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section 3 CRCR
Financial Care
| Question | Answer |
|---|---|
| EMTALA | Emergency Medical Treatment and Labor Act |
| EMTALA Requirements | hospitals provide MSE medical screening examination to determine EMC Emergency Medical Condition. Must stabilizing health treatment to everyone that request it . Do not ask about insurance or payment if it delays treatment |
| Emergency department Registration | patients are triaged and medically screened by medical personnel where a quick registration record is generated to specifically allow order entry. After triage the patient is placed in the bed or may return to the waiting room |
| Registration for Unscheduled Patient in ER | Must satisfy EMTALA requirements the remaining registration is completed at bedside or in the registration area. Copayment is discussed during discharge |
| MPI | Master Patient Index |
| What is MPI | Full name, soc, DOB, Photo ID |
| Primary Care Physician | oversees care and makes referrals to specialist . May be a family practitioner, OB GYN, pediatrician |
| Referring Physician | referred patient to another physician for care |
| Attending Physician | writes order for service in charge of care for a specified period of time also called admitting physician for advice on care |
| Consulting Physician | used by attending physician for advice on care |
| Patient Dumping | Sending a patient to another facility for care that should be completed in the ED and if the patient is referred for follow up care and a physician accepts the referral the physician must provide the care regardless of the patient ability to pay |
| Inpatient | used if a patient needs further treatment at a hospital because the patient cannot be treated or evaluated in 24 hours or the patient does not improve in 24 hours or can be converted to observation |
| Observation | used to evaluate the patient for possible admission because treatment is expected to last 24 hours |
| Two Midnight Rule | hospitals account for the total hospital time and outpatient time before inpatient admission |
| Discharge process | 1. physician writes the order 2. caseworker plan is finalized 3. Patient instructions are given 4. Access services checks for courtesy discharge if not then patient must see financial counselor 5. Registration is updated |
| Types of Registration Forms | Consent to treat, privacy notice, and condition of admission, important message from Medicare, Power of Attorney/Advanced directive, Medicare Outpatient Observation Notice, Patients Bill of Rights |
| Consent to treat | used to inform the patient about the admission and other conditions that must be agreed to as part of the agreement for the hospital to provide care |
| Privacy Notice | issued by HHS and HIPPA no disclosure of protected health information and must get written notice to patient |
| Condition of Admission | used to inform the patient about the admission and other conditions that must be agreed to as part of the agreements to provide care |
| Important Message From Medicare | All beneficiaries that are inpatients have a right to dispute discharge decisions and beneficiaries can appeal it. Issued by Hospitals within two days after admission and no later than 2 days calendar days before discharge |
| MOON | Medicare Outpatient Observation Notice |
| What is MOON | Medicare Outpatient Observation Notice. Explains why the patient is an outpatient receiving observation services and not impatient of hospital for more than 24 hours. Mandated by CMA issued by hospitals within 36 hours of observation |
| Advance Directive | signed by a competent person giving direction to healthcare providers about treatment choices |
| What are the types of advanced directives | Power of Attorney and living will |
| Power of Attorney | allows a patient to name an individual 18 or older to act on the patients behalf |
| Living Will | allows the patients to state treatment wishes in writing but does not name the patient advocate |
| Bed Control | census management. it is an accurate recording of patient bed status |
| Bed Control: Assignment | based on diagnosis and clinical condition. Entered during registration . Patient place is based on intensity of care |
| Bed Control: Transfer Procedure | requires a request and must be medically necessary. Registration record is updated when patient arrives at new facility |
| Case Manager | Employed by provider. Manage care plans and other health plans |
| Charge Audit report | verifies against logs schedules and medical record use CPT or HCPCS |
| Case Management Responsibilities | Monitor resources and coordinates discharge planning process. Discharge planing starts as soon as admission |
| Types of Case Management Review | Perspective view (pre cert) Concurrent review, discharge, retrospective review after service |
| Case Management Responsibility | The purpose is to monitor progression of higher resource consumptive cases to help effective use resources consumptive during the care of the patient and maximize patient outcomes |
| Denials and appeals | Managed by case managers |
| Charge Captuer | how a provider charges patients and the health plan. Revenue associated with service. The process of recording a change for service or item on a patient's record |
| Importance of charges | accurate capture in a timely manner generates more revenue. More timely accurate billing and collection. Ensures that bills do not have to be held for late charges. Decreases questions relating to duplicate charges, or changing codes |
| What is the charge Master | List of services procedures room accommodations supplies and drug s or radiopharmaceuticals billed to the hospital inpatient or outpatient |
| Elements of a charge master | CMD, department number and the revenue generating area, billing or charge description charge account, CPT or HCPCS code , modifiers, revenue codes , and general Ledger |
| CMD | Charge description master number |
| Charge account | dollar amount assigned to the charge line item |
| Modifiers | 2 digit alphanumeric characters that can be appended to the CPT or HCPCS that provides additional information |
| Revenue Codes | 4 digit number established by National Uniform Billing that categorizes and classifies a line item int the charge mast er |
| General Ledger | used for accounting purposes that detects the revenue to the appropriate department |
| NUBC | National Uniform Billing |
| Charge Master Challeges | 1.omission of charges, not all charges considered results in missed revenue 2.obsolete or invalid Codes results in claim denial and negatively affects reimbursement, 3.The omission of required modifiers results in health plan denials an impacts revenue |
| Charge Master Maintenance | Completed by individual or department in Billing, HIM, Managed care , compliance, Information Systems, Service area Departments and Physicians responsible for creating and review of medical protocols |
| HCPCS Codes | |
| What is HIM | the management of all patient medical records and primary source of clinical data used for reimbursement by health plans and liability payers |
| HIM | health information Management |
| Why is HIM required | serves as a legal documentation makes sure complete data for claims. The medical record is review for a patients clinical information which is coded into the medical record system. The claims information is sent to the patient accounting system. |
| Responsibilities of HIM | serves as legal documentation for patient and provider. makes sure data is complete for claims |
| Importance of HIM | helps with health insurance claims. Effects reimbursement of providers because medical records serve as the basis for reimbursement of payment from 3rd party payers. Used to substantiate health insurance claims filed by physician, provider, and patient. |
| Electronic Health Record | EHR |
| What is EHR | record assignment diagnostic codes chart or medical record. The digital version of a paper chart . Gives information securely and instantly to authorized users. |
| EHR System | medical and treatment histories . Diagnosis, meds, treatment plans, immunization dates , allergies and radiology |
| EHR and Claim generation | connected to coding an charge software . The connection between clinical documentation process to the coding and charge process that supports claims |
| Finance , Coding, & the Revenue Cycle | Reimbursement and budget personnel actively model coding and reimbursement changes both positive and negative. This leads to coding and assignment of MS-DRGS & CPT/HCPCS codes. Place controls on downcoding and upcoding that create compliance issues |
| Senior Leadership, Coding, and the Revenue Cycle | ICD-10 allows for them to work with physicians to improve the outcomes enhances reimbursement and drives significant improvement |
| Patient Access, Coding, and Revenue Cycle | Diagnoses and Procedure codes are used to validate medical necessity . Coding must be obtained prior to the appointment and mapped correctly to the health plans requirements. |
| Patient accounting and billing, Coding, and Revenue | claim edits to meet health plan requirements. Use a number of claim edits to ensure that claims meet all healthcare requirements prior to submission to health plans for payments. Generally CPT/HCPCS codes and ICD-10 codes are edited to meet requirements |
| Prompt Payment , | can be determined by health plan contracts or by state and government rules |
| UB-04 Source of Data Summary | Patient access staff has a significant role in ensuring that the UB-04 form is completed accurately |
| UB-04 Codes to know | condition codes, occurrence codes, Occurrence span codes, and value codes |
| Claim Edits | rules developed to verify the accuracy and completeness of claims based on each plans policy |
| EDI | Electronic Data Interchange |
| What is the EDI for claim forms | UB-04=8371I, CMS 1500=837-P |
| Electronic Claim Submission | 1. Submit receipt and processing is all electronic 2. providers can electronically monitor receipt of claims 3. online claim adjudication is performed and providers recieve result so providers collect patient liability with payment turnaround minimized |
| Counting Impatient Days | Midnight to midnight method 1 day begins at midnight and ends 24 hours later |
| Outpatient Series | one single claim but must submit interim bill used for extending out patient status if over 30 days an interim bill is sent every 30 days |
| Time Limits for Billing | PPACA state that claims beyond one year of service are denied by medicare. Physicians and other suppliers have 30 days |
| Rural Health Clinic | CPT Code 520 and 521 needed for billing process |
| RHC | Rural Health Clinique |
| Hospice Exclusions | service not deemed medically necessary and custodial care perspective rates |
| SNF and billing rules | part A and some services in part b post hospital care, Patient is discharged from the acute care to post hospital |
| Ambulance Billing | Goes directly to the health plan except if there is a diagnostic service that the hospital cannot provide, Divides services into 600 procedural groups. |
| Hospital Based Physicians | HBP |
| What is HBP billing | acute care setting not contracted by a health plan |
| Clinic Billing | CMS regulations for facility and professional billing are 2 claims 2 copays and 2 coinsurance |
| Telehealth | Two way real time communication between patient and provider |
| Healthcare Contracts | all contracts include a type of discounted payment methodology. These discounted payment models can be as simple as a percentage discount to complex cares rates with outliers |
| Common Payment Models | per diem discount, per diem payment, Diagnostic Related Group, Ambulatory Payment Classification , Fee schedule, case rates, Package Episodic Pricing, Bundled Payments (Medicare) and Capitatiation |
| DRG | Diagnostic Related Group |
| APC | Ambulatory Payment Classification |
| Per Diem Discount | Indemnity FFS Payment model. health plans and providers can and do negotiate a discount agreement resulting in the provider agreeing to a percentage discount of charges. |
| Per Diem Payment | per day a fixed amount per patient per day inpatient stay FFS used by PPO HMO MCO |
| What is Diagnosis related group | classifying inpatient on the basis of diagnostic procedure |
| Ambulatory Payment Classification | divides all included outpatient services into 600 procedure groups |
| Fee Schedule | used with outpatient services based on CPT or HCPCS codes |
| Case Rates | Patient condition for single payment fixed price |
| Package (Eposidic) Pricing | lump sum or bundle payment is negotiated between the health plan and provider |
| BPCI | Medicare Bundled Care Initiative |
| What is BPCI | a payment arrangement that included financial and quality accountability. Designed to aline hospital incentives with provider incentives to non-physicians to coordinate patient care |
| Capitation | provider receives a flat fee every month per individual for enrolled in a managed care health plan. Per member per monthon |
| Fixed contracting | 60% of providers revenue is based on fixed operation revenues |
| Silent PPOs | refers to a scheme where health plans that do not offer preferred provider organization policies apply contracted PPO discounted rates to patient's bills that are not part of the PPO network |
| How Silent PPOs Work | claim is sent to the health plan. health plan runs provider's tax ID through a PPO discount database or repricing company gets a claim. Once a hit the claim is repriced & reduce the bill. EOB states provideragrees Discount is written off |
| Admission Orders | admitted for inpatient/outpatient observation |
| Fee for Service | Original Medicare |
| Revenue Capture and Recognition | grouped by revenue codes for billing. |
| How Charges Are Recorded | There are room and board charges and Aciliation charges |
| What are Level 1 HCPCS Codes | Approved by American Medical Association's CPT-4 codes. All CPT-4 codes are included within the HCPCS listing code |
| What are level 2 HCPCS Codes | CMS developed codes to classify supplies and non physician services such as DME, ambulance, medical and surgical supplies and drugs. This begins with a single letter A-V |
| What are level 3 HCPCS Codes | assigned by Medicare Administrative Contractor (MAC). Used to describe a new procedure. letter begins with W-Z |
| HCPCS Codes | Indicate that a procedure was altered by circumstances but not changed in the definition or code. Used to indicate that a procedure was altered by a circumstance but not charged in its definition or code There are 3 levels of modifiers |
| HCPCS Modifiers | 3 levels that impact reimbursement. When used correctly they provide an accurate picture of service provided. Can be assign in the charge master or coding process. |
| Level 1 HCPCS Modifier | 22-74 more information on provider services and how they affect the procedure |
| Level 2 HCPCS Modifiers | Letters and numbers to denote the orientation of the body |
| Level 3 HCPCS Modifiers | Assigned by MAC. WA=cosmetic surgery. WI administration of Food and Drug Administration approved drug |
| Coding and Revenue Cycle | Finance, senior leadership, patient access, and patient account billing rely on codes that are assigned |
| Claims Process | The activity required to send a request for payment to a 3rd party health plan for payment of benefits under a health plan or liability insurance. |
| Clean Claims | All activities required to to send a request for payment to a 3rd party are complete . Has no defect. May pe sent electronically or by paper |
| What is a UB-04 | Uniform Billing form -04. Data is uniform based on the National Uniform Billing Commitiee |
| what is a CMS 1500 | A form used by health professionals |
| What is ICD-10-CM | codes used to designate diagnostic procedure and morbidity, Based on WHO International classification of diseases. |
| What is ICD-10- PCS | Procedure codes |
| Hard Code | On the Charge Master for procedure Coding |
| Soft Code | assigned by HIM |
| Hospital Claim forms | CMS 1450, UB-04, Or 838-I |
| Medical Professional Claim form | CMS 1500, 837-P |
| Common Billing Requirements | ER report, the history and physical exam, therapy notes, operative reports, discharges and summary |
| Counting Inpatient Days | Begins a midnight and ends 24 hours later. Admission counts as 1 full day. Discharge, death, leave of absents is not counted as a day. If death discharge, leave of absents occurs on the same day as admission no charge |
| Provider type billing rules | based on provider types |
| What are Diagnostic Related Group | classifying inpatient based on resources fixed payment amount |
| Fee schedule | Used with outpatient services. Based on CPT and HCPCS codes |
| Case Rate | based on patient specific condition or use of resource, Fix price for specified proceedures |
Created by:
greenaka1908