Billing and Coding in Sync in the Revenue Cycle Presented By: DHA UBO Program Office Contract...

transcript

Billing and Coding in Sync in the Revenue CyclePresented By:

DHA UBO Program Office Contract Support

25 February 2014 @ 0800-0900 EST27 February 2014 @ 1400-1500 EST

For entry into the webinar, log into: http://altarum.adobeconnect.com/ubo.

Enter as a guest with your full name and Service or NCR MD affiliation for attendance verification.

Instructions for CEU credit are at the end of this presentation.

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Objectives

• Overview of the Revenue Cycle • Communication between Coding and Billing• Institutional Billing Guidelines• Professional Billing Guidelines• Tips for submitting clean claims• Billing Scenarios• EOB (Explanation of Benefits) and Denials • How to become a Certified Biller

The MHS Revenue Cycle

Step 6: Institutional

and Professional

Coding

Establishing Good Communication

• Each area of the Revenue Cycle works together to collect the information that pertains to the patient during their encounter

• That information creates the picture for the third-party insurance company of what care and services were provided during that episode of care

• Each area of the Revenue Cycle has rules and guidelines they must follow: – To register a patient – Provide services– Code for the patient care – Bill for patient’s services

Establishing Good Communication

• When a claim is denied, the biller must review the reason• Sometimes another area of the Revenue Cycle (such as

registration, coding, or the system) had incorrect information or insufficient information in order to process the claim

• The biller must find out why it was returned and figure out how to fix it so that the claim will be paid

• This may mean returning to the coding department to ask questions about diagnosis codes appended to the claim

• Each insurance company has its own payer manual; and they often require different or additional information – such as the addition of a particular modifier or condition code

• Billers and Coders need to work together to give the “story” of the encounter in the codes required by the third-party payer

Communication Between Coders and Billers

• Accurate coding is required for proper payment from insurance companies and other payers

• Build good relationships with coders so you can produce clean claims

• Build good relationships with your Patient Administration Directorate (PAD) staff. If they enter incorrect information in CHCS at the front end, you may never see a claim for that beneficiary

• Billers need to share and communicate with coders in order for coders to understand how coding affects the reimbursement process and is required for clean claims

• Billers need to understand what a clean claim looks like. Learn the basics of coding so you can recognize when codes may or may not be correct and know why the coder used that particular code

• Set up meetings and training opportunities so coders and billers can learn together

Billing Guidelines

How do I find the billing guidelines?• Individual payer manuals (available online)• Check the UBO User Guide– It can be found on the UBO website (

http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/Teleconferences.cfm)

• Resources such as: The Uniform Billing Editor (gives information on what data elements are required/situational for each field locator on the UB-04) (Published by: Optum )

• UBO modules entitled: – Data and Billing in Sync – UB-04/837I– Data and Billing in Sync – CMS-1500 (02/12)/837P

Institutional Billing Guidelines

UB-04 Claim Form

UB-04 Overview

• The UB-04 is commonly referred to as the “Institutional Billing Form”

• The 837I is the electronic transaction set for transmitting the information for the Institutional Claim

• An on-demand, Web-based course outlining the paper and electronic data elements most commonly used for billing MHS institutional claims is available

UB-04 Institutional Claim Form

• Training has been developed for Billers who use the UB-04 claim form/837I transaction set

• The training also incorporates examples for electronic billing• Each module is interactive• To learn the required/situational data elements, select desired FL• Each FL includes examples and reference information• Course contains 7 modules:– Demographics, Institutional Information, Additional

Information, Services Performed/Charging, Insurance Information, Diagnoses/Procedures, and Provider Information

• At the conclusion of each module, a quiz is provided; and at the end of the course there is a final test which covers information from all 7 modules

Demographics

Module 1 – Demographics

• This module covers information obtained in the registration process

• Incorrect demographic information can result in denials• Make sure all information for the patient’s episode of care is

current for both address and contact information

Institutional Information

Module 2 – Institutional Information

• Institutional information relates to items such as the medical record number or the federal tax id number.

• It also identifies whether the claim is an inpatient or outpatient claim

• Much of the information is populated by the system• The information is used by the insurance company to identify the

facility

Additional Information

Module 3 – Additional Information

• Condition Codes – these codes help determine patient eligibility and benefits and are used to administer primary or secondary insurance coverage

• Occurrence Codes – these codes are used to determine liability, coordinate benefits, and administer subrogation clauses in benefit programs

• Value Codes – these fields contain codes and the related dollar amounts identifying monetary data required for processing claims

• These codes identify additional information about the patient and the need for medical services

• These codes define significant events, insurance coverage conditions, or clinical data that can often affect payer processing and payment of the claim

Services Performed/Charging

Module 4 – Services Performed/Charging

• Information provided in this section include revenue codes, units, CPT® and HCPCS codes, descriptions, and the rate

• Examples are given for inpatient, outpatient, and pharmacy

Insurance Information

Module 5 – Insurance Information

• Collecting the correct insurance information is crucial to getting the claim paid

• Identifying the relationship between the patient and the holder of the insurance card is also a critical element

• Identifying and billing the primary insurance payer will get the claim paid correctly

Diagnoses/Procedures

Module 6 – Diagnoses/Procedures

• This module covers the various kinds of diagnosis codes used for inpatient and outpatient coding, admitting diagnosis codes and patient’s reason for the visit

• Explains and gives a listing of the POA (Present on Admission) codes

• Explains what the Other Diagnosis Codes are and when to use them, such as E codes and V codes

• Explains the principal procedure codes and how the data elements should be entered on the UB-04 form

Provider Information

Module 7 – Provider Information

• The information covered in this module indicates to the payer the name and identifier of the provider who was the attending, operating, or other provider during the dates of care for this claim

• Explains the National Provider Identifier for the Billing Provider• Covers the attending Provider Name and Identifiers• Covers the Operating Physician name and Identifiers• Covers Other Provider Name and Identifiers

UB-04/837I Module Format and Functionality

Navigate using task

bar or button

Modules are

grouped by related sections

UB-04/837I Learning Checks and Post-Test

• At the conclusion of each module, there is a narrative-based learning check

• This learning check is meant to reinforce the material just covered and not every form locator is used.

• At the conclusion of the 7th Module, take the Post-Test containing 10 questions for certificate

• If the participant receives a score of 70+% a certificate of completion will be sent

• If you would like a CEU certificate for completing the modules, you will need to send an email to the UBO.Learningcenter@altarum.org

• All CEU requests will be cross-referenced and verified with the online registration.

• http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/Teleconferences.cfm

Professional Billing Guidelines

The CMS-1500 (02/12) Form

CMS-1500

• This is the form used to submit the professional charges to the third-party payer

• The 837P is the electronic transaction set for transmitting the information for the Professional Claim

• We take the episode of care and break it down into a series of codes that are read by the insurance payer

• There are required and situational data elements that must be present on the CMS-1500 claim form/837P transaction set

Data and Billing in Sync - CMS-1500/837P

UBO has provided training for the revised CMS-1500 form/837P transaction set• It can be found on the UBO website at this link: http://

www.tricare.mil/ocfo/mcfs/ubo/learning_center/Teleconferences.cfm

• The course is broken down into 5 modules:– Insurance Information, Demographics, Diagnosis and

Procedures, and Provider Information

Insurance Information

Module 1 – Insurance Information

• Covers the third-party payer(s) responsible for paying the claim• The information that identifies the patient to the payer• The relationship of the policyholder to the patient

Demographics

Module 2 – Demographics

• Name• Date of Birth• Sex• Address

Additional Information

Module 3 - Additional Information

• Covers code sets and dates required depending on the patient’s condition or type of claim being submitted

Diagnosis and Procedures

Module 4 - Diagnosis and Procedures

• Covers diagnosis codes – which identify the reason why the patient is being treated

• Covers procedure codes – which identify what treatment the patient received at this encounter

• Covers the charges associated with the treatment provided at this encounter

Provider Information

Module 5 - Provider Information

• Required information on the provider who treated the patient• Or provided supplies to the patient• Identifies the provider to the payer responsible for paying the

The new CMS-1500 Claim Form (02/12)

• The form will be used as of 1 April 2014• Payers will accept paper claims submitted on the new form• Updated information can be found at www.nucc.org• Both the updated claim form and updated claim manual are

available (see the July 2013 Instruction Manual)• The form has been changed to accommodate the reporting and

dual coding needs for both ICD-9 and ICD-10• The form was updated to align with the changes in the 5010 837P

transaction set and to accommodate upcoming ICD-10 reporting needs

Changes to the new CMS-1500 form

• Replaced the 1500 rectangular symbol with black and white two-dimensional QR (Quick Response code)

• Changed Tricare Champus to Tricare• Replaced “SSN” with “ID#”• Item Number 8 – Deleted “PATIENT STATUS” and content of field

and changed title to “RESERVED FOR NUCC USE”• Item Number 9b – Deleted ‘OTHER INSURED’S DATE OF BIRTH,

SEX’ – changed title to “RESERVED FOR NUCC USE”• Item 9c – deleted “EMPLOYERS NAME OR SCHOOL” – changed title

to “RESERVED FOR NUCC USE”• Item 10d – changed title from “RESERVED FOR LOCAL USE” to

“CLAIM CODES (designated by NUCC)

• Item Number 11b – deleted “EMPLOYERS NAME OR SCHOOL” – changed title to “OTHER CLAIM ID (designated by NUCC)– added dotted line in the left-hand side of the field to

accommodate a 2-byte qualifier (Note: valid qualifiers are provided in the NUCC 07/13 Instruction Manual)• Item Number 14 – changed title to “DATE OF CURRENT ILLNESS,

INJURY OR PREGNANCY (LMP)”– removed the arrow and text in the right-hand side of the field– added “QUAL” with a dotted line to accommodate a 3-byte

qualifier (Note: valid qualifiers are provided in the NUCC 07/13 Instruction Manual)

• Item Number 15 – Changed title from “IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE” to “OTHER DATE”

- ADDED “QUAL” with two dotted lines to accommodate a

3-byte qualifier (Note: valid qualifiers are provided in the 07/13 Instruction Manual)

• Item Number 17 – added a dotted line in the left-hand side of the field to accommodate a 2-byte qualifier (Note: valid qualifiers are provided in the 07/13 Instruction Manual)

• Item Number 19 – changed title from “RESERVED FOR LOCAL USE” to “ADDITIONAL CLAIM INFO (designated by NUCC)

• Item Number 21 – added “ICD IND” and 2 dotted lines to accommodate a 1-byte indicator (Note: valid qualifiers are provided in the 07/13 Instruction Manual)– added 8 additional lines for diagnosis codes– changed labels for the diagnosis code lines to alpha characters

(A-L)– removed the period within the diagnosis code lines

• Item Number 22 – changed title from “MEDICAID RESUBMISSION” to “RESUBMISSION”

• Item Number 30 – Deleted “BALANCE DUE”– Changed title to “RSVD FOR NUCC USE”

Tips for Submitting Clean Paper Claims

• DO Use only original claim forms • DO Make sure claims are printed darkly• DO Remember that insurance companies scan all claim forms• Avoid folding claims, if possible• Avoid using terms such as “re-filed claim” or “second request”• Avoid handwritten claims• Don’t use all UPPERCASE letters• Don’t use punctuation or decimals• Don’t send unnecessary attachments• Don’t use staples, paperclips, or stick-on notes• Don’t mark the claim with highlighters• Don’t use circles or additional markings• Don’t attach labels or stickers• Don’t add notes or instructional assistance

Billing Scenario

• MHS does not recognize outpatient consultation codes CPT® (99241-99245) or inpatient consultation codes (99251-99255)

• Providers are required to use E&M CPT® codes depending upon whether the visit is for inpatient or outpatient

• Billing Department receives a claim with the following CPT® Codes• 99243• DX - 345.91

• This claim should be returned to have the CPT® code corrected to the correct E&M level office visit code

Billing Scenario

• Billing department receives a claim with the following CPT® codes:• 99253• 99251• DX - 189.4

• This claim should be sent back to be reviewed since the MHS does not recognize inpatient consultation codes.– CPT® codes (99221-99223) should appear on the claim with

modifier AI for the initial visit and CPT® (99231-99233) for any subsequent visits.

EOB (Explanation of Benefits)

SAMPLE

1) Explanation of Benefits (EOB) — A claims statement that is sent whenever a health plan is used for services or products from a healthcare provider. It shows how a patient’s benefits cover the cost of a service from a provider and what the patient owes. The EOB is not a bill.

2) Service/Product — The type of services or products received from a provider.3) Dates of Service — The date(s) services were rendered.4) Amount Billed — The full amount billed by a provider to the health plan.5) Your Plan Discounts & Payments — This section details the amounts that are not

patient responsibility.6) Premera Network Discount — The amount saved by using a provider that belongs to

a Premera network (or other health plan as appropriate). 7) Amount Paid By Your Health Plan — The portion of the charges eligible for benefits

minus the patient’s copay, deductible, coinsurance, network discount and amount paid by another source up to the billed amount.

8) Amount Paid By Another Source — Examples of other sources include: a health funding account, other health insurance, automobile insurance, homeowners’ insurance, disability insurance, etc. This amount may not be itemized and may only show in the Totals row of the Claim Detail.

9) Copay — A set amount patient’s pay for certain covered services such as office visits or prescriptions. Copays are usually paid at the time of service.

10) Deductible —The amount patient’s are required to pay each year for covered services before the health plan starts paying benefits.

11) Coinsurance — A percentage of covered expenses that patient’s pay after the deductible is met.

12) Amount Not Covered — The portion of the amount billed that was not covered or eligible for payment under the patient’s health plan.

13) Your Total Responsibility — This section details the portion of the bill that is the patient’s responsibility to pay. This amount might include the copay, deductible, coinsurance, any amount over the maximum reimbursable charge, or products/services not covered by the patient’s health plan.

14) Claim Notes — When present, these notes provide general information about the claim and may also provide specific explanation of activity that occurred in the Amount Not Covered, Amount Paid by Another Source, and What Your Plan Paid fields. For example, if the claim was denied because a provider submitted the same claim twice, a note would outline the claim denied as a duplicate.

15) Benefit Booklet Information — If applicable, contains information about why portions of a claim were denied.

Retrieved From: https://www.premera.com/wa/member/manage-my-account/explanation-of-benefits/

Becoming a Certified Biller

How to Become a Certified Biller

How to Become a Nationally Certified Biller

• Certified Revenue Cycle Executive (CRCE)– CRCE-I (Institutional)

• Patient Access• Billing• Credit/Collections• Revenue Cycle Management

– CRCE-P (Professional)• Front Desk• Billing• Credit/Collections• Revenue Cycle Management

– The applicant must have a minimum of four (4) years of experience in a healthcare related field. A two (2) year associate degree or a degree from an accredited university or college can be substituted for two (2) years of experience. When using an educational waiver for experience, a transcript copy must accompany the application.

American Association of Healthcare Administrative Management (AAHAM)• Certified Revenue Cycle Specialist (CRCS)• CRCS-I

– Designed for the revenue cycle within an Institution– Hospital Environment– Must know patient access, billing and credit & collections

• CRCS-P – Designed for the revenue cycle in a professional environment– Physicians office– Clinic– Must know front desk, billing, and credit & collections

• Membership with AAHAM not required, although encouraged• One-year employment in the healthcare revenue cycle is recommended• Dual Certification is available• Re-certification has two options

– Retake and pass the exam every three years– Joins as a national member within the year you become certified and earn CEUs

15 hours must be earned from attending AAHAM related educational programs The other 15 hours can be earned through other educational opportunities (i.e. UBO

approved monthly webinars)– Be in good standing by 31 January of each year

Retrieved From: http://www.aaham.org/Certification/CRCS.aspx

• Certified Revenue Cycle Professional (CRCP)– CRCP-I

• Patient Access• Billing• Credit/Collections• Revenue Cycle Management

– CRCP-P• Front Desk• Billing• Credit/Collections• Revenue Cycle Management

– CRCP-I/CRCP-P exams are available to National AAHAM members, in good standing. The applicant must have a minimum of two (2) years of experience in a healthcare related field. A two (2) year associate degree or a degree from an accredited university or college can be substituted for the two (2) years of experience. When using an educational waiver for experience, a transcript copy must accompany the application.

American Academy of Professional Coders (AAPC)• Certified Professional Biller (CPB)

– Understanding different types of insurance plans – Applying payer policy, Local Coverage Determinations (LCD), and National Coverage

Determinations (NCD) for successful claim submission (Centers for Medicare and Medicaid Services)

– Knowing CPT®, ICD-9-CM (ICD-10 10/01/14), and HCPCS Level II coding guidelines– Navigating the varying rules and regulations which apply to the healthcare industry,

including HIPAA, False Claims Act, Fair Debt Collections Act, and Stark – Knowing the life cycle of a medical billing claim and how to improve the revenue

cycle – Expertise in effective claim follow-up, patient follow-up, and denial resolution– Exam Covers

• Types of Insurance• Billing Regulations• HIPAA & Compliance• Reimbursement & Collections• Coding • Case Analysis

American Academy of Professional Coders (AAPC) cont.

• Certification Requirements– We recommend having an associate’s degree.– Pay examination fee at the time of application submission.– Maintain current membership with the AAPC.

• New members must submit membership payment with examination application.

• Renewing members must have a current membership at the time of submission and when exam results are released.

– All exams will be reported with exact scores and areas of study (65% or less).

– CEUs required to maintain credentials

Retrieved From: http://www.aapc.com/certification/medical-billing-certification.aspx

How Certification Benefits the Biller

• Earning certification demonstrates a high level of achievement and distinguishes you as a leader and role model in the revenue cycle industry. The certification validates your proficiency and commitment to your profession and can play an integral role in your career strategy

• Earning certification can help you by:– Giving you a competitive advantage with current and

prospective employers– Granting you the recognition you deserve – Building a network of peers in the influential group that shares

your certification designation– Continuing to expand your skills and expertise through

continuing education

How Certification Benefits the Employer

• Earning certification demonstrates an individual’s expertise. It shows they possess the knowledge to meet the industry’s highest standards and the capacity to pass a rigorous certification examination. It shows commitment to their profession and ongoing career development. It also represents professionalism in the individual’s pursuit of excellence to quality of service in their career and the healthcare industry.

• By hiring certified individuals and investing in certification for your staff you can:– Increase the competency of your staff– Increase quality and productivity– Build a strong team– Promote ongoing education and training– Reduce exposure to fraud and abuse

Summary

• The MHS Revenue Cycle impacts everyone• It is crucial for billers and coders to have good communication• Understanding and knowing the coding, billing and payer

guidelines help claims to get paid compliantly, accurately and timely

• DHA UBO and DHA UBU have guidelines for the Services and NCR MD to follow

• DHA UBO has web-based training available for both the UB-04/837I and CMS-1500/837P and provides monthly webinars on topics relevant to the MHS Revenue Cycle

• The revised CMS-1500 (02/12), required by CMS, will become effective for all payers on 1 April 2014– TPOCS will be updated to complete this version

Thank You

Questions?

Instructions for CEU Credit

This in-service webinar has been approved by the American Academy of Professional Coders (AAPC) for 1.0 Continuing Education Unit (CEU) credit for DoD personnel (.mil address required). Granting of this approval in no way constitutes endorsement by the AAPC of the program, content, or the program sponsor. There is no charge for this credit.

• Live broadcast webinar (Post-Test not required) – Login prior to the broadcast with your: 1) full name; 2) Service affiliation; and 3) e-mail address– View the entire broadcast– After completion of both of the live broadcasts and after attendance records have been verified, a Certificate of Approval

including an AAPC Index Number will be sent via e-mail to participants who logged in or e-mailed as required. This may take several business days.

• Archived webinar (Post-Test required)– View the entire archived webinar (free and available on demand at http://

www.tricare.mil/ocfo/mcfs/ubo/learning_center/training.cfm)– Complete a Post-Test available within the archived webinar– E-mail answers to UBO.LearningCenter@altarum.org– If you receive a passing score of at least 70%, we will e-mail MHS personnel with a .mil email address a Certificate of Approval

including an AAPC Index Number

• The original Certificate of Approval may not be altered except to add the participant’s name and webinar date or the date the archived Webinar was viewed. Certificates should be maintained on file for at least six months beyond your renewal date in the event you are selected for CEU verification by AAPC

• For additional information or questions regarding AAPC CEUs, please contact the AAPC.

• Other organizations, such as American Health Information Management Association (AHIMA), American College of Healthcare Executives (ACHE), and American Association of Healthcare Administrative Managers (AAHAM), may also grant credit for DHA UBO Webinars. Check with the organization directly for qualification and reporting guidance.

Billing and Coding in Sync in the Revenue Cycle Presented By: DHA UBO Program Office Contract...

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