Medical Billing RCM Module

Revenue Cycle Management

1. REVENUE CYCLE MANAGEMENT Confidential

2. There are different departments in the Revenue Cycle Management. This module will help you understand the functions of each department. Confidential

3. Confidential Pre-Registration Pre Registration is fixing an appointment Patient would generally call the provider’s office or Hospital to fix an appointment Any non-emergency service should be Pre-registered

4. Confidential Registration At the time of Registration, patient provides personal details and Insurance details (Patient’s Demographics) During Registration, patient is also required to sign few important forms. They are AOB, ABN and Consent form We will learn about these forms in the next slide

5. Confidential AOB ABN CONSENT Registration ASSIGNMENT OF BENEFITS Patient provides authorization to the insurance to release the payment for medical services to the providers directly Patient authorizes the Release of Information ADVANCE BENEFICIARY NOTICE By signing ABN, patient agrees to make the payment to the provider in case MEDICARE ( Insurance) does not pay for the services stating, “Not Medically Necessary” ABN is applicable only for MEDICARE INSURANCE It is also called as “ Waiver Of Liability” By signing Consent Form, patient agrees to the treatment or service planned by the provider

6. Confidential Confidential Treatment After completing the registration patient meets the doctor for the treatment.

7. Confidential Confidential Confidential Medical Records Department What is a Medical Record? Medical record is a legal document providing a chronicle of a patient’s medical history and care. It is a document containing sufficient data written in sequences of events to justify the diagnosis, and warrant the treatment given and the end results. Medical Records Department maintains an adequate medical record for every individual who is evaluated or treated as an inpatient, outpatient or emergency patient. Examples of Medical Records Consultation note, Operative Report, Anesthesia Report, X-Ray, Lab Report etc.

8. Confidential Confidential Confidential Confidential Medical Records Department Medical Records could be stored in a paper form or electronically. Medical Records Department ensures that Medical Records are available as and when required and in any form required EHR – Electronic Health Record EMR – Electronic Medical Record

9. Confidential Confidential Confidential Confidential Confidential Coding Coding team converts the diseases and treatments in to numeric or alpha numeric codes. Diagnosis Coding is the translation of written descriptions of diseases, illnesses and injuries into codes. It is coded using ICD guidelines. ICD-10-CM is the current version which is effective as of October 1 st 2015 . Format of ICD 10 - T82.311A, L89.152 ICD is governed by World Health Organization (WHO). ICD-10-CM – International Classification of Diseases 10 th Revision Clinical Modification Diagnosis Code

10. Confidential Confidential Confidential Confidential Confidential Coding ICD 10 Code Format 1st 2nd 3rd 4th 5th 6 th 7 th Category Etiology, Anatomical Site, Severity Extension Alpha (Except “U”) Numeric Characters 3 to 7 can be any combination of alpha or numeric The Characters after decimal provides specificity

11. Confidential Confidential Confidential Confidential Confidential Coding The Healthcare Common procedure Coding System (HCPCS) is divided into two Procedure Codes HCPCS Level I - CPT Level I of the HCPCS is comprised of Current Procedural Terminology (CPT) , a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professional. Format of CPT – 64447 (CPT consists of 5 digits)

12. Confidential HCPCS Level II / National Codes Coding Procedure Codes Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services such as ambulance services and durable medical equipment, prosthetics, orthotics etc. Format of National Codes; A4586, J4820 ( National codes are alpha numeric. First character will be alpha ranging from letters “ A ” to “ V ”)

13. Confidential Coding Modifiers A Modifier is a 2 character codes that adds more meaning to the procedure codes. Example; Dr. John performed cataract surgery for a patient on both eyes. If procedure code performed is 66984 , Doctor can indicate that service was performed on both eyes by adding modifier “50” (Bilateral). If procedure was performed on the left eye, modifier used will be “LT” which indicates left side or “ RT” that indicates right side.

14. Confidential Common Modifiers Modifiers Meaning 26 Professional Component TC Technical Component 50 Bilateral Procedure 51 Multiple Procedures 52 Reduced Service 53 Discontinued Service 59 Distinct Procedural Service 76 Repeat Procedure by Same Physician 77 Repeat Procedure by Another Physician 80 Assistant Surgeon 99 Multiple Modifiers LT Left Side RT Right Side

15. Confidential Common Place of Service Codes POS Code POS Name 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room (Hospital) 24 Ambulatory Surgical Center 26 Military Treatment Facility 31 Skilled Nursing Facility 34 Hospice Place of Service codes are 2-digit codes that indicates the place where the service was rendered.

16. Confidential Confidential Confidential Charge Entry After the coding is complete, the codes are entered in the billing software by the Charge Entry team to generate a bill or Claim. Also, Charge Entry team does the task of entering the patient’s demographic information to create patient’s account. Date Format – MM/DD/YYYY Name Format - Last Name, First Name, Middle Initial or First Name, Middle, Last Name Remember! Example; Doe, John M or John M Doe

17. Confidential Confidential Confidential Claims Transmission Once the claim is created, it has to be sent to the insurance for evaluation. Claims could be sent to the insurance in two ways Paper Electronic Paper claims are mailed to the claims mailing address or faxed to the insurance directly. Electronic claims goes through a third party called Clearinghouse

18. Confidential Electronic transmission - Flow Billing Office Clearinghouse Payer Incomplete claims or claims with errors are rejected and sent back to the Billing Office Clearinghouse performs edits using scrubber software to check errors Clean claims are transmitted to payer Claims that has no errors and pass through the Clearinghouse edits are called Clean Claims

19. Confidential Payer or Insurance Payers, upon receiving the claims, Adjudicates the claim. After the adjudication process, claim could be Paid Denied or Pended Regardless of the outcome, Insurance sends out correspondence (like EOB, ERA ) to the providers to notify the final status of the claim. EOB – Explanation of Benefits (Paper ) ERA – Electronic Remittance Advice (Electronic) ERA is commonly called as “RA” Remittance Advice

20. Confidential Cash Posting or Payment Posting Account Information Patient Name DOB Account Number       Doe, John 05-08-1980 JOD58747852221       Transaction Details DOS CPT MOD Amount Billed Paid Balance 04-05-2016 76200 26 $200.00 $200 $0 There is no patient's responsibility Check Details Check Number - 859685213 (Aetna Insurance) Check Issue Date 05-01-2016 Whether the claim is paid or denied, after receiving the EOB/ERA, Cash Posting team will post the payment or denial information in the billing software. Cash Posting team works on any correspondence that is received from the Insurance. Below is the example of payment posted by the Cash Posting team

21. Confidential Cash Posting or Payment Posting Cash Posting is the department who would receive and work on any correspondence sent by the insurance like EOB’s, Letter’s requesting information, Pay Checks etc. If claim is paid – Cash Posting team would post the payment in the respective patient’s account. If claim is denied – Cash Posting team would post the denial information in the respective patient’s account and forward claims to AR team. Cash Posting team also carries out the task of billing the secondary insurance or patient based on the details received from Insurance through EOB’s When patient is billed, a statement goes out to the patient

22. Confidential Accounts Receivables Accounts Receivables team is responsible for working on denied claims to bring a resolution. AR Team also works on claims where insurance has not responded about the processing status over 30-45 days. Upon receiving the denial AR team would first analyze the claim and call the insurance if required.

23. Confidential Collections Collections team could be set up internally or hired externally. When insurance indicates patient is responsible to make the payment, Cash Posting team would send out the statement to the patient. When patient does not make a payment to the provider , such accounts will be sent over to the collections team or agency. Accounts are forwarded to the collections team only after a minimum of 3 attempts are made by the provider’s office to collect the payment in at least 3 billing cycles. Each billing cycle ranges from 30 to 45 days.

24. Confidential Quality & Compliance Compliance Adhering to a rule, policy, standard, or law of both Federal and State. Quality Quality is a program for the systematic monitoring and evaluation of the various departments within RCM to ensure that standards of quality are being met.

25. Confidential REVENUE CYCLE MANAGEMENT End of Presentation