1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 9 Physician Medical Billing

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Claim Forms  The patient information form is completed by a new patient at registration.  The assignment of benefits form is signed by the patient or guarantor so that the physician will be paid directly by the insurance carrier.

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Claim Forms  The release of information ensures that information will only be released to authorized entities.  The verification of benefits form with complete documentation is handy if claim is denied.

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Superbills  Contain ICD-9-CM and CPT codes for services office routinely provides  Individualized to meet specific needs of the practice  Printed by medical office specialist, attached to chart, and follows patient through visit

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Superbills  Also called encounter forms, charge slips, or routing slips  Source document for entering patient data into computerized system

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims  Claims are submitted on paper or optically scanned and converted to an electronic form by the insurance company.  Claim attachments are added to the paper claim if additional information is required.

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims  Electronic claims or electronic media claim (EMCs) are submitted via central processing unit (CPU).  Electronic form advantages include lower cost, fewer rejected claims, and faster payment.

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims  Electronic form disadvantages include disrupted transmission and inability of some billing programs to create electronic attachments.  Dirty claims have missing or incorrect data.

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500  The form was developed by Centers for Medicare and Medicaid Services to accelerate billing process.  Patient and insured information is in form locators 1–13.

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500  Physician and supplier information is in form locators 14–33.  Specific guidelines are according to payer and state and local levels.

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes HIPAA Requirements  Transaction and code sets  Uniform identifiers  Privacy  Security

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500 Instructions  Section I form locators 1–13 include patient and payer information.  Section II form locators 14–33 include physician and supplier information.  Claims without errors or missing information are “clean claims.”

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Physician Identification Numbers  Types of numbers used are state license numbers, employer identification numbers, and tax identification numbers.  NPI or National Provider Identification will be issued by Medicare and will replace identification numbers.

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Physician Identification Numbers  Referring physician (form locator 17a)  Ordering physician (form locator 17a)  Performing physician (form locator 24k)  Billing entity (form locator 33)

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Delayed or Rejected CMS-1500s  Problems are due to incorrect or missing information.  There are solutions to prevent reoccurrence of problems and delayed or denied claims.

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Secondary Claims  Secondary insurance covers a person in addition to primary policy.  Supplemental insurance, usually a Medigap policy, supplements Medicare payments.  Coordination of benefits occurs so that the total payment does not exceed 100% of charges.

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Secondary Claims  Rules exist for determining primary payer: –Lone policy –Policy in effect the longest –Birthday rule for dependent children –Certain rules regarding governmental policies –Refer to the list on pages 255–256

18. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 10 Hospital Medical Billing

19. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Inpatient Billing  Master patient index: Main database of all the hospital’s patients  Patient control number (PCN): Assigned at admission and unique to that confinement  Registration/admission process: Gather personal and insurance information

20. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Types of Payers  HMO: Health maintenance organizations  PPO: Preferred provider organizations  EPO: Exclusive provider organization  POS: Point-of-service plans  Commercial and indemnity plans  Workers’ compensation  Medicare, Medicaid, TRICARE Prime, TRICARE Extra, TRICARE standard

21. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Submission of Claims  This is dependent upon the medical record’s timely completion.  Role of medical office specialist includes scheduling time for physician completion of records.  Deficiencies are noted by discharge analyst.

22. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Charge Description Master (CDM)  Shows all charges and items provided.  It assists with high volume of billing for services received by hospital patients.  Services and procedures are keyed into computer.  It includes the procedure code, code and service description, charge, and revenue code

23. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Inpatient Care  Hospital confinement is greater than 24 hours.  Hospice facilities provide care for terminally ill patients.  Skilled nursing facilities provide care for patients following hospital stay.

24. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Inpatient Care  Rehabilitation facilities provide services such as physical therapy, occupational therapy, and/or speech therapy to patients following hospital stay.

25. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Outpatient Care  Ambulatory surgery centers are freestanding facilities with or without affiliation with a particular hospital.  Ambulatory surgery units are departments within a hospital that provide outpatient services.

26. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Outpatient Care  Emergency care departments provide immediate attention to prevent the loss of life or limb.  Urgent care centers provide immediate attention but there is no risk of loss of life or limb.

27. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Principal Diagnosis  Affects payment  Chosen by physician to represent the “most resource intensive” or “most specific” diagnosis

28. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Principal Diagnosis  ICD-9-CM Volumes I, II, III are utilized to determine the proper diagnosis: –Volumes I and II are utilized to determine the proper diagnosis. –Volume 3 of the ICD-9-CM is only used for hospital procedures. –Codes in Volume 3 are utilized when the procedure is surgical in nature, carries a procedural risk, carries an anesthetic risk, and/or requires specialized training.

29. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Diagnosis Related Group System  Form of prospective pay using categories of similar patients  Patient classification past and current  Variables responsible for DRG classification

30. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Diagnosis Related Group System  CMI based on several factors  Cost outlier: An atypical case that cannot be assigned a DRG  DRG creep: An unethical practice, upcoding

31. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes UB-04  Hospital claim form implemented in 1996 following HIPAA  Required by CMS  Accepted by private providers

32. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Instructions for UB-04  UB-04 form divided into four sections and includes the following: –82 different form locators –Patient information (1–39), billing information (40–49 and claim line 23), payer information (50–65), and diagnosis information (66–81)

33. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Instructions for UB-04  Form locators 1–81 numbered from top to bottom and left to right  Four-digit codes required to identify data