This document provides an overview of the different departments within the revenue cycle management process. It describes the key functions of each department including pre-registration, registration, treatment, medical records, coding, charge entry, claims transmission, payer cash posting, accounts receivables, collections, and quality and compliance. The document explains the purpose and processes involved at each step of the revenue cycle to manage patient information, code procedures, bill for services, obtain payment, and ensure compliance.

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2. There are different departments in the Revenue Cycle Management.
This module will help you understand the functions of each
department.
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Pre
Registration
Registration
Treatment
Medical
Records
Department
Coding
Charge Entry
Claims
Transmission
Payer Cash Posting
Accounts
Receivables
Collections
Quality &
Compliance

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Pre-Registration
•Pre Registration is fixing an appointment
•Patient would generally call the provider’s office or Hospital to fix an
appointment
•Any non-emergency service should be Pre-registered

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Registration
• At the time of Registration, patient provides personal details and
Insurance details (Patient’s Demographics)
•During Registration, patient is also required to sign few important
forms. They are AOB, ABN and Consent form
We will learn about these forms in the
next slide

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AOB
ABN
CONSENT
Registration
ASSIGNMENT OF BENEFITS
•Patient provides authorization to the insurance to release
the payment for medical services to the providers directly
•Patient authorizes the Release of Information
ADVANCE BENEFICIARY NOTICE
•By signing ABN, patient agrees to make the payment to the
provider in case MEDICARE (Insurance) does not pay for
the services stating, “Not Medically Necessary”
ABN is applicable only for MEDICARE INSURANCE
It is also called as “Waiver Of Liability”
By signing Consent Form, patient agrees to the treatment or
service planned by the provider

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Treatment
•After completing the registration patient meets the doctor for the
treatment.

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Medical Records Department
What is a Medical Record?
Medical record is a legal document providing a chronicle of a patient’s
medical history and care. It is a document containing sufficient data
written in sequences of events to justify the diagnosis, and warrant the
treatment given and the end results.
Medical Records Department maintains an adequate medical record for
every individual who is evaluated or treated as an inpatient, outpatient or
emergency patient.
Examples of Medical Records
Consultation note, Operative Report, Anesthesia Report, X-Ray, Lab
Report etc.

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Medical Records Department
•Medical Records could be stored in a paper form or electronically.
• Medical Records Department ensures that Medical Records are
available as and when required and in any form required
EHR – Electronic Health Record
EMR – Electronic Medical Record

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Coding
Coding team converts the diseases and treatments in to numeric or
alpha numeric codes.
Diagnosis Coding is the translation of written descriptions of diseases,
illnesses and injuries into codes.
It is coded using ICD guidelines. ICD-10-CM is the current version
which is effective as of October 1st 2015.
Format of ICD 10 - T82.311A, L89.152
ICD is governed by World Health Organization (WHO).
ICD-10-CM – International Classification of Diseases 10th
Revision Clinical Modification
Diagnosis Code

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Coding
ICD 10 Code Format
1st 2nd 3rd 4th 5th 6th 7th
Category Etiology, Anatomical Site, Severity Extension
Alpha
(Except “U”)
Numeric
Characters 3 to 7 can be any combination of alpha or numeric
The Characters after decimal
provides specificity

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Coding
The Healthcare Common procedure Coding System (HCPCS) is
divided into two
Procedure Codes
HCPCS Level I - CPT
Level I of the HCPCS is comprised of Current Procedural Terminology
(CPT) , a numeric coding system maintained by the American Medical
Association (AMA). The CPT is a uniform coding system consisting of
descriptive terms and identifying codes that are used primarily to
identify medical services and procedures furnished by physicians and
other health care professional.
Format of CPT – 64447 (CPT consists of 5 digits)

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HCPCS Level II / National Codes
Coding
Procedure Codes
Level II of the HCPCS is a standardized coding system that is used primarily
to identify products, supplies, and services such as ambulance services and
durable medical equipment, prosthetics, orthotics etc.
Format of National Codes; A4586, J4820 (National codes are alpha
numeric. First character will be alpha ranging from letters “A” to “V”)

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Coding
Modifiers
A Modifier is a 2 character codes that adds more meaning to the
procedure codes.
Example; Dr. John performed cataract surgery for a patient on both eyes.
If procedure code performed is 66984, Doctor can indicate that service
was performed on both eyes by adding modifier “50” (Bilateral).
If procedure was performed on the left eye, modifier used will be “LT”
which indicates left side or “RT” that indicates right side.

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Common Modifiers
Modifiers Meaning
26 Professional Component
TC Technical Component
50 Bilateral Procedure
51 Multiple Procedures
52 Reduced Service
53 Discontinued Service
59 Distinct Procedural Service
76 Repeat Procedure by Same Physician
77 Repeat Procedure by Another Physician
80 Assistant Surgeon
99 Multiple Modifiers
LT Left Side
RT Right Side

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Common Place of Service Codes
POS Code POS Name
11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room (Hospital)
24 Ambulatory Surgical Center
26 Military Treatment Facility
31 Skilled Nursing Facility
34 Hospice
Place of Service codes are 2-digit codes that indicates the
place where the service was rendered.

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Charge Entry
After the coding is complete, the codes are
entered in the billing software by the Charge
Entry team to generate a bill or Claim.
Also, Charge Entry team does the task of entering the patient’s
demographic information to create patient’s account.
Date Format – MM/DD/YYYY
Name Format - Last Name, First Name, Middle Initial
or
First Name, Middle, Last Name
Remember!
Example; Doe, John M or John M Doe

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Claims Transmission
Once the claim is created, it has to be sent to the insurance for evaluation.
Claims could be sent to the insurance in two ways
Paper Electronic
Paper claims are mailed to the claims mailing address or faxed to the
insurance directly.
Electronic claims goes through a third party called Clearinghouse

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Electronic transmission - Flow
Billing Office Clearinghouse Payer
Incomplete claims or claims with errors are rejected and sent back to the
Billing Office
Clearinghouse performs edits using
scrubber software to check errors
Clean claims are
transmitted to payer
Claims that has no errors and pass through the Clearinghouse edits are
called Clean Claims

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Payer or Insurance
Payers, upon receiving the claims,
Adjudicates the claim. After the adjudication
process, claim could be
Paid
Denied or
Pended
Regardless of the outcome, Insurance sends out correspondence (like EOB, ERA)
to the providers to notify the final status of the claim.
EOB – Explanation of Benefits (Paper )
ERA – Electronic Remittance Advice (Electronic)
ERA is commonly called as “RA” Remittance Advice

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Cash Posting or Payment Posting
Account Information
Patient Name DOB Account Number
Doe, John 05-08-1980 JOD58747852221
Transaction Details
DOS CPT MOD Amount Billed Paid Balance
04-05-2016 76200 26 $200.00 $200 $0
There is no patient's responsibility
Check Details Check Number - 859685213 (Aetna Insurance)
Check Issue Date 05-01-2016
Whether the claim is paid or denied, after receiving
the EOB/ERA, Cash Posting team will post the
payment or denial information in the billing
software.
Cash Posting team works on any correspondence
that is received from the Insurance.
Below is the example of payment posted by the Cash Posting team

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Cash Posting or Payment Posting
Cash Posting is the department who would receive
and work on any correspondence sent by the
insurance like EOB’s, Letter’s requesting
information, Pay Checks etc.
If claim is paid – Cash Posting team would post the payment in the respective
patient’s account.
If claim is denied – Cash Posting team would post the denial information in the
respective patient’s account and forward claims to AR team.
Cash Posting team also carries out the task of billing the secondary insurance or
patient based on the details received from Insurance through EOB’s
When patient is billed, a statement goes out to the patient

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Accounts Receivables
Accounts Receivables team is responsible for
working on denied claims to bring a resolution.
AR Team also works on claims where insurance has
not responded about the processing status over 30-
45 days.
Upon receiving the denial AR team would first
analyze the claim and call the insurance if required.

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Collections
Collections team could be set up internally or hired externally.
When insurance indicates patient is responsible to make the payment, Cash
Posting team would send out the statement to the patient.
When patient does not make a payment to the provider , such accounts will be
sent over to the collections team or agency.
Accounts are forwarded to the collections team
only after a minimum of 3 attempts are made
by the provider’s office to collect the payment
in at least 3 billing cycles.
Each billing cycle ranges from 30 to 45 days.

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Quality & Compliance
Compliance
Adhering to a rule, policy, standard, or law of both Federal and State.
Quality
Quality is a program for the systematic monitoring and evaluation of
the various departments within RCM to ensure that standards of
quality are being met.

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End
of
Presentation