Introduction to PhysicianProfessional Claims andBilling
How does a Physician medical insuranceclaim begin? At a minimum an insurance claim beginswith: A patient A provider A ...
Ways that patient contact occur: An Appointment A Walk-in Urgent/Emergency visit Scheduled Admissions “Rounds” ( hosp...
When appointments are made: Identify the patient type (new vsestablished) The nature of the visit should beidentified, i...
New patient -vs.- Established patient New patient is one that has not receivedany face to face professional services from...
Patient Sees the Provider The provider must clearly document in thehealth record Any patient history, exam and medical d...
Claim Creation: Information Requiredon a Claim Patient identifying information Patient insurance information Patient Di...
Initiating a claim for a non-hospitalsetting Patient data is provided via schedules, visit logsor other information surro...
Initiating a claim for a non-hospitalsetting continued… Settings in which the provider completesthe encounter form or cha...
Initiating a claim for a hospital based settingOption 1 Physicians or other professional clinical staff willselect the di...
Initiating a claim for a hospital based settingOption 2 Professional coding staff track patient encounters viacensus list...
Initiating a claim for a hospital basedoutreach setting Physicians or other professional clinical staff areresponsible fo...
Charge Entry Claims may be entered by Patient AccessServices Staff in some of the clinical areas Claims may be entered c...
“The Physician Claim”a.k.a.CMS 1500
Information found on CMS 1500 Patient identification Patient insurance data Services and diagnosis (ICD-9-CM/CPT/HCPCS)...
TES TES (Transaction Editing System) is a billinginterface that contains claim edits to help identifyservice information ...
Claimsmanager A billing edit interface that focuses oncoding content including but not limited tothe following: Invalid ...
A word about fraud and abuse…Fraud and Abuse Guidelines Fraud: “Intentional” deception ormisrepresentation that someone m...
Coding and billing as an identified potential riskarea for fraud and abuse Billing for items or services not renderedor n...
Coding and billing as an identified potential riskarea for fraud and abuse Knowing misuse of provider identificationnumbe...
Tips to prevent fraud and abuse relatedto coding: Never make changes to a diagnosis code or CPTcode on a claim or edited ...
Tips to prevent fraud and abuse relatedto coding: When using a CPT modifier, make sure thecombination with the CPT code i...
Introduction to physician professional claims and billing
Introduction to physician professional claims and billing
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Introduction to physician professional claims and billing

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Introduction to physician professional claims and billing

  1. 1. Introduction to PhysicianProfessional Claims andBilling
  2. 2. How does a Physician medical insuranceclaim begin? At a minimum an insurance claim beginswith: A patient A provider A service rendered to a patient
  3. 3. Ways that patient contact occur: An Appointment A Walk-in Urgent/Emergency visit Scheduled Admissions “Rounds” ( hospital daily care,consultations, nursing home visits, homevisits., etc) Scheduled Procedures/Surgery
  4. 4. When appointments are made: Identify the patient type (new vsestablished) The nature of the visit should beidentified, i.e. sick visit, annual physical,etc. Notification of insurance status: thepatient should alert the provider regardingany insurance coverage or changes incoverage
  5. 5. New patient -vs.- Established patient New patient is one that has not receivedany face to face professional services fromthe provider or another provider of thesame specialty in the same group practicewithin the last 3 years Established patient has received face toface services within the last 3 years by theprovider/provider specialty of the samegroup… CPT Evaluation and Management Guidelines
  6. 6. Patient Sees the Provider The provider must clearly document in thehealth record Any patient history, exam and medical decisionmaking as applicable Procedures performed Tests ordered or performed Any independent interpretations Any referrals or instructions to the patient &/oroffice/ancillary staff Consultations: who requested, exam/findings,response to referral source
  7. 7. Claim Creation: Information Requiredon a Claim Patient identifying information Patient insurance information Patient Diagnoses(ICD-9-CM) Patient Services/Procedures(CPT-4/HCPCS) Provider information Site of Service information (office,inpatient hospital, home, etc)
  8. 8. Initiating a claim for a non-hospitalsetting Patient data is provided via schedules, visit logsor other information surrounding encounters Encounter forms or charge tickets are utilized byproviders to communicate the services providedto the bill following scheduled visits or otherencounters Physicians or other professional clinical staff willselect the diagnoses/services best describing thepatient encounter (most clinics) OR Professional coding staff will review and/or selectthe diagnoses/services as documented in thepatient record
  9. 9. Initiating a claim for a non-hospitalsetting continued… Settings in which the provider completesthe encounter form or charge documentwill submit the completed forms for chargeentry Settings in which the encounterform/charge document is submitted to acoder will require completion by the coder.The coder will review the documentationand select the appropriate ICD-9-CM andCPT codes for the service.
  10. 10. Initiating a claim for a hospital based settingOption 1 Physicians or other professional clinical staff willselect the diagnoses/services best describing thepatient encounter Diagnoses and services are communicated toprofessional coding staff via an encounterdocument Encounter documents are verified for accuracyand completeness Encounter documents are batched for billing Services are randomly picked by the coder forreview to verify services are billed as documentedin the medical record
  11. 11. Initiating a claim for a hospital based settingOption 2 Professional coding staff track patient encounters viacensus listings and service logs provided by the facility orphysician office Coding staff will then identify potential encountersperformed by their assigned physician group Coding staff will review medical record documentation forthe applicable services that corresponds with informationfound via census and visit logs ICD-9-CM and CPT service will be coded and recorded onthe appropriate encounter document for billing Encounter documents are subsequently batched for billing
  12. 12. Initiating a claim for a hospital basedoutreach setting Physicians or other professional clinical staff areresponsible for notifying coding staff of servicesrendered at outreach locations Providers will select the diagnoses/services bestdescribing the patient encounter Diagnoses and services are communicated toprofessional coding staff via an encounterdocument Encounter documents are verified for accuracyand completeness and in some cases coded bythe coding staff Encounter documents are batched for billing
  13. 13. Charge Entry Claims may be entered by Patient AccessServices Staff in some of the clinical areas Claims may be entered centrally byClinical Financial Services Some coding staff have been trained toenter services that they have coded
  14. 14. “The Physician Claim”a.k.a.CMS 1500
  15. 15. Information found on CMS 1500 Patient identification Patient insurance data Services and diagnosis (ICD-9-CM/CPT/HCPCS) Provider information Authorization to file a claim Authorization for payment allowance Information related to patient’s current illness orhospitalization Charges Payments (as applicable)
  16. 16. TES TES (Transaction Editing System) is a billinginterface that contains claim edits to help identifyservice information that does not contain all ofthe required billing information Claims or “invoices” that are missing informationor have a deficiency will suspend in the TESsystem for a responsible user to correct Individuals that are responsible for correctingdata include coding staff, patient access servicesstaff and insurance staff
  17. 17. Claimsmanager A billing edit interface that focuses oncoding content including but not limited tothe following: Invalid diagnosis/procedures Bundling rules Coverage of services (medical necessity) Coding staff are responsible for thecorrection/evaluation of coding edits thatare suspended by Claimsmanager
  18. 18. A word about fraud and abuse…Fraud and Abuse Guidelines Fraud: “Intentional” deception ormisrepresentation that someone makesknowing it is false, that could result in anunauthorized payment. Abuse: “Actions that are inconsistent withaccepted sound medical, business or fiscalpractices. Abuse directly or indirectly results inunnecessary costs to the [Medicare] programthru improper payment.”
  19. 19. Coding and billing as an identified potential riskarea for fraud and abuse Billing for items or services not renderedor not provided as claimed (fraud) Submitting claims for equipment, medicalsupplies and services that are notreasonable and necessary (abuse) Double billing resulting in duplicatepayment (abuse) Billing for non-covered services as covered(fraud)
  20. 20. Coding and billing as an identified potential riskarea for fraud and abuse Knowing misuse of provider identificationnumbers, which results in improper billing (fraud) Unbundling (assigning multiple codes for aservice that is covered by a single comprehensivecode) (fraud) Failure to properly use coding modifiers (fraud) Clustering (selection of the same level of E/Mservice repetitively) (abuse) Upcoding or coding at a higher level of servicethan actually provided (fraud and abuse)
  21. 21. Tips to prevent fraud and abuse relatedto coding: Never make changes to a diagnosis code or CPTcode on a claim or edited invoice withoutevaluating the documentation first Use the correct version of ICD-9-CM/CPT/HCPCSbased on the date of service ICD-9-CM codes should be selected to the highestspecificity based on documentation Select the CPT code which best describes theservice performed. For services that do not havea specific CPT code to describe, use the unlistedcode from the appropriate category When using a CPT modifier, make sure thecombination with the CPT code is appropriate
  22. 22. Tips to prevent fraud and abuse relatedto coding: When using a CPT modifier, make sure thecombination with the CPT code is appropriate Use a comprehensive CPT code if available inreporting a procedure or surgery. Never usemultiple codes to describe a service when a singlecomprehensive code is available Familiarize yourself and stay up to date on payercoverage policies that you frequently code Communication: keep providers well informedregarding documentation and codingrequirements

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