The Presentation gives us a brief idea on how does US healthcare revenue cycle is managed

1. Healthcare Revenue Cycle Management-
Front End
Jyoti Sharma

2. Appointment
• Patient calls or walks to provider office for the appointment

3. Date of Service
• Once the appointment is fixed, Patient goes to see the provider.
• Now in Covid Situation Patients can have the tele-visits as well.
• If patient go to office, they need to fill a form with their details
and sometimes office assistant does that for the patient.
• Patient provides ID cards such as driver’s license, Insurance ID
card.
• Patient must sign a Breach of confidentiality consent at provider’s
office.

4. Onset of Service
• Doctor spends time with patient by checking his history, current
illness/complaints.
• Then doctor reviews some body systems for patient.
• Recommends a treatment plan.
• Performs some tests in house/orders from outside if there is no in-
house lab.
• Performs some procedures which are necessary part of the
treatment.

5. Medical Document/Record/Health Record
• Doctor gives the dictation to the medical transcriptionist for the
Medical record keeping.
• Nowadays we have EHR(electronic health record) which is filled by
provider or by his/her assistant in the office in order to keep
patient’s medical record.

6. Medical Coding
• Once the medical record is ready either by Medical Transcription
or by EHR, it is sent to coder.
• Coders review the complete medical records and assign
appropriate CPT and ICD codes as per Coding guidelines.
• Coders look for the CCI edits if there are two or more procedures
done in the visit to assign the correct modifiers.
• Coders check the correct location for the procedure performed
and assign POS to all CPT codes.
• For one visit one DOS the POS will always be same, never put
different POS with different codes in same visit.

7. Medical Billing- Demographics Entry
• For new patient complete demographics entry has to be done,
before adding the new record always check the patient with DOB
in PMS to not duplicate the same patient record.
• If patient is already existing in the PMS, review all the information
with the new information received and update the required fields
with correct information.

8. Critical Fields- Demographics Entry
• Patient Tab: Name, DOB, Gender, SSN, Address including ZIP code,
contact number, relationship with insured, Marital Status,
Responsible party if patient is minor.
• Insurance Tab: Insurance name with correct payer ID and address,
Insured name, Insurance Id, Group Number, Group Name, Insured’s
DOB
• Referral Tab: Referring provider, Effective date of referral, Visits
authorized, Authorization number if applicable.

9. Medical Billing- Charges Entry/Claim
Generation
• Once demographics are entered, we move to enter the charges for
the patient.
• When the health records are generated via EHR, we do not
manually enter charges, but review the charges which come
directly to Claim’s center.

10. Critical Fields- Charges Entry
• Patient’s condition like employment, accident
• DOS
• POS
• TOS
• Facility
• CPT
• ICD’s mapping
• Modifiers if applicable
• Units

11. Claim Submission
• Once the charges are entered, we review the edits if they fall off
by clearing house and then submit the charges.
• Clearing house will either accept the claims or reject them.
• EDI reports review is needed to identify the rejection reasons and
fix those.
• Most of the times rejections are due to some error in the
demographics, charges or coding.
• Once the rejection is fixed, we need to submit the claim again.