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Med Billing Issues

Current Issues in Medical billing as of 2020

Four basic Methods of Physician reimbursement claims Per diem/Visit payments, Per episode payments, Capitation payments, Fee-for-Service payments
Per Diem/Visit payments A flat rate, per day or per visit without consideration of the level of the visit or time spent
Per Episode payments Bundles all services into one payment (aka case rate). Often used for ASC's, inpatient services & ED visits
Capitation payments Monthly payment amount, per patient without consideration for the number of patient visits per month
Fee-for-Service payments Itemized billing, with service or procedure amounts based on agreed fee schedule per insurance company
What is the most common reimbursement method for office or clinic-based physician services? Capitation and Fee-for-Service
Managed care plans are typically? Capitated (with some slight variations)
Managed care risk adjustment features include: Flat, per-member, per-month (PMPM) capitated rate
What influences a risk adjusted plan's capitation (or incentive)? The patient's condition(s) or diagnosis
Providers would receive at least the contracted monthly capitation, with the potential for additional revenue based on? The individual patient's risk score
How is the risk score calculated? By weighted diagnosis codes
True or False: Traditional PMPM capitation is a fixed amount that does not vary during the contract period. True: For PMPM's there is no signifiance placed on service or diagnosis codes. The services are covered as long as they fall within the scope of the capitation.
Examples of Managed Care Plans include Medicare Advantage plans, Affordable Care Act (ACA) or Health and Human Services (HHS) plans
Fee-for-service plans are valued according to CPT codes
Fee-for-service plans claims can be delayed or denied based on Medical necessity
Medical necessity is determined by Diagnosis codes
Type of plan which require the most detailed specificity for code assignment in order to be reimbursed correctly Fee-for-service
Examples of Fee-for-Service Plans include Medicare, Preferred Provider Organizations (PPO's), and Private Insurance Plans
Methods for staff to identify a patient's insurance plan in an EMR include *The use of standard terminology to identify the plan and apply a flag or pop-up *Facilities which use a superbill or encounter form should set-up templates for the identifying the patient's insurance
What is the goal for understanding reimbursement methods? Improve the staff work flow and increase the accuracy of data or codes
The reason risk adjustment was developed? To help insurers understand the cost implications of healthcare conditions and disesases, and use those implications to predict future costs
Fee-for-Service claim example: CPT code 99213 (E&M code, established patient, level 3) is based on what? RVU and allowed amount, the diagnosis codes has no bearing as long as medical necessity is met for the billed procedure
Capitated claim example: ICD-10-CM E11.65 (Type 2 diabetes mellitus with hyperglycemia) is based on what? Relative factor, the CPT code would have no value. It's important to note that in this plan providers are paid monthly for each patient. For this reason, diagnosis code(s) could impact the actual amount paid per patient
Billing for risk adjustment plans may be confusing because the importance is placed on what? Certain diagnosis codes not a single date of service
The reported period is a calendar year along with the weighted value of all qualifying diagnosis codes added together as a component of the patient's? Total risk score
It is important to report all relevant __________ and __________ that exist by the end of the year. conditions; status codes
Other factors to include in claims for risk adjusted plans are Any complications, manifestions, chronic conditions, or those considered to be in remission
Chronic condition examples include Morbid obesity and personality disorders
Conditions in remission include Alcohol/drug depence and leukemia
Status condition examples include Amputations and transplants
True or False: Diagnosis codes can be reported during face-to-face encounters by qualifying providers. True
Examples of Eligible providers include Medical doctors (MD), nurse practioners (NP), and physician assistants (PA)
Examples of Non-eligible providers include Registered nurses (RN) and medical assistants (MA)
Why is it important to be proactive about patient care when billing for risk adjustment? When patients with chronic illnesses aren't seen periodically the result is an incomplete picture of their health. Patients should be seen quarterly or even monthly.
2019 Medicare Physician Fee Schedule Final Rule documentation changes effected which codes? CPT E&M office visit codes
Rule that allows providers to acknowledge the patient's previous documented history? CMS's Final Rule for 2019
Goal of CMS's Final Rule To elminate redudancy in patient charting and improve workflow
How will 2021 coding change effect E&M codes? The number of codes available for clinic or office visits will be reduced to minimize the time spent review documents, querying providers, and fine-tunning templates to meet certain levels of care.
Condition categories (HHCs) added to the CMS-HHC Risk Adjustment model for 2019 HCC 56, 58 (with the current 58 being changed to 59), 60, 138
HCC 56 Drug abuse, uncomplicated, except cannabis
HCC 58 Reactive and unspecified psychosis
HCC 60 Personality Disorders
HCC 138 Chronic Kidney Disease, moderate (Stage 3)
What changes to HCC 55 (Drug/Alcohol Dependence) will occur? This CC will be modified by adding drug and alcohol overdose codes, also a renaming of "Drug/Alcohol Dependence, or Abuse/Use with Complications"
To ensure proper reimbursement is received for services rendered a facility should practice? Compare the medical record documentation to the Explanation of Benefits (EOB) or Remittance Advice (RA) documents sent from the insurer
A best practice for reviewing the complete cycle of a claim Reconcile a random sample of claims that have been processed by reviewing the EOBs.
The single largest payer of healthcare claims CMS
Because funds for Medicare are paid over time into the system by beneficiaries it is considered a Benefit, not a true risk-based insurance
Medicare coverage is base on this concept Medical necessity, and services defined by CMS
Medicare does not use these two concepts for coverage Authorizations or pre-certifications
What does Medicare use to justify medical necessity for services rendered? Diagnosis codes
The nature of this type of carrier is if they don't collect more in premiums than they pay out in claims the carrier will lose money Commercial insurance
Commercial claims are based on Characteristics of the insured
Commercial claims are paid based on The terms of the contract
Created by: jr84
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