Issues and Trends in HBI Ch 17

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  • Teaching Notes:
     
    Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material.
     
  • Learning Outcome: 17.1 Distinguish between inpatient and outpatient hospital services.
    Teaching Notes:
     
    Identify and discuss with students differences between inpatient and outpatient care.
    Note that the medical insurance specialist should be aware of the coding systems and billing cycle used in hospitals.
  • Learning Outcome: 17.1 Distinguish between inpatient and outpatient hospital services.
    Teaching Notes:
     
    Ask students to provide an example of an emergency visit and the kind of services available.
    Identify and discuss with students differences between ambulatory care, the ambulatory surgical unit, and an ambulatory surgical center.
    Note that medical office staff members bill for the procedures physicians perform in the hospital environment.
  • Learning Outcome: 17.1 Distinguish between inpatient and outpatient hospital services.
    Teaching Notes:
     
    Different types of outpatient services are also provided in the patient’s home setting.
    Ask students to provide an example of the kind of services provided by a home health agency.
    Identify and discuss with students differences between at-home recovery and hospice care.
  • Learning Outcome: 17.2 List the major steps relating to hospital billing and reimbursement.
    Teaching Notes:
     Hospitals generally have large departments that are responsible for major business functions.
    Hospitals are also structured into departments for patient care.
  • Learning Outcome: 17.2 List the major steps relating to hospital billing and reimbursement.
    Teaching Notes:
      In line with HIPAA security requirements, the confidentiality and security of patients’ medical records are guarded by all hospital staff members.
    Patients are charged according to the type of accommodations and services they receive.
  • Learning Outcome: 17.2 List the major steps relating to hospital billing and reimbursement.
    Teaching Notes:
     
    Identify and discuss with students the patient’s information contained in the master patient index (e.g., full name; birth date; sex; address; admission and/or treatment date; admitting physician; attending physician; and health record number).
    Ask students to describe the relationship between the HIM and registration departments in a hospital.
     
  • Learning Outcome: 17.2 List the major steps relating to hospital billing and reimbursement.
    Teaching Notes:
     
    Identify and discuss the difference between an admitting physician and an attending physician.
    Examine and discuss with students how HINN, observation services, and the charge master ensure accurate reimbursement.
     
    Note that in the physician’s office, the charge master is called an encounter form, superbill, or charge slip.
  • Learning Outcome: 17.3 Contrast coding diagnoses for hospital inpatient cases and for physician office services.
    Teaching Notes:
     
    Examine and discuss the coding examples on page 660 with students. (Provide rule-out coding examples for further discussion.)
    Ask students to describe the advantages of a uniform coding data set such as the UHDDS.
     
    Optional Assignment:
    Ask students to write a short paragraph that provides an example of a rule-out code and why it is used in hospital coding.
  • Learning Outcome: 17.3 Contrast coding diagnoses for hospital inpatient cases and for physician office services.
    Teaching Notes:
     
    Examine and discuss with students the differences between the PDX and the ADX (provide one example of each).
    Ask students to explain how sequencing helps to ensure accurate coding.
     
  • Learning Outcome: 17.3 Contrast coding diagnoses for hospital inpatient cases and for physician office services.
    Teaching Notes:
     
    Ask students to provide examples of and discuss the differences between comorbidities and complications.
  • Learning Outcome: 17.4 Explain the coding system used for hospital procedures.
    Teaching Notes:
     
    ICD-10-PCS has a multi-axial code structure, meaning that a table format is used to present options for building a code.
    An axis is a column or row in a table; columns are vertical, while rows are horizontal.
    The coder picks the correct values from one of the rows in a table to build a seven-character code for each procedure.
  • Learning Outcome: 17.5 Discuss the factors that affect the rate that Medicare pays for inpatient services.
    Teaching Notes:
     
    Ask students to explain how the IPPS uses DRGs to classify the appropriate category codes.
    Examine and discuss with students the advantages of using grouper software.
  • Learning Outcome: 17.5 Discuss the factors that affect the rate that Medicare pays for inpatient services.
    Teaching Notes:
     
    Ask students to describe the advantages of MS-DRGs.
     
    Ask students to describe three examples of major diagnostic categories.
  • Learning Outcome: 17.5 Discuss the factors that affect the rate that Medicare pays for inpatient services.
    Teaching Notes:
     
    Examine and discuss the five codes that are used for POA indicator reporting with students. (See page 664; Y, N, W, U, .1.)
    Ask students to describe HACs and never events.
  • Learning Outcome: 17.5 Discuss the factors that affect the rate that Medicare pays for inpatient services.
    Teaching Notes:
     
    Ask students to define and provide an example for each term listed on this slide.
  • Learning Outcome: 17.6 Interpret hospital healthcare claim forms.
    Teaching Notes:
     
    Examine and discuss the UB-04 form in Figure 17.4, and its description in Table 17.1, with students.
  • Learning Outcome: 17.6 Interpret hospital healthcare claim forms.
    Teaching Notes:
     The UB-04 claim form has 81 data fields, some of which require multiple entries.
    The information for the form locators often requires choosing from a list of codes.
    Private payer-required fields may be slightly different than Medicare.
  • Issues and Trends in HBI Ch 17

    1. 1. CHAPTER 17 Hospital Billing and Reimbursement © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
    2. 2. Learning Outcomes 17-2 When you finish this chapter, you will be able to: 17.1 Distinguish between inpatient and outpatient hospital services. 17.2 List the major steps relating to hospital billing and reimbursement. 17.3 Contrast coding diagnoses for hospital inpatient cases and for physician office services. 17.4 Explain the coding system used for hospital procedures.
    3. 3. Learning Outcomes (continued) When you finish this chapter, you will be able to: 17.5 Discuss the factors that affect the rate that Medicare pays for inpatient services. 17.6 Interpret hospital healthcare claim forms. 17-3
    4. 4. 17-4 Key Terms • admitting diagnosis (ADX) • ambulatory care • ambulatory patient classification (APC) • ambulatory surgical center (ASC) • ambulatory surgical unit (ASU) • at-home recovery care • attending physician • case mix index • • • • • charge master CMS-1450 comorbidities complications diagnosis-related groups (DRGs) • emergency • grouper • health information management (HIM)
    5. 5. Key Terms (continued) • HIPAA X12 837 Health Care Claim: Institutional (8371) • home health agency (HHA) • home healthcare • hospice care • hospital-acquired condition (HAC) • hospital-issued notice of noncoverage (HINN) • ICD-10-PCS 17-5 • inpatient • inpatient-only list • Inpatient Prospective Payment System (IPPS) • major diagnostic categories (MDCs) • master patient index (MPI) • Medicare-Severity DRGs (MS-DRGs) • never events • observation services
    6. 6. 17-6 Key Terms (continued) • Outpatient Prospective Payment System (OPPS) • present on admission (POA) • principal diagnosis (PDX) • principal procedure • registration • sequencing • skilled nursing facility (SNF) • three-day payment window • UB-92 • UB-04 • Uniform Hospital Discharge Data Set (UHDDS)
    7. 7. 17.1 Healthcare Facilities: Inpatient Versus Outpatient 17-7 • Inpatient—person admitted for services that require an overnight stay • Inpatient services: – Those involving an overnight stay – Provided by general and specialized hospitals, skilled nursing facilities, and long-term care facilities • Skilled nursing facility (SNF)—facility in which licensed nurses provide services under a physician’s direction
    8. 8. 17.1 Healthcare Facilities: Inpatient Versus Outpatient (continued) 17-8 • Emergency—situation where a delay in patient treatment would lead to a significant increase in the threat to life or body part • Outpatient services: – Provided by ambulatory surgical centers or units, home health agencies, and hospice staff – Ambulatory care—outpatient care that does not require an overnight hospital stay – Ambulatory surgical unit (ASU)—hospital department that provides outpatient surgery – Ambulatory surgical center (ASC)—clinic that provides outpatient surgery
    9. 9. 17.1 Healthcare Facilities: Inpatient Versus Outpatient (continued) 17-9 • Outpatient services are also provided in patients’ home settings: – Home healthcare—care given to patients in their homes – Home health agency (HHA)—organization that provides home care services – At-home recovery care—assistance with daily living provided in the home – Hospice care—public or private organization that provides services for terminally ill people
    10. 10. 17.2 Hospital Billing Cycle 17-10 • The first major step in the hospital claims processing sequence: – Patient is admitted and registered – Personal and financial information is entered in the hospital’s health record system – Insurance coverage is verified – Consent forms are signed by the patient – A notice of the hospital’s privacy policy is presented to the patient – Some pretreatment payments are collected
    11. 11. 17.2 Hospital Billing Cycle (continued) • The second step: – The patient’s treatments and transfers among the various departments in the hospital are tracked and recorded • The third step: – Discharge and billing – Follows the discharge of the patient from the facility and the completion of the patient’s record 17-11
    12. 12. 17.2 Hospital Billing Cycle (continued) 17-12 • Health information management (HIM)— hospital department that organizes and maintains patient medical records • Registration—process of gathering information about a patient during admission to a hospital • Master patient index (MPI)—hospital’s main patient database
    13. 13. 17.2 Hospital Billing Cycle (continued) 17-13 • Attending physician—clinician primarily responsible for a patient’s care from the beginning of a hospitalization • Hospital-issued notice of noncoverage (HINN)—form used for inpatient hospital services • Observation services—service provided in a hospital room but billed as an outpatient service • Charge master—hospital’s list of the codes and charges for its services
    14. 14. 17.3 Hospital Diagnostic Coding 17-14 • Diagnostic coding for inpatient services follows the rules of the Uniform Hospital Discharge Data Set (UHDDS)—classification system for inpatient health data • Inpatient coding differs from physician and outpatient diagnostic coding in two ways: 1. The main diagnosis, called the principal rather than the primary diagnosis, is established after study in the hospital setting 2. Coding an unconfirmed condition (rule-out) as the admitting diagnosis is permitted
    15. 15. 17.3 Hospital Diagnostic Coding (continued) 17-15 • Principal diagnosis (PDX)—condition established after study to be chiefly responsible for admission • Admitting diagnosis (ADX)—patient’s condition determined at admission to an inpatient facility • Sequencing—guideline for listing the correct order of a principal diagnosis
    16. 16. 17.3 Hospital Diagnostic Coding (continued) 17-16 • Comorbidities—admitted patient’s coexisting conditions that affect the length of hospital stay or course of treatment • Complications—conditions an admitted patient develops after surgery or treatment that affect length of hospital stay or course of treatment
    17. 17. 17.4 Hospital Procedure Coding 17-17 • Volume 3 of the ICD-9-CM, Procedures, was replaced on October 1, 2013, by ICD-10-PCS to report procedures for inpatient services – Table format used to build codes – Sixteen sections with seven character codes • Principal procedure—procedure most closely related to treatment of the principal diagnosis
    18. 18. 17.5 Payers and Payment Methods 17-18 • Medicare pays for inpatient services under its Inpatient Prospective Payment System (IPPS) —Medicare payment system for hospital services – Uses diagnosis-related groups (DRGs) to classify patients into similar treatment and length-of-hospitalstay units and sets prices for each classification group – Diagnosis-related groups (DRG)—system of analyzing conditions and treatments for similar groups of patients – Grouper—Software used to assign DRGs
    19. 19. 17.5 Payers and Payment Methods (continued) 17-19 • Each hospital’s case mix index is an average of the DRG weights handled for a specific period of time • Other factors affect the pay rate a hospital negotiates with CMS: geographic location, labor and supply costs, and teaching costs • MS-DRGs—new type of DRG designed to better reflect the differing severity of illness among patients who have the same basic diagnosis • Major diagnostic categories (MDC)— categories where MS-DRGs are grouped
    20. 20. 17.5 Payers and Payment Methods (continued) 17-20 • Present on admission (POA)—code used when a condition exists at the time the order for inpatient admission occurs • Hospital-acquired condition (HAC)—condition a hospital causes or allows to develop • Never events—preventable medical errors resulting in serious consequences for the patient
    21. 21. 17.5 Payers and Payment Methods (continued) 17-21 • Outpatient Prospective Payment System (OPPS)—payment system for Medicare Part B services provided on an outpatient basis • Ambulatory patient classification (APC)— Medicare payment classification for outpatient services • Inpatient-only list – procedures billed from the facility inpatient setting only • Three-day payment window – Medicare rule bundling outpatient services within three days before admission into DRG payment
    22. 22. 17.6 Claims and Follow-up 17-22 • UB-04—Current paper claim form for hospital billing – CMS-1450—another name for the UB-04 paper claim form – UB-92—former hospital paper claim form • The UB-04 reports: – Patient data – Information on the insured – Facility and patient type
    23. 23. 17.6 Claims and Follow-up (continued) 17-23 • The UB-04 reports (continued): – The source of the admission – Various conditions that affect payment – Whether Medicare is the primary payer (for Medicare claims) – The principal and other diagnosis codes – The admitting diagnosis – The principal procedure code – The attending physician – Other key physicians – Charges
    24. 24. Summary
    25. 25. Summary
    26. 26. Summary

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