Health Informatics: Assignment Week 5

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CHAPTER

9 Checkout Procedures

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

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

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

Key Terms (Continued)

• package

• payments

• place of service (POS)

code

• query

• real-time claim

adjudication (RTCA)

• self-pay patients

• unbundling

• walkout receipt

9-5

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.

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

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

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

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

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

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

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

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.

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

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

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.

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)

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

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.

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.