A Revenue Cycle Process Approach VALERIUS BAYES NEWBY Education BLOCHOWIAK
Preface x Parti Chapter1 WORKING WITH MEDICAL INSURANCE AND BILLING Chapter 3 Introduction to the Revenue Cycle 2 1.1 Working in the Medical Insurance Field 3 1.2 Medical Insurance Basics 6 1.3 Healthcare Plans 8 1.4 Health Maintenance Organizations 11 1.5 Preferred Provider Organizations 15 1.6 Consumer-Driven Health Plans 15 1.7 Medical Insurance Payers 16 1.8 The Revenue Cycle 18 1.9 Achieving Success 23 1.10 Moving Ahead 26 Chapter Review 27 Patient Encounters and Billing Information 72 3.1 New Versus Established Patients 73 3.2 Information for New Patients 73 3.3 Information for Established Patients 82 3.4 Verifying Patient Eligibility for Insurance Benefits 85 3.5 Determining Preauthorization and Referral Requirements 88 3.6 Determining the Primary Insurance 90 3.7 Working with Encounter Forms 93 Chapter 2 Electronic Health Records, HIPAA, and HITECH: Sharing and Protecting Patients' Health Information 33 2.1 Medical Record Documentation: Electronic Health Records 34 2.2 Healthcare Regulation: HIPAA, HITECH, and ACA 41 2.3 Covered Entities and Business Associates 44 2.4 HIPAA Privacy Rule 46 2.5 HIPAA Security Rule 54 2.6 HITECH Breach Notification Rule 56 2.7 HIPAA Electronic Health Care Transactions and Code Sets 57 2.8 Omnibus Rule and Enforcement 60 2.9 Fraud and Abuse Regulations 61 2.10 Compliance Plans 63 Chapter Review 65
3.8 Understanding Time-of-Service (TOS) Payments 95 3.9 Calculating TOS Payments 97 Chapter Review 101 4 ci_aiivi cooing Diagnostic Coding: ICD-10-CM 108 4.1 ICD-10-CM 109 4.2 Organization oficd-10-cm 110 4.3 The Alphabetic Index 111 4.4 The Tabular List 114 4.5 ICD-10-CM Official Guidelines for Coding and Reporting 119 4.6 Overview of ICD-10-CM Chapters 125 4.7 Coding Steps 129 4.8 ICD-10-CM and ICD-9-CM 131 Chapter Review 133 5 Procedural Coding: CPT and HCPCS 139 5.1 Current Procedural Terminology, Fourth Edition (CPT) 140 5.2 Organization 142 5.3 Format and Symbols 147 5.4 CPT Modifiers 150 5.5 Coding Steps 153 5.6 Evaluation and Management Codes 155 5.7 Anesthesia Codes 168 5.8 Surgery Codes 169 5.9 Radiology Codes 174 5.10 Pathology and Laboratory Codes 175 5.11 Medicine Codes 176 5.12 Category II and III Codes 178 5.13 HCPCS 179 Chapter Review 185 Visit Charges and Compliant Billing 193 6.1 Compliant Billing 194 6.2 Knowledge of Billing Rules 194 6.3 Compliance Errors 199 6.4 Strategies for Compliance 201 6.5 Audits 204 6.6 Physician Fees 209 6.7 Payer Fee Schedules 211 6.8 Calculating RBRVS Payments 212 6.9 Fee-Based Payment Methods 214 6.10 Capitation 216 6.11 Collecting TOS Payments and Checking Out Patients 218 Chapter Review 220 107 vi Contents
Part 3 CLAIMS 227 Chapter 7 Healthcare Claim Preparation and Transmission 228 7.1 Introduction to Healthcare Claims 229 7.2 Completing the CMS-1500 Claim: Patient Information Section 230 7.3 Types of Providers 238 7.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section 238 7.5 The HIPAA 837P Claim 251 7.6 Completing the HIPAA 837P Claim 254 7.7 Checking Claims Before Transmission 260 7.8 Clearinghouses and Claim Transmission 262 Chapter Review 264 Chapter 8 Private Payers/ACA Plans 271 8.1 Group Health Plans 272 8.2 Types of Private Payers 275 8.3 Consumer-Driven Health Plans 279 8.4 Major Private Payers and the BlueCross BlueShield Association 282 8.5 Affordable Care Act (ACA) Plans 285 8.6 Participation Contracts 287 8.7 Interpreting Compensation and Billing Guidelines 292 8.8 Private Payer Billing Management: Plan Summary Grids 297 8.9 Preparing Correct Claims 299 8.10 Capitation Management 305 Chapter Review 306 Chapter 9 Medicare 315 9.1 Eligibility for Medicare 316 9.2 The Medicare Program 316 9.3 Medicare Coverage and Benefits 318 9.4 Medicare Participating Providers 323 9.5 Nonparticipating Providers 330 9.6 Original Medicare Plan 332 9.7 Medicare Advantage Plans 334 9.8 Additional Coverage Options 335 9.9 Medicare Billing and Compliance 337 9.10 Preparing Primary Medicare Claims 341 Chapter Review 344 Chapter 10 Medicaid 351 10.1 The Medicaid Program 352 10.2 Eligibility 352 10.3 State Programs 355 10.4 Medicaid Enrollment Verification 358 10.5 Covered and Excluded Services 362 10.6 Plans and Payments 363 10.7 Third-Party Liability 365 10.8 Claim Filing and Completion Guidelines 365 Chapter Review 368 Chapter 11 TRICARE and CHAMPVA 373 11.1 The TRICARE Program 3 74 11.2 Provider Participation and Nonparticipation 374 11.3 TRICARE Plans 376 11.4 TRICARE and Other Insurance Plans 380 11.5 CHAMPVA 381 11.6 Filing Claims 384 Chapter Review 3 86 Chapter 12 Workers' Compensation and Disability/ Automotive Insurance 394 12.1 Federal Workers' Compensation Plans 395 12.2 State Workers' Compensation Plans 396 12.3 Workers' Compensation Terminology 398 12.4 Claim Process 400 12.5 Disability Compensation and Automotive Insurance Programs 406 Chapter Review 410 Contents vii
CLAIM FOLLOW-UP AND PAYMENT PROCESSING 419 Payments (RAs), Appeals, and Secondary Claims 420 13.1 Claim Adjudication 421 13.2 Monitoring Claim Status 424 13.3 The Remittance Advice (RA) 428 13.4 Reviewing RAs 434 13.5 Procedures for Posting 435 13.6 Appeals 437 13.7 Postpayment Audits, Refunds, and Grievances 440 13.8 Billing Secondary Payers 441 13.9 The Medicare Secondary Payer (MSP) Program, Claims, and Payments 443 Chapter Review 447 Patient Billing and Collections 452 14.1 Patient Financial Responsibility 453 14.2 Working with Patients' Statements 456 14.3 The Billing Cycle 459 14.4 Organizing for Effective Collections 460 14.5 Collection Regulations and Procedures 462 14.6 Credit Arrangements and Payment Plans 466 14.7 Collection Agencies and Credit Reporting 468 14.8 Writing Off Uncollectible Accounts 471 14.9 Record Retention 473 Chapter Review 474 Primary Case Studies 478 15.1 Method of Claim Completion 15.2 About the Practice 479 15.3 Claim Case Studies 485 RA/Secondary Case Studies 515 479 16.1 Completing Secondary Claims 516 16.2 Handling Denied Claims 516 16.3 Processing Medicare RAs and Preparing Secondary Claims 518 16.4 Processing Commercial Payer RAs and Preparing Secondary Claims 520 16.5 Calculating Patients' Balances 522 Parts HOSPITAL SERVICES 529 Chapter 17 Hospital Billing and Reimbursement 530 17.1 Healthcare Facilities: Inpatient Versus Outpatient 531 17.2 Hospital Billing Cycle 532 17.3 Hospital Diagnosis Coding 543 17.4 Hospital Procedure Coding 544 17.5 Payers and Payment Methods 547 17.6 Claims and Follow-up 552 Chapter Review 563 viii Contents
PART 6 CLAIM CODING: ICD-9-CM 569 Chapter 18 Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM 570 18.1 ICD-9-CM 571 18.2 Organization oficd-9-cm 572 18.3 The Alphabetic Index 573 18.4 The Tabular List 576 18.5 Tabular List of Chapters 581 18.6 V Codes and E Codes 586 18.7 Coding Steps 588 18.8 Official Coding Guidelines 591 18.9 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