance of the Revenue Cycle Process

At its core, the revenue cycle process in healthcare is a comprehensive approach to managing patient billing and payments. It begins when a patient first schedules an appointment and continues through to the collection of payments. This cycle includes patient registration, insurance verification, charge capture, claim submission, payment posting, and follow-up for denied claims or unpaid balances.

While it’s typically seen as back-office administrative work, and it is in many ways, it’s nonetheless one of the most critical components contributing to the overall health of any healthcare provider. A well-managed revenue cycle ensures that providers are reimbursed for their services in a timely and accurate manner. It also helps in maintaining a positive patient experience, as billing and payment processes are integral to patient satisfaction. With the increasing complexity of healthcare regulations and insurance policies, the efficiency of the revenue cycle process has become more important than ever.

Steps to Effectively Review Your Revenue Cycle Process

Reviewing your revenue cycle process effectively involves several key steps. Here are the most crucial ones:

  1. Conduct a Thorough Audit: Begin with a comprehensive audit of the entire revenue cycle. This should include assessing patient registration accuracy, billing processes, coding accuracy, and the efficiency of payment collections.
  2. Analyze Denials and Rejections: Understanding the reasons behind claim denials and rejections can provide valuable insights. Identifying common patterns can help in rectifying systemic issues.
  3. Evaluate Patient Payment Processes: Assess the methods and ease of patient payments. This includes examining billing clarity and the convenience of payment options offered to patients.
  4. Benchmark and Set Goals: Compare your processes with industry benchmarks. Set realistic improvement goals based on this analysis.
  5. Implement Process Improvements: Based on your findings, implement changes aimed at improving efficiency and accuracy. This might include staff training, software upgrades, or changes in workflow.

The Central Role of Medical Billings in the Revenue Cycle Process

Medical billing plays a key role in the revenue cycle process. It involves preparing and submitting claims to insurance companies and then following up on those claims to ensure payment is received. This stage is critical and directly impacts the revenue flow of a healthcare provider. Here are some factors that contribute to a lean cycle:

  • Accuracy in Coding: Accurate medical coding is vital to ensure claims are processed smoothly by insurance companies. Any errors can lead to claim rejections or denials, delaying revenue.
  • Timely Submission: Timely submission of claims is essential. Delays in submission can lead to delayed payments and affect the overall financial health of the practice.
  • Effective Follow-Up: Regular follow-up on submitted claims is necessary to address any issues promptly and ensure timely payment.

Trust AMS Solutions to Refine and Improve Your Revenue Cycle

Effectively reviewing and managing the revenue cycle process is essential for the financial health of any healthcare practice. Remember, an optimized revenue cycle process not only benefits the financial bottom line but also enhances patient satisfaction and trust in your healthcare services. Take the next step in your practice’s financial well-being, and contact AMS Solutions today.

December 9, 2023 by AMS Solutions 0 Comments

Healthcare is a complex and rapidly evolving field, and one of the most critical elements for any smoothly functioning medical practice is primary care billing and coding. These are the processes vital for making sure that services, treatments, and more are all billed accurately and efficiently, and have a direct impact on both revenue and patient satisfaction. AMS Solutions specializes in simplifying these intricate procedures, offering tailored services that cater to the unique needs of primary care providers. Let’s take a closer look.

What Is Primary Care Billing?

Primary care billing is a foundational, though highly complex, aspect of healthcare management, encompassing a range of services from routine check-ups to the management of chronic conditions. Unlike specialized medical billing, primary care billing deals with a broad spectrum of patient needs, requiring a diverse understanding of billing codes and insurance policies. At the heart of this process is the need for accuracy and promptness, ensuring that healthcare providers are reimbursed for their services without delay.

Effective primary care billing hinges on a deep comprehension of the latest billing guidelines and regulations. It’s not just about submitting claims; it’s about understanding the intricacies of insurance plans, patient eligibility, and the ever-evolving landscape of healthcare policies. This is where AMS Solutions shines, offering expertise and technology-driven solutions that streamline billing processes, reducing errors and enhancing overall efficiency.

Key Guidelines for Primary Care Coding

Primary care coding is a detailed and precise process that demands a thorough understanding of medical terminology and coding systems. This is where specific guidelines come into play, guiding primary care providers in accurately coding diagnoses and procedures. Making sure these codes are correctly applied is a major part of keeping reimbursement rates and compliance up to par. 

One of the key elements in primary care coding is the use of the International Classification of Diseases (ICD) codes, which must be updated regularly to reflect the latest medical findings and treatments. In addition, primary care practices must stay abreast of the Current Procedural Terminology (CPT) codes, which relate to the various medical, surgical, and diagnostic services offered. Staying informed and compliant with these coding standards is a demanding task, but it’s crucial for the financial health of any primary care practice.

Challenges in Primary Care Billing and Coding

Despite the best efforts of healthcare providers, primary care billing and coding can present several challenges. Common issues include:

  • Coding Errors: Misapplying codes is a frequent issue that can lead to claim rejections.
  • Undercoding and Overcoding: Undercoding results in lost revenue, while overcoding can trigger audits and lead to penalties.
  • Constantly Changing Regulations: Keeping up with these changes is crucial to ensure compliance and prevent legal issues. This requires ongoing training and updates, which can be resource-intensive.
  • Navigating Insurance Policies: Dealing with various insurance plans and understanding their specific policies and coverage limitations is a significant challenge.

Best Practices for Effective Billing and Coding

Adopting best practices in primary care billing and coding is essential for maintaining efficiency and accuracy. These include:

  • Regularly training staff on the latest coding updates.
  • Implementing thorough documentation practices.
  • Using advanced billing software for accuracy and efficiency.

These strategies help in minimizing errors and optimizing revenue.

Trust AMS Solutions to be Your Partner in Primary Care Billing and Coding

While the primary care billing and coding space can be complex for a small or medium-sized practice to effectively navigate, we make it simple and reliable. Our expertise ensures that your practice’s billing and coding are handled proficiently, freeing you to focus on patient care. Partner with AMS Solutions for seamless, efficient billing and coding solutions tailored to your practice’s needs. Reach out today to discuss your organization’s needs and to get started.

November 23, 2023 by AMS Solutions 0 Comments

Navigating the complexities of medical billing claims is a significant challenge for many small and mid-sized healthcare providers. Among these challenges, claim denials stand out as a particularly frustrating issue, often leading to delays in reimbursement and financial strain. These denials not only affect the financial health of medical practices but also impact patient satisfaction and trust. 

The foundation of lowering your organization’s denial rate is understanding why medical billing claims are denied, and then having actionable ways to fix those issues. In this post, we’ll look at the most common reasons behind claim denials and how AMS Solutions can help in effectively managing and reducing these occurrences.

Understanding Medical Billing Claim Denials

Medical billing claim denials can be a significant source of operational and financial inefficiency for healthcare providers. A claim denial occurs when an insurance company refuses to pay for a medical service, often due to errors or discrepancies in the billing process. These denials can happen for various reasons, ranging from simple administrative oversights to more complex issues like coding errors or misunderstandings about insurance coverage.

The frequency of claim denials in the healthcare industry is a major concern. Not only do they lead to delayed or lost revenue, but they also require additional resources to rectify. This can create a cycle of administrative burden, diverting attention from patient care to paperwork. Understanding these denials’ root causes is the first step in developing strategies to minimize them, ultimately leading to a more efficient and financially stable healthcare practice.

The Most Common Reasons for Medical Billing Claim Denials

Identifying the primary causes of medical billing claim denials is crucial for any healthcare provider looking to improve their billing processes. Here are some of the most common reasons for these denials:

  • Coding Errors: Incorrect or outdated procedures and diagnosis codes can lead to denials. These errors may stem from simple data entry mistakes or a lack of understanding of the latest coding standards.
  • Incomplete Patient Information: Missing or inaccurate patient details, such as name, date of birth, or insurance policy numbers, can result in a claim being rejected.
  • Service Not Covered by Insurer: Sometimes, a claim is denied because the service provided is not covered under the patient’s current insurance plan. This often occurs due to misunderstandings or lack of verification of the patient’s coverage.
  • Lack of Prior Authorization: Many insurance plans require prior authorization for certain treatments or procedures. Failing to obtain this authorization can lead to denials.
  • Duplicate Claims: Submitting multiple claims for the same service can trigger a denial, often due to confusion or errors in the billing process.

Preventing Medical Billing Claim Denials

To mitigate the issue of medical billing claim denials, healthcare providers can adopt several key strategies:

  • Ensure Accurate Coding: Keeping up-to-date with the latest coding standards and conducting regular training for coding staff can greatly reduce errors.
  • Thorough Patient Data Collection: Rigorous collection and verification of patient information can prevent denials due to incomplete or incorrect data.
  • Understand Insurance Policies: Familiarity with the various insurance policies and their specific coverage details is crucial. This includes verifying patient coverage and understanding the requirements for prior authorization.
  • Regular Claim Audits: Conducting regular audits of the billing process can help identify and rectify common errors leading to denials.
  • Leveraging Technology: Utilizing advanced billing software can streamline the billing process, reduce errors, and ensure compliance with current regulations.

Trust AMS Solutions to Navigate and Resolve Your Medical Billing Claim Denials

Partner with us to transform your billing challenges into opportunities for growth and success, and focus on what matters most, your patients. Our specialized approach ensures accurate, timely, and compliant billing, reducing denial rates and enhancing your financial stability. Contact AMS Solutions today for expert guidance in overcoming medical billing claim denials.

November 15, 2023 by AMS Solutions 0 Comments

The world of healthcare is incomprehensibly complex, and the core need of medical coding is a critical component. Medical coding is often seen as the backbone of revenue cycle management, and this process of translating complex medical procedures, diagnoses, and equipment into universal codes is more than just administrative work, it’s one of the most important places to enforce financial health and compliance. 

Medical coding and billing experts specialize in navigating this complex terrain while offering top-tier medical billing and collections services. We’re going to take a close look at the overall impact of medical coding on the revenue cycle, and what can be done to improve and streamline the process. 

The Role of Medical Coding in Revenue Cycle Management

Medical coding stands at the heart of the revenue cycle in healthcare, serving as a critical bridge between patient care and billing. It involves the meticulous conversion of healthcare diagnoses, treatments, procedures, medical services, and even equipment into universal medical alphanumeric codes. These codes are pivotal in determining how much healthcare providers are paid, making them a cornerstone in the financial viability of medical practices.

The impact of medical coding on the revenue cycle cannot be understated. Accurate and efficient coding is essential for timely and correct billing, which in turn ensures a steady cash flow for healthcare providers. When coding is precise, claims are processed more smoothly, reducing the likelihood of denials or delays that can significantly disrupt the revenue cycle. Conversely, inaccurate coding can lead to claim rejections, underpayments, or even compliance issues, all of which can have detrimental effects on a practice’s revenue.

Primary Benefits of Accurate Medical Coding

Accurate medical coding extends several benefits to healthcare providers, crucial for maintaining a robust and efficient revenue cycle. The right coding and billing team will ensure that your coding is accurate, compliant, and geared toward maximizing your revenue cycle’s effectiveness.

First and foremost, it significantly reduces the chances of claim denials. When medical services are coded correctly, claims are more likely to be approved the first time around, which speeds up the reimbursement process and ensures a steady cash flow. Another key benefit is enhanced patient satisfaction. Accurate coding leads to transparent billing, where patients receive clear and correct statements for the services they’ve received. This transparency fosters trust and reduces confusion or disputes over billing, contributing to a positive patient experience.

Additionally, efficient medical coding practices streamline the entire billing process. By minimizing coding errors, the need for re-submissions and follow-ups is reduced, freeing up valuable time and resources. This efficiency not only boosts the financial health of healthcare providers but also allows them to focus more on patient care.

Overcoming Challenges in Medical Coding

One of the most common issues is coding errors, which can stem from various factors like outdated code sets, complex case scenarios, or simple human error. These mistakes can lead to claim denials, delays, and even compliance risks, all of which negatively impact the revenue cycle.

Compliance issues are another significant challenge in medical coding. With constantly evolving healthcare regulations and coding standards, staying compliant requires continuous education and vigilance. Non-compliance not only risks financial penalties but can also damage the reputation of a healthcare provider.

Trust AMS Solutions to be Your Partner in Enhancing Your Revenue Cycle

Our team ensures accuracy, compliance, and efficiency, turning complex coding challenges into streamlined processes. We’re committed to enhancing your revenue cycle, reducing claim denials, and improving patient satisfaction. Trust us to be your reliable partner in navigating the complexities of medical billing and collections, ultimately boosting your financial performance and allowing you to focus on providing exceptional patient care. Choose AMS Solutions for unmatched expertise in medical coding and revenue cycle management; reach out today to get started.

Two young women doctors sitting on the sofa
October 15, 2023 by AMS Solutions 0 Comments

Medical billing is a critical component in the healthcare industry, bridging the gap between healthcare providers and insurance companies. It’s a process that ensures medical professionals are compensated for their services. However, as with any rapid-evolving industry, the various complexities and nuances involved can pose challenges for many medical practices, leading to delayed or denied claims, which in turn affect the cash flow and overall financial health of the practice.

This is where medical billing companies come into play. They take up all of the administrative work needed for the billing and coding, which would normally be done by in-house staff, allowing the workforce of a healthcare provider to focus more closely on the care they provide to their patients. We’re going to look at what these medical billing companies do, how they work, and look at how outsourcing medical billing can help your business. 

What Do Medical Billing Companies Do?

Medical billing companies are one of the most effective ways to streamline a provider’s reimbursement process and shorten the billing and payment cycle. They are responsible for taking the medical services and procedures that are performed, translating them into the industry standard codes, and submitting claims for reimbursement. 

The journey of a reimbursement claim typically begins with patient visits, where coders convert the diagnoses and treatment details into universal medical codes. Following this, medical billers prepare the claims, ensuring they are error-free and compliant with insurance regulations before submitting them to the respective insurance providers.

Most medical billing companies will also follow up on submitted claims, address any denials, and ensure that the healthcare providers are reimbursed accurately and promptly. They can offer other administrative services as well, like analytics, collections, and more. 

Is It Important To Have A Medical Billing Company For My Medical Practice?

For most small and mid-sized practices, the importance of partnering with a dedicated medical billing company is hard to overstate. They serve as a buffer, ensuring that your medical practice remains financially stable and compliant with ever-evolving healthcare regulations. Medical billing companies possess the expertise to handle complex billing issues, reducing the likelihood of errors that could lead to claim denials or delays. They also free up time for your medical staff, allowing them to focus on patient care rather than administrative tasks.

Benefits of Hiring a Medical Billing Company for Your Practice

Providers that outsource their medical billing needs to a dedicated billing company can reap a range of benefits. Here are just a few of the benefits that your organization could see:

  • They have the expertise and technology to scrutinize every claim for errors
  • They stay updated on the latest coding standards and insurance policies
  • They can actionable insights into your billing processes
  • They allow your staff to focus on your patients

How AMS Solutions Leads In Effective Medical Billing

AMS Solutions is seen as a leader in the medical billing field and employs a team of dedicated and specialized professionals. Our specialists nimbly navigate the complex landscape of healthcare billing. We take the time to tailor our services to match the unique needs of each medical practice, ensuring a seamless billing process from patient visits to final reimbursements. We also lean on cutting-edge technology to ensure accuracy and compliance in every claim, significantly reducing the chances of delaying or denying your payments. 

Trusting another entity with your medical billing and coding needs is a big step for any practice, but even more so for practices that don’t have money to waste. However, partnering with AMS Solutions is a step towards financial robustness and operational efficiency for your medical practice. Let us help you elevate your practice to the next level of provider service, reach out to AMS Solutions today.

October 12, 2023 by AMS Solutions 0 Comments

The processes of medical billing and coding are critical to the healthcare industry, but there are still countless people who wonder what do medical billing and coding do. The job actually requires a substantial blend of medical knowledge, technical skills, and attention to detail, and it helps make sure that healthcare providers are paid accurately and on time for the services they render.

In this post, we’ll be taking a more in-depth look at the job of medical billing and coding, and the processes behind them. We’ll also look at some of the challenges that can pop up from time to time, and how a billing and coding administrator like AMS Solutions is prepared to help your organization scale rapidly.

Understanding The Job Of Medical Billing and Coding

To get a better idea of what medical billing and coding are, you’ll need to understand that both are distinct but closely related functions within the healthcare industry. 

Medical billing involves the process of creating billing claims from provided healthcare services and submitting these to insurance companies for reimbursement. On the other hand, medical coding is the translation of medical diagnoses, procedures, and equipment into universal medical alphanumeric codes. These codes provide a standardized language, which is essential for ensuring accurate billing and record-keeping.

The symbiotic relationship between billing and coding ensures that healthcare providers are reimbursed accurately and promptly, which in turn, supports the financial health of medical establishments. Both functions are critical in maintaining the integrity and efficiency of the healthcare financial ecosystem, easily illustrating why the field is critical.

The Process of Medical Billing

The process of medical billing is pretty meticulous. When a patient visits a healthcare provider, their demographic and insurance information is recorded. Afterward, all of the information is used to generate a bill that delineates all of the services rendered and their costs. This bill is typically then submitted to an insurance company for review and eventual payment. One of the biggest factors in the process is the intricacies, which demand a high degree of accuracy to ensure proper reimbursement.

The Process of Medical Coding

Medical coding, the counterpart to medical billing, is equally vital in the healthcare reimbursement cycle. It entails recording the various diagnoses, procedures, and treatments into codes that are universally recognized. These codes form the basis of billing and ensure that the services provided are accurately represented and reimbursed. The coding process begins with the review of medical documentation from which the relevant codes are derived and then used in the billing process. Accuracy and timeliness in coding are paramount to prevent claim denials and delays in payment.

How AMS Solutions Can Assist

AMS Solutions is one of the most trusted and proficient medical billing and coding administrators by creating a team that is well-versed in the latest coding standards, billing regulations, and insurance requirements, ensuring that your medical establishment remains compliant while optimizing revenue collections. We help alleviate the heavy administrative burden that comes along with having to keep an in-house billing and coding team up to the demands of an ever-changing industry. This way, you’ll be able to focus on what matters most, providing the care you’re known for. 

Partner With AMS Solutions For Hassle-Free Billing and Coding Administration

Understanding medical billing and coding is crucial for maintaining the financial viability of any provider. The intricate and often confusing practices involved in billing and coding are the linchpins of the entire healthcare reimbursement cycle. If you think it may be time for your organization to leave the billing and coding to the professionals and focus on your patients, reach out to AMS Solutions today. 

September 30, 2023 by AMS Solutions 0 Comments

Those who work in the medical field have a significant amount of responsibility. Not only the doctors and nurses who treat you but also the coding and billing professionals that work behind the scenes on paperwork and medical records. There are countless medical regulations and processes that go into medical coding, and it is crucial that the coding is done properly. We’re going to look at what proper coding is, and exactly what is the importance of knowing proper CPT coding.

What Is A CPT Code?

CPT stands for Current Procedural Technology, and CPT codes create a uniform reporting and coding language that is used to make reporting easier, as well as more efficient and accurate. CPT codes are used for medical billing that is either five digits, or four digits and one letter long, and they indicate medical or administrative management procedures. They are used for claims processing as well as for the creation and modification of medical care review guidelines.

Why Is Proper CPT Coding Important?

Most medical facilities rely on insurance providers for the majority of their funding and revenue. Other sources like healthcare programs contribute as well, but the greatest portion is provided by insurers. Insurance companies make their money by charging policyholders a premium, or fee, that is often paid monthly. Since there are many more people who have insurance than are sick at any one time, it allows the insurers to cover most of the medical expenses or costs for those who hold policies. That said, there is a huge portion of income coming from reimbursements, and a very tiny share coming from patients’ pockets. 


This is why proper CPT coding is so crucial. Every single patient that visits a hospital, care center, or doctor’s office has a file of medical records that need to be kept updated and accurately documented. If the coding and billing are done incorrectly, it can result in the hospital losing significant amounts of money in lost reimbursements. Additionally, accurate and correct billing and coding are needed to ensure that patients are being charged more than they should be and that their respective insurer is charged the correct portion of the costs.

Types Of CPT Codes

There are codes assigned for every potential procedure or service that medical providers can provide or perform. CPT codes even include many unlisted codes for procedures or special services that are not specified in other unique CPT codes. There are three categories of CPT codes created by the AMA, the categories are:

CPT Category I

Category I contains the largest body of standard codes. These are the codes most commonly used by healthcare providers to report frequently used services and procedures.

CPT Category II

Category II contains supplemental codes that are used for performance management and other administrative purposes. There are codes relating to patient history, diagnostics, patient safety, and follow-up procedures.

CPT Category III

CPT Category III contains the most infrequently used CPT codes. It also contains temporary codes that are used to code and bill experimental services, rare procedures, or emerging treatments. 

Understanding CPT Codes And The Importance Of Proper Coding Is Vital For Accurate Recordkeeping

Hopefully, we’ve been able to shed some light on just why proper CPT coding is so essential to the continued operation of healthcare facilities. Without accurate and proper CPT coding, patients would be charged wrong amounts for procedures they never had performed, and the facility would lose out on potentially millions in insurance reimbursements. This can jeopardize not only the health of patients but the longevity of the medical facility as well. 

September 12, 2023 by AMS Solutions 0 Comments

Are you looking to get into the medical billing career field? Then it’s important that you know what that job will entail based on the type of facility you’re working for. There are clear differences between billing between healthcare and other industries within the medical field. The processing of medical claims across varying facility types and specialties is significantly different. No matter what, medical billers work with one of two types of billing: institutional billing or professional billing. We’re going to look more closely at the differences between facility vs professional claims.

What is Professional Billing?

The staff in a doctor’s office handles many different tasks, from greeting patients and getting them checked in, to scheduling appointments and collecting money. Medical billing is also handled within the office as well. The claims that are generated for the work done by suppliers, physicians, and other non-institutional providers are considered professional billing.


These professional charges are billed on the standard CMS-1500, which is a red ink on white paper claim form that both suppliers and physicians use for claim billing. Not all claims are billed on paper. Most insurance companies, including Medicare and Medicaid, primarily accept electronic claims. When the claims are submitted electronically, it’s the 837-P rather than a CMS-1500.

What is Institutional Billing?

Institutional billing is the billing of claims for work done by institutions. Healthcare facilities like hospitals, nursing homes, and similar facilities that offer inpatient and outpatient services use institutional billing. Not only will it include services performed by the facility, but also the use of various pieces of equipment, the use of laboratory services, radiological imaging services or equipment, and more.

Biggest Differences Between Billing Types

When you compare the basics, it may seem like there isn’t much difference between professional and institutional billing. However, there are some key ways they are separated. The biggest differences between a facility claim vs a professional claim are the duties available as well as the types of forms used. 

Different Forms

Professional billing claims are billed using a CMS-1500 form. The CMS-1500 is a standard form that has red ink on white paper. It is used not just for physicians, but for supplier claim billing as well. If the billing is done electronically, the digital version of the CMS-1500 is the 837-P, with the P standing for professional claims.


Institutional claims are billed using a form called a UB-04. The paper version of this form is also red ink on white paper and is used for the physical billing of institutional charges. The electronic version of the UB-04 is the 837-I, with the I standing for institutional claims.

Roles Addressed

When looking at professional vs facility billing, there are unique claims for different industries and jobs. Facility claims deal with hospital and laboratory services, while professional claims are for physicians that work in medical offices.

Duties and Skills

Regardless of the type of billing, professional vs. facility, medical billing professionals have a crucial responsibility. Medical billers must learn about five distinct areas of billing, including:

  1. Understanding how to obtain or use information about each insurance company to submit claims efficiently.
  2. Knowing how to perform their duties while maintaining medical confidentiality and avoiding HIPAA violations.
  3. Having a working familiarity with the specific billing software that is used will result in massive time savings for training, will reduce errors, and prevent issues and headaches in general.
  4. Understanding that coordination of benefits information is vital and that submitting claims in the proper order reduces delays in payment.
  5. Understanding that each portion of a medical claim is representative of information collected during the entire time from patient scheduling through treatment.

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