Informational Software

“...many operations previously performed manually are automated within [informational medical billing] system software.”

Medical billing software has become more sophisticated, and many operations previously performed manually are now being linked to, or included in, billing software packages. Unlike basic software which relies heavily on user knowledge, judgement and entry skills, informational software uses internal data bases and dictionaries to increase productivity and minimize the number of entry errors.3 Medical billing software packages with no, or limited, data base and dictionary capabilities can be linked to other independent software packages specifically designed to meet a particular billing need. For example, software capable of recalling all diagnosis codes (ICD-9 codes) and all procedure codes is available. Related software packages can be linked to billing software or used to create dictionaries containing limited coding information. 

Another characteristic of informational billing software is the ability to recall patient and provider identifying information and in some cases the service items on the last claim submitted for payment. The user can then update the last bill by merely adding line items to the claim or deleting them. Adding line items to a claim is facilitated by the software’s data bases or dictionaries. As the user enters a code or service number, the system’s software automatically recalls the CPT codes, charge information and other pertinent information stored in the software’s data base(s). If the procedure code or diagnosis code is not in the software’s dictionaries, the software can be configured to accept additional codes and information or it can limit choices to those in the system. With a few keyboard entries the user can create a new claim using new information and information already stored within the system.

Like basic medical billing software, informational billing software also provides information to the user about validity tests, completeness tests, logic tests and other program controls established by the software developer. It can be linked to other software packages designed to analyze claim information to see if it will pass Medicare and private sector scrutiny. It can edit services entered on a claim and notify the user of invalid code combinations, missing diagnosis and other errors that might prevent the timely processing of the claim. The user draws upon information provided by the system, and outside the system, to resolve errors identified by the software.

Vulnerabilities inherent in information software are more likely to stem from manipulation of software configuration and data bases and not the software programs themselves. Limited procedure coding options may steer claim decisions to higher valued procedure codes and encourage the use of diagnostic codes not supported in the patient’s medical record. Ultimately it is the software user’s choices and decisions and not the software that affects the accuracy of claims submitted to Medicare. Improperly configured informational software data bases and dictionaries can be misused. Misuse increases the probability of error and exposes physicians and other users to potential payment errors.  

 Interactive Software

Vendor software packages usually contain many options that can be used to generate a claim. These software packages can be vulnerable to misuse and inadvertent error.

Interactive medical billing software represents the state-of-the-art in software billing. Interactive software expedites data entry and offers users several options to facilitate claims processing. Bar coding is one option available that reduces input error. Other options include electronic links to an office laboratory or other medical services that allow the user to obtain billing information directly from the laboratory, other data files and other office areas. Interactive software recalls patient, provider and last claim information. The software recognizes multiple insurance payers and the different coding rules and codes used by them. Interactive systems can be programmed to link procedure codes to ensure the right code is submitted to each of the patient’s insurers. For example, a private insurance carrier may require the use of procedure code 36145 when billing for venipuncture. Medicare requires G0001 for the same service. The software automatically selects the right code for each insurer. 

Interactive systems usually do more than give feedback that something is missing on a claim. They provide information to help the user correct the problem. For example, when the user enters an invalid CPT code, the interactive medical billing software advises that an invalid CPT was entered. The software may produce a list of valid codes in the system and prompts the user to select one of the codes or enter a new code. Some systems also show the expected payment for each code. 

Each software user decides what “prompts” will be in the system. These prompts may also provide feedback as to how coding will affect reimbursement, show other coding options and the expected Medicare reimbursement for each option. The user can accept a system prompt, bypass it or modify it. Interactive systems reduce entry errors. The software uses a form of artificial intelligence to “learn” from past claims activity which services will be paid or denied. Providers can also purchase additional software that analyzes their claim information for compliance with Medicare’s correct coding initiative. Software manufactures and others are also working to identify HCFA’s black box edits.4 As the body of knowledge about these edits increases, software applications will no doubt be not far behind. What distinguishes interactive software from other medical billing software is its ability to provide the user with information and the likely consequences (no pay, more pay, less pay) of their decision. 

Data bases and dictionaries that restrict user choice of diagnostic codes, CPT codes, place of service codes and other claim data can contribute to payment errors.5 The system may be programmed with default diagnostic codes. Whenever medical services or tests are billed, the default diagnostic code can automatically be added to the claim to ensure that the service, procedure or supply billed to Medicare will avoid Medicare safeguards and be paid. The end result produces claims that are flawlessly executed; unfortunately, the medical record may not support the services billed to Medicare. Diagnostic information must be in the patient medical record for the date of service. If it is not, Medicare will recover any money paid in error.