Outsourcing vs. In-house Billing for Rheumatology Practices
by BillingFreedom | Feb 21, 2025
Rheumatology billing and coding are essential components of managing a rheumatology practice’s financial health. Billing involves accurately documenting and submitting claims for services provided by rheumatologists who specialize in treating conditions like arthritis and autoimmune diseases.
Coding, on the other hand, involves converting medical procedures and diagnoses into specific codes that insurance companies use to determine reimbursement. Effective billing and coding not only ensure proper compensation for services rendered but also streamline the practice’s revenue cycle, reducing delays and denials and improving cash flow for continued success.
What Is The Difference Between Outsourcing And In-House Rheumatology Billing And Coding?
Outsourcing and in-house rheumatology billing and coding refer to two distinct approaches for handling the medical billing and coding process within a rheumatology practice.
In-house billing and coding
This means that the practice employs its staff to handle all billing and coding tasks. This includes transcribing medical procedures and diagnoses into the appropriate codes, submitting claims to insurance companies, and following up on denied or unpaid claims. The main advantage of in-house billing is that the practice has direct control over the process and can ensure that its staff is familiar with the specific needs and nuances of its patients and services. However, it can also be resource-intensive, requiring dedicated staff, ongoing training, and time-consuming management.
Outsourced billing and coding
On the other hand, involves hiring an external company or service to handle all billing and coding functions. This third-party provider typically has specialized knowledge in rheumatology billing and coding, ensuring accurate claim submission, adherence to regulatory requirements, and effective follow-up on claims. Outsourcing can free up internal resources, reduce administrative burdens, and often improve accuracy and efficiency. However, it may come with additional costs and less direct control over the billing process.
Ultimately, the choice between in-house and outsourced billing and coding depends on the rheumatology practice's specific needs, budget, and management preferences.
Pros And Cons Of Outsourcing Vs. In-House Rheumatology Billing And Coding
Here is the comparison between in-house and outsourced rheumatology billing and coding:
|
Factor |
In-house Rheumatology Billing and Coding |
Outsourced Rheumatology Billing and Coding |
|
Control |
Direct control over billing and coding processes. |
Less control over the billing process. |
|
Expertise |
Requires staff to stay updated on coding regulations and practices. |
Specialized expertise in rheumatology billing and coding. |
|
Cost |
Higher overhead due to salaries, training, and management. |
Potentially more cost-effective by eliminating the need for in-house staff. |
|
Efficiency |
It can be time-consuming, increasing the risk of errors and delays. |
It can improve efficiency, leading to claim processing and payments faster. |
|
Communication |
Immediate communication and resolution of issues. |
Potential communication delays with external vendors. |
|
Flexibility |
Greater flexibility to adjust billing processes as needed. |
More flexibility as the process is handled internally. |
|
Patient Knowledge |
In-house staff are more familiar with specific patient needs and history. |
Outsourcing companies may have a different familiarity with patients. |
|
Risk of Errors |
Higher risk of errors due to fewer resources and oversight. |
Lower risk of errors due to specialized expertise and experience. |
|
Focus on Core Operations |
Requires significant internal focus on billing and coding tasks. |
Frees up internal resources to focus more on patient care and operations. |
Coding And Billing Tips For Rheumatology Practices
Melissa Silva, an independent rheumatology coding consultant, has shared eight valuable tips to help practices ensure compliance while maximizing their revenue. These strategies are designed to streamline the coding process, improve accuracy, and ensure that practices are reimbursed fully for the services they provide. By following her expert advice, practices can navigate the complexities of rheumatology billing with confidence, ensuring they meet regulatory requirements while optimizing their revenue cycle.
Tip #1: Verify Drug Units Before Billing
Why is this crucial? The billing process can be tricky because different drugs are billed using different unit measurements. For instance, some drugs are billed at one unit per milligram, while others are billed at 10 or even 100 units per milligram. Double-checking is necessary for practices to avoid over- or under-billing.
Silva’s Tip: To avoid mistakes, develop a quick-reference guide detailing the correct billing units for each drug, including common milligram-to-unit conversions.
Tip #2: Differentiate Between Specialty and Buy-and-Bill Drugs
When dealing with buy-and-bill drugs, the practice buys the medication upfront and keeps it in stock. After administration via injection or infusion, the practice can bill the insurance company for those medications.
However, with specialty drugs, the practice orders the medication specifically for the patient, but the specialty pharmacy bills the insurance company directly. Billing a specialty drug by mistake can lead to complications—while the insurance company may initially pay, the practice will likely need to return the payment, and some insurers may even charge interest or audit the practice’s infusion billing.
Silva’s Tip: Maintain a clear list distinguishing specialty drugs from buy-and-bill drugs, and verify this before submitting a claim.
Tip #3: Bill for Wasted Medications
Sometimes, patients may only use part of the vial of medication during their treatment. However, if the practice purchases the medication, they are entitled to bill for the full amount.
Silva’s Tip: Use these two codes when billing for discarded drugs:
- The J code for the drug with the units administered.
- The same J code with modifier -JW for the unused units.
Tip #4: Understand Payer-Specific Rules for Multiple Injections
Billing for multiple injections on the same day can be tricky because each insurer may have different requirements. Some insurers may want separate line items for each injection, while others prefer listing a single code with multiple units or using -RT and -LT modifiers when applicable.
Silva’s Tip: Never assume the rules. Always check with each payer directly to understand their specific guidelines for billing multiple injections on the same day.
Tip #5: Prioritize Specificity in Documentation
In recent years, diagnosis codes across many medical specialties, including rheumatology, have become more specific. For example, rheumatoid arthritis codes now require details such as the affected body location (left or right), the presence of a rheumatoid factor, and whether specific organs or systems are involved.
Few Common Codes For Rheumatology Practices
A01.04 Typhoid arthritis
A02.23 Salmonella arthritis
A18.02 Tuberculous arthritis of other joints
A39.83 Meningococcal arthritis
B06.82 Rubella arthritis
B26.85 Mumps arthritis
B42.82 Sporotrichosis arthritis
M05.9-M06.9: Rheumatoid arthritis codes. Errors can occur if the subtype or laterality needs to be documented correctly.
M32.0-M32.9: Systemic lupus erythematosus codes. Errors may arise if specific organ involvement needs to be documented.
M45.0-M45.9: Ankylosing spondylitis codes. Errors can occur if the site or severity needs to be documented accurately.
M79.7: Fibromyalgia. Errors may arise if fibromyalgia is not documented when it is a significant part of the patient’s condition.
Silva’s Tip: Stay updated on annual coding changes and collaborate with physicians to ensure detailed and precise documentation, which will help avoid coding errors and improve reimbursement accuracy.
Tip #6: Use the Correct Diagnosis Code with Medication Administration Code
Accurate coding is essential when it comes to prior authorizations for infusions, as most insurance companies require this step. If you submit the wrong diagnosis code, it can invalidate the prior authorization and lead to a denial.
Silva’s Tip: Always review the prior authorization details before billing to ensure the correct diagnosis code is used, preventing potential denials or delays in payment.
Tip #7: Reporting E/M Visits Along with Injections
If a provider conducts a separately identifiable Evaluation and Management (E/M) service on the same day as an injection, it may be possible to bill for both services. Use the modifier -25 to indicate the separate E/M service, alongside the injection code.
Silva’s Tip: Ensure that the documentation clearly supports a separate E/M service. Also, check each payer’s coding policy to understand how they handle billing for E/M services and injections, as some may require different diagnosis codes.
Tip #8: Collaborate with Your Life Science Rep
Life science representatives are valuable resources for rheumatology practices, especially when dealing with new drugs or infusion types such as port infusions. They can provide guidance on billing for new medications and inform you when Q codes transition to J codes, along with the specific J codes to use for each drug.
Silva’s Tip: Partner with your life science rep to stay updated on the latest coding requirements and ensure you're billing correctly for new drugs or procedures.
Why Outsourcing Your Rheumatology Billing to BillingFreedom is the Best Choice?
Outsourcing your rheumatology billing to BillingFreedom ensures that your practice is in expert hands. Our team specializes in rheumatology coding and billing and stays updated with the latest coding changes, payer rules, and compliance regulations. From handling prior authorizations for infusions to distinguishing between specialty and buy-and-bill drugs, we ensure that all billing processes are accurate and compliant.
By anticipating annual coding changes and understanding each payer’s unique requirements, we help prevent costly denials, recoupments, and audits that can impact your bottom line.
With BillingFreedom, you also gain a team dedicated to maximizing your revenue. We ensure that your practice is properly compensated for every service rendered, including billing for discarded medications and multiple injections on the same day. Our expertise in handling complex billing issues allows you to focus on patient care, knowing that your billing is accurate, timely, and efficient.
Partner with us to streamline your billing process and enhance your practice’s financial health.
For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472.
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