Revenue cycle management (RCM) tracks patient care from registration to final payment. It involves providers, payers, patients, and billing companies. Medicare and Medicaid are government insurance programs managed by CMS. Health insurance covers regular checkups, vision, dental, and hospitals. Medicare has four parts that cover different services like inpatient care, outpatient care, and prescription drugs. Medical coding translates diagnoses, procedures, and services into codes to facilitate billing and data analysis. The revenue cycle includes steps like entering patient demographics, medical coding, charge entry, payment posting, accounts receivable management, and patient billing.

1. Created By - Ashish Sinha

2. What is RCM ?
 Revenue cycle management (RCM) is the financial
process that healthcare facilities use to track patient
care episodes from registration and appointment
scheduling to the final payment of a balance.

3. RCM
 RCM includes four things:
 Provider
 Payer
 Patient
 Billing Company

4. Centre of Medicare & Medicaid
Services (CMS)
 The Centers for Medicare & Medicaid Services, CMS, is
part of the Department of Health and Human
Services.
 Medicare & Medicaid are two separate government
firms managed by CMS:
1. Medicare (US Citizen >64 years)
2. Medicaid (US Citizen below BPL)

5. Health Insurance
 Insurance taken out to cover the cost of medical care.
In USA there is General Health Insurance which
includes main 4 things:
 Regular Checkup
 Vision
 Dental
 Hospital (Durable Medical Equipments)

6. Medicare
 Medicare are of 4 types:
1. Part A
2. Part B
3. Part C
4. Part D
Part A:-Most people don't pay a premium for Part A because they or a
spouse already paid for it through their payroll taxes while working.
Medicare Part A (Hospital Insurance) helps cover inpatient care in
hospitals, including critical access hospitals, and skilled nursing
facilities (not custodial or long-term care). It also helps cover hospice
care and some home health care. Beneficiaries must meet certain
conditions to get these benefits.

7. Medicare
 Part B:-Most people pay a monthly premium for Part B. Medicare Part
B (Medical Insurance) helps cover doctors' services and outpatient
care. It also covers some other medical services that Part A doesn't
cover, such as some of the services of physical and occupational
therapists, and some home health care. Part B helps pay for these
covered services and supplies when they are medically necessary.
 Part C:- It is not a separate benefit. Part C is the part of Medicare policy
that allows private health insurance companies to provide Medicare
benefits. These Medicare private health plans, such as HMOs and
PPOs, are known as Medicare Advantage Plans. If you want, you can
choose to get your Medicare coverage through a Medicare Advantage
Plan instead of through Original Medicare.

8. Medicare
Medicare Advantage Plans must offer at least the same benefits as
Original Medicare (those covered under Parts A and B) but can
do so with different rules, costs, and coverage restrictions. You
also typically get Part D as part of your Medicare
Advantage benefits package. Many different kinds of
Medicare Advantage Plans are available. You may pay a monthly
premium for this coverage, in addition to your Part B premium.
 Part D:- Medicare Part D (outpatient Prescription Drug
Insurance)is the part of Medicare that provides
outpatient prescription drug coverage. Part D is provided only
through private insurance companies that have contracts with
the government—it is never provided directly by the government
(like Original Medicare is).

9. Medicare
If you want Part D, you must choose Part D coverage
that works with your Medicare health benefits. If you
have Original Medicare, choose a stand-alone Part D
plan (PDP)
MCR Part A:- Inpatient Services
MCR Part B:- Outpatient Services

10. Part D
 Prescription Drug Coverage - Most people will pay a monthly
premium for this coverage. Starting January 1, 2006, new
Medicare prescription drug coverage will be available to everyone
with Medicare. Everyone with Medicare can get this coverage
that may help lower prescription drug costs and help protect
against higher costs in the future. Medicare Prescription Drug
Coverage is insurance. Private companies provide the coverage.
Beneficiaries choose the drug plan and pay a monthly premium.
Like other insurance, if a beneficiary decides not to enroll in a
drug plan when they are first eligible, they may pay a penalty if
they choose to join later.

11. Process Of Checkup
1. Appointment
2. Visit to Receptionist
3. Give Insurance copy
4. Visit to Doc
5. Doctor will diagnose and provide solution

12. Process Of Checkup
 When you give insurance card to receptionist, He/ She
will do patient demographics (Enter patient details in
his/ her system e.g. Name, Address, Policy type etc.)
 Problem is also known as diagnosis and solution is the
procedure steps taken by the doctor.
 After the Solution, your claim will be created which
includes (DOS-Date of service, Procedure, Diagnosis &
Charges)

13. Revenue Cycle Management
 Demographics
 Medical Coding
 Charge Entry
 Payment posting
 Accounts Receivable
 Patient Calling

14. Demographics
 The definition of patient demographics starts to get
polluted with items such as patient and emergency
contact information and patient medical records.
1. Name
2. Address
3. Contact details
4. Insurance type
5. Policy Number
6. Medical Records

15. Medical Coding
 Medical coding is the transformation of healthcare
diagnosis, procedures, medical services, and equipment
into universal medical alphanumeric codes.
 Latest version of medical coding is ICD-10, earlier we are
using ICD-9
 ICD-9 was used till Oct’14,2015.
 ICD-10 was started after Oct’15,2015.
 It was developed and maintained by WHO.
 In USA CMS make guidelines of implementation.

16. Why do we need Coding ?
 Medical billing and coding workers are the health
care professionals in charge of processing patient data
such as treatment records and related insurance
information.Medical insurance billers and coders are
tasked with coding a patient's diagnosis along with a
request for payments from the patient's insurance
company.

17. Why We Code
 Let’s start with a simple question about medical coding: Why do we
code medical reports? Wouldn’t it be enough to list the symptoms,
diagnoses, and procedures, send them to an insurance company, and
wait to hear which services will be reimbursed?
 To answer that, we have to look at the massive amount of data that
every patient visit entails. If you go into the doctor with a sore throat,
and present the doctor with symptoms like a fever, sore throat, and
enlarged lymph nodes, these will be recorded, along with the
procedures the doctor performs and the medicine the doctor
prescribes.
 In a straightforward case like this, the doctor will only officially report
his diagnosis, but that still means the portion of that report that will be
coded contains a diagnosis, a procedure, and a prescription.

18. Why We Code
 Take a step back, and this is suddenly a lot of very specific information.
And that’s just for a relatively simple doctor’s visit. What happens when
a patient comes into the doctor with a complicated injury or sickness,
like an ocular impairment related to their Type-2 diabetes? As injuries,
conditions, and illnesses get more complex, the amount of data that
needs to be conveyed to insurance companies increases significantly.
 According to the Centers for Disease Control (CDC), there were over
1.2 billion patient visits in the past year. That’s a stat that includes
visits to physician offices, hospital outpatient facilities and emergency
rooms. If there were just five pieces of coded information per visit,
which is an almost unrealistically low estimate, that’d be 6 billion
individual pieces of information that needs to be transferred every year.
In a system loaded with data, medical coding allows for the efficient
transfer of huge amounts of information.

19. Why We Code
 Coding also allows for uniform documentation between medical
facilities. The code for streptococcal sore throat is the same in Arkansas
as it is in Hawaii. Having uniform data allows for efficient research and
analysis, which government and health agencies use to track health
trends much more efficiently. If the CDC, for example, wants to analyze
the prevalence of viral pneumonia, they can search for the number of
recent pneumonia diagnoses by looking for the ICD-9-CM code 480.
 Finally, coding allows administrations to look at the prevalence and
effectiveness of treatment in their facility. This is especially important
to large medical facilities like hospitals. Like government agencies
tracking, say, the incidence of a certain disease, medical facilities can
track the efficiency of their practice by analyzing
 Now that we understand the importance of this practice, let’s take a
look at the three types of code that you’ll have to become familiar with
as a medical coder.

20. Types of Coding
 CPT Codes (Current Procedural Terminology)
 HCPCS (Healthcare Common procedural Coding System)
 DX Codes (Diagnosis Codes)
 Modifiers

21. CPT Codes
 Current Procedural Terminology (CPT) is a
medical code set that is used to report medical,
surgical, and diagnostic procedures and services to
entities such as physicians, health insurance
companies and accreditation organizations.
 It is of 5 digits and could be numeric or alphanumeric.
Alphabet will be the last letter.
 Used for MCR Part B Outpatient Services.

22. HCPCS
 The Healthcare Common Procedure Coding System
(HCPCS, often pronounced by its acronym as "hick
picks") is a set of health care procedure codes based
on the American Medical Association's Current
Procedural Terminology (CPT).
 It is of 5 digits and could be numeric or alphanumeric.
Alphabet will be the first letter.
 Used for Part A Inpatient Services

23. DX Codes
 Diagnostic coding is the translation of written
descriptions of diseases, illnesses and injuries
into codes from a particular classification. In medical
classification, diagnosis codes are used as part of the
clinical coding process alongside intervention codes.
 These are of 3-5 digits with decimal points and are of
only numeric value

24. Modifiers
 Code modifier billing guidelines.
Code modifiers help further describe a procedure
code without changing the definition of the code.
 Modifier codes are of 2 digits either alpha or numeric.
 Its actually inform that where the problem is.

25. Certification of Coding
 CPC (Certified Professional Coders)
CPC is for outpatient Services – Part B
Certification provided by AAPC in USA
 CPC(H) (Certified Professional Coders Hospitals)
It is for Inpatient services – Part A
Certification provided by AAPC
 CCS (Certified Coding Specialist)
Certification provide by AHIMA

26. Charge Entry – Medical Billing
 Medical billers and coders are tasked with coding a
patient's diagnosis along with a request for payments
from the patient's insurance company.
 It includes Diagnosis , Treatment & Charges.

27. Medical Billing
 Claims are in two forms:-
1. HCFA / CMS1500
(Healthcare Finance Administration)
It is used for Part B (Outpatient Services)
It includes 33 fields (Approx)
1. UB04 / CMS1450
It is used for MCR Part A (Inpatient / Hospital Services)

30. Medical Billing
 In earlier days when claims were send to Insurance
companies called as Filing now known as Electronic
Transmission / E-Filing.

31. Accounts Receivable
 The aggregate of money owed to the health
care practice by all patients and/or insurers.

32. Accounts Receivable
 The aging of your AR is crucial to watch because the
older bills get, the harder and more costly they become
to collect
 When your AR slips and you have a very large backlog
or balance, it can seem like you’ll never be able to
tackle it.
 If patient insurance eligibility is not being verified or
we’re not connecting with the patient prior to them
presenting to the office, it creates a massive amount of
work on the back end to try and resolve open AR or
open claims.

33. Fee Schedule
 A fee schedule is a complete listing of fees used by
Medicare to pay doctors or other providers/suppliers.
This comprehensive listing of fee maximums is used
to reimburse a physician and/or other providers on
a fee-for-service.

34. Accounts Receivable
 What is Billed Amount?
A billed amount is the amount which was charged by the
doctor for treatment.
• What is allowed amount?
Allowed amount is the amount fixed by CMS to pay the
doctor for his/her services.

35. Insurance
 A patient must have a Insurance or he/she can have
multiple insurance also.
 Multiple Insurance be Like:-
1. 1st Insurance – Primary Insurance
2. 2nd Insurance – Secondary Insurance
3. 3rd Insurance – Tertiary Insurance

36. Account Receivable
 Co Insurance – If patient have more than 1 insurance
 Co Pay – Patient also need to pay in this type of Pay
Co Insurance – In Co insurance the amount which was
need to pay by the secondary insurance company
(apart from the amount paid by the primary
insurance) is called Co Insurance.
Co Pay – In Co Pay the amount which need to pay by the
patient (apart from the amount paid by the primary
insurance) is called Co Pay.

37. Accounts Receivable
 Payers could be of two types:-
 Federal / Government
 Commercial Payers
 Federal payers are MCR (>64 years) &b MCD (Below
BPL) {Companies Like CHAMPUS, TRICARE,
CHAMPUR are for Defence}
 Commercial Payers are like AETNA, CIGNA, BCBS,
UHG, ANTHEM etc.

38. Accounts Receivable
 TFL – Timely Filing Limit
There is a time limit to file any claim. Different
companies have different time frame.
MCR – 1 year
MCD – 60 days
Commercial – 6 Months & can be vary from company to
company

39. Accounts Receivable
 AR Days
 AR Days are like:-
From Claim Filing day-----------> Payment Received day
Average MCR took 18-24 days
If we didn’t receive the payment within these days then
the insurance compoany must send an EOB or ERA to
Doc & Patient.

40. Accounts Receivable
 What is EOB?
An explanation of benefits (commonly referred to as
an EOB form) is a statement sent by a health insurance
company to covered individuals explaining what medical
treatments and/or services were paid for on their behalf.
The EOB is commonly attached to a check or statement of
electronic payment.
 What is ERA?
Second, Electronic Remittance Advice (ERA) is an
electronic report in a standard, computer-readable format
sent by insurance companies to providers as an explanation
of payment and adjudication of medical claims.

41. Accounts Receivable
 Reasons of Non Receiving of Payment.
1. Denials
2. On Hold
3. Partially paid
Explanation will be given by the Insurance company in
each case of Non Payment.

42. Accounts Receivable
 What is receivable ?
It is total value of claims filed in $ value.
Time frame for Accounts Receivable:-
30-60-90-120
We need to close the AR maximum within 90 days of
claims.

43. Payment Posting
 It is a type of accounting- enter details of payment from
Insurance companies.
 6 things to look at during payment posting:
1. Payments entered within 1 day or less of receipt.
2. Explanation of Benefits (EOB).
3. calculate write offs,
4. coinsurance,
5. deductibles and
6. patient payments.

44. Payment Posting
 Details of all payment data comes in payment posting.
 A/C Closing
 Cut Off Date – It is important to have a cut off date so that we
can check the monthly or annual amount income of the
company.
 Payment posting also includes
 Monthly Closing amount
 Total billed amount
 Total allowed amount
 Total write off amount

45. Patient AR
 Normally every citizen of USA have Insurance policy but
many circumstances occurs where patient need to pay the
amount.
1. Co-Pay
2. No Insurance
3. No Coverage
4. Deductible
5. Out of state coverage
6. Benefits exhausted
7. Workers compensation also not covered by normal
Insurance companies

46. Patient AR
 Co Pay – Partial amount need to pay by the patient.
 No Insurance – If patient not carrying any Insurance
policy
 No Coverage – If Insurance policy is not covering for that
particular treatment.
 Deductible - The amount you pay for covered health
care services before your insurance plan starts to pay. With
a $2,000 deductible, for example, you pay the first $2,000
of covered services yourself. After you pay your deductible,
you usually pay only a copayment or coinsurance for
covered services. (Deductible amount could be your tax
also.

47. Patient AR
 Out of state coverage – In USA different have there
different policies. It is possible that if you have an
insurance policy issued under Texas state will not work
in Pennsylvania.
 Benefits Exhausted – If the amount need to pay the
doctor is crossing the Insurance amount limit in that
case patient need to pay the amount.
 Workers Compensation – It is a policy provided by
the corporate’s to their employee. They have there
different criteria's.

48. PHI & HIPAA
 According to the US Department of Health and
Human Services, protected health information
(PHI) is individually identifiable information.
 HIPAA (Health Insurance Portability and
Accountability Act of 1996) is United States
legislation that provides data privacy and security
provisions for safeguarding medical information.

49. EMR – Electronic Medical Records
U.SEMR is also called EHR (Electronic Health Records) or CPR (Computerized Patient
Records)
1. EMR systems capture patient data
2. EMR software integrates with other data sources
3. EMR assists in provider decision making
4. EMR captures data at the point of care using a database, rules engine
and knowledge bases as the primary sources of information, then integrates
it with other records for that Member.
5. Integration with multiple databases is through HL7(Health Level 7)
Eg: EMR would include integration with hospital, billing, practice management,
laboratory, imaging and pharmacy systems.
Functions of an EMR:
1. Patient Charting
2. Order Communication Systems
3. Clinical Decision-Making Support Systems
4. Document/Image Management
5. Patient Portal
6. Statistics and Reporting
Only 25% of Providers have adopted EMR in the .

50. PHI & HIPAA
 A covered entity is any health plan, health care clearing
house, or health care provider who transmits any health
information in electronic form in connection with a
qualified transaction and their business associates. HIPAA
Affected Areas are expected to adhere to the HIPAA Privacy
and Security Rules as well as any other area or unit that
creates, uses, or stores PHI from another HIPAA Affected
Area or outside covered entity.
 Data are "individually identifiable" if they include any of
the 18 types of identifiers for an individual or for the
individual's employer or family member, or if the provider
or researcher is aware that the information could be used,
either alone or in combination with other information, to
identify an individual. These identifiers are:

51. PHI & HIPAA
 Name
 Address (all geographic subdivisions smaller than
state, including street address, city, county, or ZIP
code)
 All elements (except years) of dates related to an
individual (including birth date, admission date,
discharge date, date of death, and exact age if over 89)
 Telephone numbers
 FAX number
 Email address

52. PHI & HIPAA
 Social Security number
 Medical record number
 Health plan beneficiary number
 Account number
 Certificate/license number
 Vehicle identifiers and serial numbers, including
license plate numbers

53. PHI & HIPAA
 Device identifiers or serial numbers
 Web URLs
 IP address
 Biometric identifiers, including finger or voice prints
 Full-face photographic images and any comparable images
 Any other unique identifying number, characteristic, or
code
 All protected health information is subject to federal
Health Insurance Portability and Accountability Act
(HIPAA)regulation.

54. RCM
THANK YOU
Made By – Ashish Sinha