February 04, 2020
5 min read

Single-center study raises larger issues about proper billing

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Franklin Campbell
Frank Campbell

Two CMS codes for advanced care planning — 99497 and 99498 — were used less than 20 times at a tertiary care center in Iowa during in a nearly 3-year period, according to findings published in the Journal of the American Board of Family Medicine. Additionally, the center was successfully reimbursed only about one-quarter of the time, potentially resulting in lost revenues.

Billing errors are not limited to advanced care planning, and the findings from the single-center study speak to larger issues about reimbursement, according to Frank Campbell, MHA, MBA, former chief strategic and business planning officer at the University of Mississippi Medical Center.

Physicians were required to start using ICD-10 codes in 2015. Campbell said the 500% increase in new codes stemming from the rocky changeover caused a “dramatic increase” in the rates of edits and denials from insurers.

He said most experts place the rate of errors in medical claims between 7% and 10%, but in some instances, the rate could be even higher. “There have been several recent studies that have shown billing errors related to certain programs — like Medicare Advantage — are as high as 40% to 50%,” he said.

Campbell, now a professor at Tulane University’s Freeman School of Business, said the JABFM study, though small, illustrates how challenging billing can be.

‘A little extra for your bottom line’

The authors of the JABFM study noted that CMS code 99497 can be charged for the first 30 minutes — half that time must be spent “face-to-face with the patient, family member(s), and/or surrogate discussing goals of care and wishes in the event of future serious health issues.” The second CMS code, 99498, can be used for each additional 30 minutes of these conversations. CMS issued final payment rules for the reimbursement of advance care planning in early January 2016.

Jeanette Daly
Jeanette M. Daly

Jeanette M. Daly, RN, PhD, a research scientist in the department of family medicine at the University of Iowa Carver College of Medicine, and colleagues assessed how frequently the advance care planning codes were used for more than 2 years after CMS issued its payment rules. Daly and colleagues found that code 99497 was successfully reimbursed just four of 17 times, and that code 99498 was never used.

According to researchers, where the codes were denied, a registered nurse very skilled in advanced care planning conversations correctly documented the conversation and its duration, but due to Medicare billing rules was not considered a licensed provider for these conversations.

“Each of those codes reimburse health systems about $80,” Daly told Healio Primary Care. “That's not a huge amount of money. But it's better than nothing, and if you could get that amount for at least 100 patients, that could mean a little extra for your bottom line.”

Barcey Levy
Barcey T. Levy

Study author Barcey T. Levy, MD, PhD, Iowa Academy of Family Physicians Endowed Chair in Rural Medicine at the University of Iowa Carver College of Medicine, added that 99497 and 99498 can be used as add-on codes during patients’ Medicare annual wellness visits. She also noted that physicians should discuss issues covered by billing codes 99497 and 99498 before “medical interventions potentially undesirable to the patient” become an issue.

Claim rejections, denials increasing

Other research also suggests proper billing and physician reimbursement continues to be a challenge in the medical community.

Healio previously reported that evaluation and management codes are susceptible to errors. In addition, results from a recent Academy of Nutrition and Dietetics survey showed that proper billing code knowledge was “stable and very low” for dieticians who were not in a supervisory role or private practice.

A broader look at medical claims shows that the knowledge gap is not limited to diet and advanced care planning discussions. NBC News reported on 2013 data from the AMA, which showed that 7.1% of paid claims contained an error. A 2014 NerdWallet study discovered mistakes in 49% of Medicare claims. Surveys by Medical Billing Advocates of America and CoPatient put the billing rate much higher, at close to 80%.

Adrian Velasquez, president, CEO and co-founder of the health care support and management company Fi-Med Management, told Healio Primary Care that with the transition from ICD-9 to ICD-10, “there were 55,000 new codes added, which increased the complexity of coding, which increased denials and rejections.”

Source: Adrian Velasquez, president, CEO and co-founder of the health care support and management company Fi-Med Management

According to the Medical Group Management Association, payers underpay health care organizations between 7% and 11% of the time. On the other hand, health care organizations that get caught overbilling — intentional or not — can face a variety of consequences.

“The consequences of overbilling range from recoupment of an overpayment claim or exclusion from Medicare,” he said. The latter of those penalties he mentioned would “mean the end of a practice or hospital,” Velasquez added.

Ways to help ensure better compensation


Many medical societies have resources available to help clinicians through various billing and coding processes to help ensure better compensation.

The American Academy of Family Physicians touts its billing and coding toolkit as way to maximize billing, collections and claims processing. AMA offers the monthly CPT Assistant newsletter, said to provide clinical examples that “demystify confusing codes” and answer frequently asked questions.

Velasquez also provided several tips to help ensure physicians receive better compensation:

  • verify patient ID and insurance at each visit;
  • verify eligibility prior to each office visit or service;
  • collect copays and patient responsibility at the time of service;
  • hire or outsource coders to code from physician notes; and
  • offer education on physician documentation and coding on an ongoing basis.

“Do not solve one claim at a time,” he continued. “Identify common denials for a bulk resolution. We will send bulk denials to a contact person at the payer for them to adjudicate the bulk claims for a bulk payment. The next step is to identify the cause of the denial and put a process in place so that denial does not occur again.”

Jon Graham, PhD, vice president of consulting at Claims Resolution Center in St. Petersburg, Florida, and Cindy Acker, president and practice manager of the Claims Resolution Center, wrote in the Journal of Oncology Practice that the person in charge of billing should ask himself or herself these questions to help ensure better reimbursement:

  • How are services rendered verified for accurate billing?
  • Are bills being sent out in a timely manner?
  • Are payers paying the contracted amount?
  • How quickly is the practice collecting what it is owed when bills go out?
  • Are claims being collected?
  • Is the practice taking part in all patient assistance programs?

These steps can help maintain the financial stability of health care organizations, Graham and Acker said.

“Exploring these issues and implementing the recommendations offered may cause some discomfort but implementing them can help [ensure] the financial viability of the practice and serve as a learning experience for all involved,” they wrote. – by Janel Miller


Cartwright DJ. Adv Wound Care (New Rochelle). 2013;doi:10.1089/wound.2013.0478.

Graham J, Acker C, J Oncol Pract. 2007; 10.1200/JOP.0742504.

Grant KB. It’s time to get a second opinion before paying that medical bill. https://www.nbcnews.com/business/consumer/its-time-get-second-opinion-paying-medical-bill-n545626. Accessed Jan. 20, 2020.

James J. Health Aff. 2014;doi:10.1377/hpb20140403.830190.

Jortberg BT, et al. J Acad Nutr Diet. 2020;doi:10.1016/j.jand.2019.05.008.

Kim P, et al. J Am Board Fam Med. 2019;doi:10.3122/jabfm.2019.06.190121.

Disclosures: Campbell, Daly, Frankin and Levy report no relevant financial disclosures. Velasquez is president, CEO and co-founder of Fi-Med Management.