A Revenue Cycle Process Approach

Transcription

1 A Revenue Cycle Process Approach VALERIUS BAYES NEWBY Education BLOCHOWIAK

2 Preface x Parti Chapter1 WORKING WITH MEDICAL INSURANCE AND BILLING Chapter 3 Introduction to the Revenue Cycle Working in the Medical Insurance Field Medical Insurance Basics Healthcare Plans Health Maintenance Organizations Preferred Provider Organizations Consumer-Driven Health Plans Medical Insurance Payers The Revenue Cycle Achieving Success Moving Ahead 26 Chapter Review 27 Patient Encounters and Billing Information New Versus Established Patients Information for New Patients Information for Established Patients Verifying Patient Eligibility for Insurance Benefits Determining Preauthorization and Referral Requirements Determining the Primary Insurance Working with Encounter Forms 93 Chapter 2 Electronic Health Records, HIPAA, and HITECH: Sharing and Protecting Patients' Health Information Medical Record Documentation: Electronic Health Records Healthcare Regulation: HIPAA, HITECH, and ACA Covered Entities and Business Associates HIPAA Privacy Rule HIPAA Security Rule HITECH Breach Notification Rule HIPAA Electronic Health Care Transactions and Code Sets Omnibus Rule and Enforcement Fraud and Abuse Regulations Compliance Plans 63 Chapter Review 65

3 3.8 Understanding Time-of-Service (TOS) Payments Calculating TOS Payments 97 Chapter Review ci_aiivi cooing Diagnostic Coding: ICD-10-CM ICD-10-CM Organization oficd-10-cm The Alphabetic Index The Tabular List ICD-10-CM Official Guidelines for Coding and Reporting Overview of ICD-10-CM Chapters Coding Steps ICD-10-CM and ICD-9-CM 131 Chapter Review Procedural Coding: CPT and HCPCS Current Procedural Terminology, Fourth Edition (CPT) Organization Format and Symbols CPT Modifiers Coding Steps Evaluation and Management Codes Anesthesia Codes Surgery Codes Radiology Codes Pathology and Laboratory Codes Medicine Codes Category II and III Codes HCPCS 179 Chapter Review 185 Visit Charges and Compliant Billing Compliant Billing Knowledge of Billing Rules Compliance Errors Strategies for Compliance Audits Physician Fees Payer Fee Schedules Calculating RBRVS Payments Fee-Based Payment Methods Capitation Collecting TOS Payments and Checking Out Patients 218 Chapter Review vi Contents

4 Part 3 CLAIMS 227 Chapter 7 Healthcare Claim Preparation and Transmission Introduction to Healthcare Claims Completing the CMS-1500 Claim: Patient Information Section Types of Providers Completing the CMS-1500 Claim: Physician/Supplier Information Section The HIPAA 837P Claim Completing the HIPAA 837P Claim Checking Claims Before Transmission Clearinghouses and Claim Transmission 262 Chapter Review 264 Chapter 8 Private Payers/ACA Plans Group Health Plans Types of Private Payers Consumer-Driven Health Plans Major Private Payers and the BlueCross BlueShield Association Affordable Care Act (ACA) Plans Participation Contracts Interpreting Compensation and Billing Guidelines Private Payer Billing Management: Plan Summary Grids Preparing Correct Claims Capitation Management 305 Chapter Review 306 Chapter 9 Medicare Eligibility for Medicare The Medicare Program Medicare Coverage and Benefits Medicare Participating Providers Nonparticipating Providers Original Medicare Plan Medicare Advantage Plans Additional Coverage Options Medicare Billing and Compliance Preparing Primary Medicare Claims 341 Chapter Review 344 Chapter 10 Medicaid The Medicaid Program Eligibility State Programs Medicaid Enrollment Verification Covered and Excluded Services Plans and Payments Third-Party Liability Claim Filing and Completion Guidelines 365 Chapter Review 368 Chapter 11 TRICARE and CHAMPVA The TRICARE Program Provider Participation and Nonparticipation TRICARE Plans TRICARE and Other Insurance Plans CHAMPVA Filing Claims 384 Chapter Review 3 86 Chapter 12 Workers' Compensation and Disability/ Automotive Insurance Federal Workers' Compensation Plans State Workers' Compensation Plans Workers' Compensation Terminology Claim Process Disability Compensation and Automotive Insurance Programs 406 Chapter Review 410 Contents vii

5 CLAIM FOLLOW-UP AND PAYMENT PROCESSING 419 Payments (RAs), Appeals, and Secondary Claims Claim Adjudication Monitoring Claim Status The Remittance Advice (RA) Reviewing RAs Procedures for Posting Appeals Postpayment Audits, Refunds, and Grievances Billing Secondary Payers The Medicare Secondary Payer (MSP) Program, Claims, and Payments 443 Chapter Review 447 Patient Billing and Collections Patient Financial Responsibility Working with Patients' Statements The Billing Cycle Organizing for Effective Collections Collection Regulations and Procedures Credit Arrangements and Payment Plans Collection Agencies and Credit Reporting Writing Off Uncollectible Accounts Record Retention 473 Chapter Review 474 Primary Case Studies Method of Claim Completion 15.2 About the Practice Claim Case Studies 485 RA/Secondary Case Studies Completing Secondary Claims Handling Denied Claims Processing Medicare RAs and Preparing Secondary Claims Processing Commercial Payer RAs and Preparing Secondary Claims Calculating Patients' Balances 522 Parts HOSPITAL SERVICES 529 Chapter 17 Hospital Billing and Reimbursement Healthcare Facilities: Inpatient Versus Outpatient Hospital Billing Cycle Hospital Diagnosis Coding Hospital Procedure Coding Payers and Payment Methods Claims and Follow-up 552 Chapter Review 563 viii Contents

6 PART 6 CLAIM CODING: ICD-9-CM 569 Chapter 18 Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM ICD-9-CM Organization oficd-9-cm The Alphabetic Index The Tabular List Tabular List of Chapters V Codes and E Codes Coding Steps Official Coding Guidelines Introducing ICD-10-CM 597 Chapter Review 601 Appendix A: Guide to Completing Claims Exercises in Chapters 8-12 and 15: Medisoft and CMS-1500 Activities in Connect A-1 Appendix B: Place of Service Codes B-1 Appendix C: Professional Websites C-1 Appendix D: Forms D-1 Abbreviations AB-1 Glossary GL-1 Index IN-1 Contents ix