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CHAPTER

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Checkout Procedures

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Learning Outcomes

When you finish this chapter, you will be able to:

9.1 List the six steps in the charge capture process.

9.2 Explain the purpose of auditing diagnosis and procedure code assignment.

9.3 Discuss the effect of health plans’ rules on billing.

9.4 Describe the use of CPT/HCPCS modifiers to communicate billing information to health plans.

9.5 Discuss strategies to avoid common coding/billing errors.

9-2

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Learning Outcomes (Continued)

When you finish this chapter, you will be able to:

9.6 Explain the difference between posting charges from a paper encounter form and posting charges from an electronic encounter from.

9.7 Identify the types of payments that may be collected following a patient’s visit.

9.8 Identify the steps needed to create walkout receipts.

9.9 Describe the use of a patient education feature in an electronic health record.

9-3

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Key Terms

accept assignment
addenda
adjustments
bundled code
CCI column 1/column 2 code pair edits
CCI edits
CCI modifier indicator
CCI mutually exclusive code (MEC) edits
charge capture

9-4

charges
claim scrubbing
code linkage
compliant billing
Correct Coding Initiative (CCI)
global period
medically unlikely edits (MUEs)
modifier
MultiLink codes

There are a lot of key terms. Following are some activities to help present them.

Put students into small groups and assign each group a set of terms to define and learn. Follow up by having each group teach their set of terms to the rest of the class.

Assign each student a set number of terms to define as a homework assignment. Follow up by discussing all of the terms as a group activity during class.

Ask students whether any of the key terms are familiar to them already; use their responses to launch a discussion about the rest of the terms.

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Key Terms (Continued)

package
payments
place of service (POS) code
query
real-time claim adjudication (RTCA)
self-pay patients
unbundling
walkout receipt

9-5

Teaching Notes: See notes on Slide 4.

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9.1 Overview: Charge Capture Process

9-6

Charge capture—process of recording billable services
The six steps of the charge capture process:
Step 1: Access encounter data.
Step 2: Audit coding compliance.
Step 3: Review billing compliance.
Step 4: Post charges.
Step 5: Calculate, collect, and post time-of-service (TOS) payments.
Step 6: Check out patient.

Learning Outcome: 9.1 List the six steps in the charge capture process.

Teaching Notes: Ask students why they believe the charge capture process needs to be done in the order shown; use responses as a springboard into discussion.

Compare and contrast the electronic method of charge capture with the paper method. Discuss the pros and cons of each.

As a group, complete “Thinking It Through” 9.1 to solidify concepts.

If desired, assign students a second scenario similar to “Thinking It Through” 9.1 to complete on their own as reinforcement.

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9.1 Overview: Charge Capture Process (Continued)

9-7

Charges—amount a provider bills for performed health care services
Payments—money paid by patients and health plans
Adjustments—changes to a patient’s account

Learning Outcome: 9.1 List the six steps in the charge capture process.

Teaching Notes: These are key terms, so they may already have been defined/discussed. If so, see notes on Slide 6. If not, go through each term and relate it to the charge capture process steps.

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9.2 Coding Compliance

9-8

Physician practices audit medical coding to ensure maximum appropriate reimbursement
Codes/claims must be current and accurate for reimbursement.
Code linkage and medical necessity must be shown.
Addenda—updates to ICD-9-CM
Claim scrubber—software that checks claims to permit error correction
Code linkage—clinically appropriate connection between a provided service and a patient’s condition or illness

Learning Outcome: 9.2 Explain the purpose of auditing diagnosis and procedure code assignment.

Teaching Notes: It is IMPORTANT TO NOTE that PHYSICIANS are ultimately responsible for coding compliance, even though they do not do the actual work. Discuss this with students – why is this the case? Is it fair? Why or why not? What could physicians do to protect themselves from non-compliance?

When discussing the addenda to ICD-9, note that the code set is updated annually. What does this mean for billers/coders?

Use the screenshots in the textbook to walk students through how payments, adjustments, and changes are handled through Medisoft Network Professional.

Assign students Exercises 9.1 and 9.2.

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9.3 Billing Compliance

9-9

Health plans and government payers reimburse practices according to their own negotiated or government-mandated fee schedule.
Health plans issue many billing rules that govern what will and will not be covered.
Medical practices must comply to be reimbursed.
Compliant billing—billing actions that satisfy official requirements
Package—combination of services included in a single procedure code

Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing.

Teaching Notes: It is IMPORTANT to explain to students that noncompliant billing may be seen as FRAUD. Ask them why; discuss.

Explain that noncompliant billing may lead to any or all of the following for a practice, physician (again, since they are ultimately responsible for compliance), or staff member: delays in claim processing/receiving payments, reduced payments, denied claims, fines/sanctions, loss of hospital privileges, exclusion from health plan programs, loss of licensing, prison.

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9.3 Billing Compliance (Continued)

9-10

Bundled code—two or more related procedure codes combined into one
Global period—days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package
Correct Coding Initiative (CCI)—computerized Medicare system that prevents overpayment
CCI edits—CPT code combinations that are used by computers to check Medicare claims

Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing.

Teaching Notes: Focus on the CCI, which is updated every quarter; use Figure 9.12 in the text for reference. Stress the key terms associated with the CCI (on subsequent slides as well) and provide as many examples as possible to reinforce terms with students. The textbook has many figures and examples useful for facilitating discussion.

If possible, have coding books/CCI addenda/etc. available in class for students to review. Consider a group activity or assignment that involves students’ checking sample coding scenarios for compliance. For example, you could present three procedures which have been coded individually when there is a bundled code for the entire process (“unbundling” is covered on Slide 11).

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9.3 Billing Compliance (Continued)

9-11

Unbundling—incorrect billing practice of breaking a panel or package of services/procedures into component parts
CCI column 1/column 2 code pair edits—Medicare code edit in which CPT codes in column 2 will not be paid if reported for same day of service, for the same patient, and by the same provider as the column 1 code

Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing.

Teaching Notes: See notes on Slide 10.

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9.3 Billing Compliance (Continued)

9-12

CCI mutually exclusive code (MEC) edits—edits for codes for services that could not have reasonably been done during one encounter
Medically unlikely edits (MUEs)—units of service edits used to lower the Medicare fee-for-service paid claims error rate

Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing.

Teaching Notes: See notes on Slide 10.

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9.4 Modifiers

9-13

Modifier—number appended to a code to report particular facts
Communicates special circumstances involved with procedures.
Tells the health plan that the physician considers the procedure to have been altered in some way.
There are both CPT and HCPCS modifiers.
CCI modifier indicator—number showing whether the use of a modifier can bypass a CCI edit

Learning Outcome: 9.4 Describe the use of CPT/HCPCS modifiers to communicate billing information to health plans.

Teaching Notes: Use Tables 9.1 and 9.2 in the text as a reference and guide for this discussion. Explain that modifiers are mainly needed for situations like the following: a service/procedure was performed multiple times or by more than one physician; a service/procedure has been increased or reduced; only part of a procedure was done; unusual difficulties occurred during the procedure.

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9.5 Strategies to Avoid Common Coding/Billing Problems

9-14

Compliance errors can result from incorrect code selection or billing practices.
Strategies for compliance include:
carefully defining bundled codes and knowing global periods,
using modifiers appropriately, and
following the practice’s compliance plan, especially the guidelines about physician queries.

Learning Outcome: 9.5 Discuss strategies to avoid common coding/billing errors.

Teaching Notes: Have students discuss ways to avoid errors such as truncated codes, billing invalid/outdated codes, upcoding, or downcoding.

Explain again that the coding process is usually the ONLY way health plans/insurance companies decide whether or not to reimburse.

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9.5 Strategies to Avoid Common Coding/Billing Problems (Continued)

9-15

Place of service (POS) code—designates location where medical services were provided
Query—request for more information from a provider

Learning Outcome: 9.5 Discuss strategies to avoid common coding/billing errors.

Teaching Notes: See notes on Slide 14. If more coverage of these key terms is needed, provide examples for students; for instance, point out that a query might be needed when there is conflicting or ambiguous information.

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9.6 Posting Charges in Medisoft
Network Professional

9-16

Process of posting charges differs when using a paper encounter form versus an EHR.
Posting charges from a paper encounter form:
Click the New button in the Transaction Entry dialog box.
Complete the required fields.
Apply the payment in the Charges Area of the Transaction Entry dialog box.
Save the charges using the Save Transactions button.
MultiLink codes—groups of procedure code entries that relate to a single activity

Learning Outcome: 9.6 Explain the difference between posting charges from a paper encounter form and posting charges from an electronic encounter from.

Teaching Notes: Explain what the “required fields” are when discussing posting charges; use textbook pages 456-460 as a guide. Discuss why the information is required rather than being optional.

Be sure to explain the different color-coding references (partially paid claims are aqua, etc.) in the Transaction section.

Have students complete Exercise 9.3.

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9.6 Posting Charges in Medisoft
Network Professional (Continued)

9-17

Posting charges from an EHR:
Transactions from an EHR do not need to be manually posted in the Transaction Entry dialog box.
After electronic encounter form data is reviewed and edited (if necessary), it is posted and automatically appears in the Transaction Entry dialog box.
Unprocessed transactions can be posted from the Unprocessed Charges dialog box or from the Unprocessed Transactions Edit dialog box.

Learning Outcome: 9.6 Explain the difference between posting charges from a paper encounter form and posting charges from an electronic encounter from.

Teaching Notes: Ask students why, if posting charges from an EHR is so much quicker, there is still a need to manually enter paper claims (because not every practice is using EHRs yet, etc.)

Give student an assignment (either in groups or individually) to research reimbursement rates, fraud, or other transaction scenarios in terms of paper encounter forms versus EHR information. Ask them to write up a brief summary of their findings, with examples – did they notice anything in terms of the accuracy/reliability of EHR records versus paper records?

Have students complete Exercises 9.4-9.7.

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9.7 Posting Patient Time-of-Service Payments

9-18

Practices routinely collect payment for the following types of charges at the time of service:
Previous balances
Copayments or coinsurance
Noncovered or overlimit fees
Charges of nonparticipating providers
Charges for self-pay patients
Deductibles for patients with consumer-driven health plans (CDHPs)

Learning Outcome: 9.7 Identify the types of payments that may be collected following a patient’s visit.

Teaching Notes: Ask students why these types of payments are collected at time of service; discuss what might happen if these payments are not collected at this time.

If desired, integrate this section’s key terms (on next slide) into this discussion; terms might make more sense if they are discussed in context.

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9.7 Posting Patient Time-of-Service Payments (Continued)

9-19

Accept assignment—participating physician’s agreement to accept allowed charge as full payment
Self-pay patients—patients with no medical insurance
Real-time claim adjudication (RTCA)—process used to contact health plans electronically to determine visit charges

Learning Outcome: 9.7 Identify the types of payments that may be collected following a patient’s visit.

Teaching Notes: When discussing “accept assignment,” note that the procedure for collecting nonPAR payment is different: usually the patient needs to pay everything up front. Ask students why this is the case.

Discuss the actual process for using RTCA (see textbook pages 471-472).

Before assigning exercises, walk through the process of entering payment information in Medisoft Network Professional with students.

Reinforce the color-coded payment key (gray, yellow, aqua).

Ask students to complete Exercises 9.8 and 9.9.

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9.8 Creating Walkout Receipts

9-20

Walkout receipt—report that lists the diagnoses, services provided, fees, and payments received and due after an encounter
To create a walkout receipt in MCPR:
Click the Print Receipt button in the Transaction Entry dialog box; the Open Report window appears.
Click the OK button; the Print Report Where? Dialog box is displayed.
Make a selection, and click the Start button.
Click the OK button to send the report to its destination.

Learning Outcome: 9.8 Identify the steps needed to create walkout receipts.

Teaching Notes: Ask students to brainstorm why walkout receipts are a good idea. In their experience, does every practice provide walkout receipts? Why or why not?

Have students complete Exercises 9.10 and 9.11.

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9.9 Printing Patient Education Materials

9-21

It may be appropriate to give patients education materials during checkout in order to:
help patients better understand their diagnoses and treatments, and
provide instructions following an office procedure.
The patient education feature of MCPR provides a built-in set of patient education articles that can be printed and given to patients.

Learning Outcome: 9.9 Describe the use of a patient education feature in an electronic health record.

Teaching Notes: Have students brainstorm what types of information might be given to patients (an article on blood pressure, information on reduced sodium diets, etc.). Have students discuss the benefits of providing this information to patients at the office, rather than saying “look it up when you get home,” or taking time during an appointment to explain everything.

Highlight the usefulness of MCPR’s built-in database of materials – no need to look elsewhere! Note that the database contains sets of articles for pediatrics, adults, seniors, women, and behavioral health.

MCPR can automatically select the proper module based on patient information and demographics if desired.

Articles can be emailed or printed in-office (discuss benefits/drawbacks of each method).

Have students complete Exercise 9.12.