Using Checklists to Meet All Codes and Payer Requirements: A Step-by-Step Guide
When it comes to healthcare, accurate medical coding and billing along with maintaining the payer compliance is a critical task that requires high professionalism and knowledge. To make this entire process effective and stress free we at Shoreline Medical Billing Company uses one of the most effective tools that streamlines the entire process and helps to navigate the challenges of complex coding systems and payer requirements, a medical billing checklist. We are sharing an in-depth, step-by-step guide for using checklists to meet all codes and payer requirements, that ensures fast claims, quicker reimbursements, and audit-ready practices.
Why Checklists Are Essential for Medical Billing
Medical billing is an intricate process where errors can result in claim denials, delayed payments, or even compliance issues. A medical billing checklist acts as a road map, directing coders, billers, and healthcare providers through each stage of the billing process. Here's why our checklists are vital.
- Identifying and Reducing the Errors: Our checklists ensure no critical steps are overlooked, minimizing coding mistakes or missing documentation.
- Ensuring Payer Compliance: Payers like Medicare, Medicaid, and private insurers have their own specific requirements. Our checklists help to align claims with their rules.
- Improving Efficiency: It is a standardized process saving time and allowing staff to focus on patient care rather than rework.
- Supporting for Audits and Internal Review: Our well-documented checklists provide a clear framework for internal reviews or payer audits.
Step-by-Step Guide for Using a Medical Billing Checklist
Here is a step-by-step guide for designing and using a medical billing checklist that meets all codes and payer standards. Each step is intended to assist the healthcare providers in maintaining accuracy and compliance.
Step 1: Collecting Patient and Insurance Information
Accurate patient and insurance data is the foundation of a clean claim. We use the checklist to verify:
Patient Demographics:
Confirm the details such as full name, date of birth, address, and contact details. Cross-check against government-issued ID to avoid mismatches.
Insurance Details:
• Insurance provider.
• Policy number and group number.
• Coverage type.
Eligibility and Benefits:
Verifying coverage status, copays, deductibles, and prior authorization requirements using the payer’s online portal or phone verification system.
Checklist:
✓ Review the Patient registration form and check that complete details are filled.
✓ Scan the Insurance card, check and confirm for active coverage.
Step 2: Looking for Patient Encounter Documentation Checklist
Proper documentation is the backbone of payer compliance. Coders rely mainly on detailed clinical notes to assign accurate codes. Using the checklist to verify that the patient’s visit is clearly documented before the coding begins.
Provider Notes:
Include the reason for the visit, medical history, examination findings, and treatment plan.
Medical Necessity:
Document why the service was necessary, aligning with payer policies (e.g., Medicare’s Local Coverage Determinations).
Time-Based Coding:
For time-based Evaluation and Management (E/M) codes, note the total time spent on the encounter, including coordination of care.
Specificity:
Use precise language to describe diagnoses and procedures to support ICD-10-CM and CPT codes.
Checklists:
✓ Check whether the chief complaint and history of present illness are clearly documented.
✓ See to that all medical necessity are provided with supporting details.
✓ Any requests for diagnostic services are signed and dated.
✓ Time spent (if billing based on time) is properly recorded.
✓ All procedures and diagnoses clearly noted.
Step 3: Assigning Accurate Codes
Coding errors can trigger denials or audits, making accuracy paramount. Our medical billing checklist guides coders through:
- ICD-10-CM Codes: For selecting the correct diagnosis codes that reflect the highest level of specificity. For example, by using E11.21 (Type 2 diabetes mellitus with diabetic nephropathy) instead of E11.9 (Type 2 diabetes mellitus without complications).
- CPT/HCPCS Codes: Choose procedure codes that match the service provided, including modifiers wherever necessary (e.g., -25 for significant, separately identifiable E/M services).
- Code Linkage: Always ensure that the diagnosis codes justify the procedures billed to demonstrate medical necessity.
- Add-On Codes: Include codes like G2211 (for complex longitudinal care) when criteria are met, as outlined in CMS guidelines..
Checklists:
✓ ICD-10-CM codes reviewed for specificity.
✓ CPT/HCPCS codes verified against provider documentation.
✓ Modifiers applied correctly (if needed).
✓ Diagnosis and procedure codes linked appropriately.
Step 4: Verify Payer-Specific Requirements
Each payer has unique rules for coding, documentation, and submission. Our checklist accounts for:
Payer Policies:
Review the payer’s billing manual or online resources for specific requirements.
Modifiers:
Always confirm payer-specific modifier usage.
Timely Filing:
Note the payer’s filing deadlines (e.g., 90 days for Medicare, 180 days for some private insurers).
Bundling Rules:
Check for bundled services to avoid unbundling errors, which can lead to denials.
Checklists:
✓ Payer policy reviewed for service-specific rules.
✓ Modifier requirements confirmed.
✓ Timely filing deadline noted.
✓ Bundling/unbundling rules applied correctly.
Step 5: Reviewing and Submitting the Claims
Before submission, a final review ensures the claim is clean. Our checklist includes:
Claim Scrubbing:
Using billing software to detect mistakes, such as missing codes, invalid modifiers, or inadequate patient data.
Documentation Match:
Verifying that all codes are matching with the provider’s notes and fulfill medical necessity.
Claim Format:
Ensure the claim adheres to the payer’s preferred format (e.g., CMS-1500 for professional services or UB-04 for institutional claims).
Electronic Submission:
Submitting claims through a clearinghouse to track the status and confirming the receipt.
Checklists:
✓ Claim scrubbed for coding and data errors.
✓ Codes and documentation cross-checked.
✓ Verify the claim format (CMS-1500/UB-04).
✓ Electronical submission of the claim and acknowledgement.
Step 6: Monitoring the Claim Status and Follow Up
Post-submission, our checklist ensures timely payment and resolution of issues:
Claims Tracking:
Monitoring claim status (accepted, refused, or pending) using our billing system.
Resolving Denials:
Examining denial grounds, rectifying problems, and resubmitting with supporting documentation.
Appealing When Necessary:
If a denial is not justified, filing an appeal with thorough proof before the payer's deadline.
Payment Posting:
Ensuring that payments reflect the contracted rates and are accurately posted to patient accounts.
Checklists:
✓ Claim status checked weekly.
✓ Denials reviewed and corrected within 48 hours.
✓ Appeals filed with supporting documentation (if needed).
✓ Payments posted and reconciled.
Best Practices for Creating an Effective Medical Billing Checklist
We at Shoreline Medical Billing Company follow these to maximize the value of your medical billing checklist, such as:
- Customized Checklists for Your Practice: Tailored and specific checklists for all your specialties (e.g., cardiology, orthopaedics) and top payers.
- Trained Staffs: Regularly training coders and billers on checklist usage.
- Keeping Up to Date: Modifying and reviewing the checklists every quarter, considering changes in payer policies or coding guidelines (such as the ICD-11 transition).
- Digitized Service: Providing real-time access by integrating checklists with billing software and EHR systems.
We can optimize reimbursements and reduce stress by following this step-by-step strategy filing clean claims, and monitoring results. At Shoreline Medical Billing Company, we are devoted to providing practitioners with resources like checklists to help them navigate the complexities of medical billing.
Ready to streamline your billing process?
Sharanya Rajmohan
Content Writer
Sharanya brings clarity to the complexities of medical billing and healthcare regulations. With a knack for turning industry shifts into straightforward, actionable insights, her blogs help readers stay informed without the jargon.
Contact Shoreline Medical Billing Company for expert support to get started today!