2. How does a Physician medical insurance
claim begin?
At a minimum an insurance claim begins
with:
A patient
A provider
A service rendered to a patient
3. Ways that patient contact occur:
An Appointment
A Walk-in
Urgent/Emergency visit
Scheduled Admissions
“Rounds” ( hospital daily care,
consultations, nursing home visits, home
visits., etc)
Scheduled Procedures/Surgery
4. When appointments are made:
Identify the patient type (new vs
established)
The nature of the visit should be
identified, i.e. sick visit, annual physical,
etc.
Notification of insurance status: the
patient should alert the provider regarding
any insurance coverage or changes in
coverage
5. New patient -vs.- Established patient
New patient is one that has not received
any face to face professional services from
the provider or another provider of the
same specialty in the same group practice
within the last 3 years
Established patient has received face to
face services within the last 3 years by the
provider/provider specialty of the same
group…
CPT Evaluation and Management Guidelines
6. Patient Sees the Provider
The provider must clearly document in the
health record
Any patient history, exam and medical decision
making as applicable
Procedures performed
Tests ordered or performed
Any independent interpretations
Any referrals or instructions to the patient &/or
office/ancillary staff
Consultations: who requested, exam/findings,
response to referral source
7. Claim Creation: Information Required
on 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. Initiating a claim for a non-hospital
setting
Patient data is provided via schedules, visit logs
or other information surrounding encounters
Encounter forms or charge tickets are utilized by
providers to communicate the services provided
to the bill following scheduled visits or other
encounters
Physicians or other professional clinical staff will
select the diagnoses/services best describing the
patient encounter (most clinics) OR
Professional coding staff will review and/or select
the diagnoses/services as documented in the
patient record
9. Initiating a claim for a non-hospital
setting continued…
Settings in which the provider completes
the encounter form or charge document
will submit the completed forms for charge
entry
Settings in which the encounter
form/charge document is submitted to a
coder will require completion by the coder.
The coder will review the documentation
and select the appropriate ICD-9-CM and
CPT codes for the service.
10. Initiating a claim for a hospital based setting
Option 1
Physicians or other professional clinical staff will
select the diagnoses/services best describing the
patient encounter
Diagnoses and services are communicated to
professional coding staff via an encounter
document
Encounter documents are verified for accuracy
and completeness
Encounter documents are batched for billing
Services are randomly picked by the coder for
review to verify services are billed as documented
in the medical record
11. Initiating a claim for a hospital based setting
Option 2
Professional coding staff track patient encounters via
census listings and service logs provided by the facility or
physician office
Coding staff will then identify potential encounters
performed by their assigned physician group
Coding staff will review medical record documentation for
the applicable services that corresponds with information
found via census and visit logs
ICD-9-CM and CPT service will be coded and recorded on
the appropriate encounter document for billing
Encounter documents are subsequently batched for billing
12. Initiating a claim for a hospital based
outreach setting
Physicians or other professional clinical staff are
responsible for notifying coding staff of services
rendered at outreach locations
Providers will select the diagnoses/services best
describing the patient encounter
Diagnoses and services are communicated to
professional coding staff via an encounter
document
Encounter documents are verified for accuracy
and completeness and in some cases coded by
the coding staff
Encounter documents are batched for billing
13. Charge Entry
Claims may be entered by Patient Access
Services Staff in some of the clinical areas
Claims may be entered centrally by
Clinical Financial Services
Some coding staff have been trained to
enter services that they have coded
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 or
hospitalization
Charges
Payments (as applicable)
16.
17.
18. TES
TES (Transaction Editing System) is a billing
interface that contains claim edits to help identify
service information that does not contain all of
the required billing information
Claims or “invoices” that are missing information
or have a deficiency will suspend in the TES
system for a responsible user to correct
Individuals that are responsible for correcting
data include coding staff, patient access services
staff and insurance staff
19. Claimsmanager
A billing edit interface that focuses on
coding content including but not limited to
the following:
Invalid diagnosis/procedures
Bundling rules
Coverage of services (medical necessity)
Coding staff are responsible for the
correction/evaluation of coding edits that
are suspended by Claimsmanager
20. A word about fraud and abuse…
Fraud and Abuse Guidelines
Fraud: “Intentional” deception or
misrepresentation that someone makes
knowing it is false, that could result in an
unauthorized payment.
Abuse: “Actions that are inconsistent with
accepted sound medical, business or fiscal
practices. Abuse directly or indirectly results in
unnecessary costs to the [Medicare] program
thru improper payment.”
21. Coding and billing as an identified potential risk
area for fraud and abuse
Billing for items or services not rendered
or not provided as claimed (fraud)
Submitting claims for equipment, medical
supplies and services that are not
reasonable and necessary (abuse)
Double billing resulting in duplicate
payment (abuse)
Billing for non-covered services as covered
(fraud)
22. Coding and billing as an identified potential risk
area for fraud and abuse
Knowing misuse of provider identification
numbers, which results in improper billing (fraud)
Unbundling (assigning multiple codes for a
service that is covered by a single comprehensive
code) (fraud)
Failure to properly use coding modifiers (fraud)
Clustering (selection of the same level of E/M
service repetitively) (abuse)
Upcoding or coding at a higher level of service
than actually provided (fraud and abuse)
23. Tips to prevent fraud and abuse related
to coding:
Never make changes to a diagnosis code or CPT
code on a claim or edited invoice without
evaluating the documentation first
Use the correct version of ICD-9-CM/CPT/HCPCS
based on the date of service
ICD-9-CM codes should be selected to the highest
specificity based on documentation
Select the CPT code which best describes the
service performed. For services that do not have
a specific CPT code to describe, use the unlisted
code from the appropriate category
When using a CPT modifier, make sure the
combination with the CPT code is appropriate
24. Tips to prevent fraud and abuse related
to coding:
When using a CPT modifier, make sure the
combination with the CPT code is appropriate
Use a comprehensive CPT code if available in
reporting a procedure or surgery. Never use
multiple codes to describe a service when a single
comprehensive code is available
Familiarize yourself and stay up to date on payer
coverage policies that you frequently code
Communication: keep providers well informed
regarding documentation and coding
requirements
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