Chapter 2 Cleverly
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Chapter 2 Cleverly
Billing and Coding for Health Services H352
What does a Healthcare firm's financial survival depend on?
A consistent and recurring flow of funds from the services they provide to patients
What is included for the revenue cycle for healthcare firms? (6)
1. Provide services
2. Documents services
3. Establish charges
4. Prepare claim/bill
5. Submit claim
6. Receive payment
What are the four critical stages of the revenue cycle?
1. Provision of services
2. Documentation of services
3. Preparation of bill
4. Collection of payment
What is a firm's price list
AKA charge master or charge description master (CDM)
A list of all items which have a specific price
Information from what 2 systems flow into the claim?
1. Medical records
What are the two basic category claims?
1. Uniform Bill 2004 (UB-04) - for hospitals
2. CMS 1500 - for physician and professional claims
What are the 5 steps in revenue cycle management?
2. Medical record and coding
3.Charge entry and charge master
4. Billing and claims preparation
5. Claims editing
What two coding systems did HIPPA designate for public and private payers?
1. International Classification of Diseases, 9th revision, Clinical Modification
2. Healthcare Common Procedure Coding System
What two categories of information does HIPPA require be reported to the payers?
1. Diagnosis codes
2. Procedure codes
What sets the codes for diagnosis and procedures?
Who provides information regarding procedures but not diagnosis?
Which procedure codes are required for medical procedures reporting for hospital inpatient?
Which codes are used for procedure reporting for hospital outpatient and physicians?
What are the three greatest concerns in billing?
1. Capture of charges for services performed
2. Incorrect billing
3. Billing late charges
What is Charge capture?
Paper document or charge slips to identify services rendered
What are the 6 common elements that
1. Charge code
2. Item description
3. Department number
5. Revenue code
6. CPT/HCPCS code
Which coding is direct coding of HCPCS codes into charge master?
Static (hard) coding
Which coding is codes left off charge master and entered by Health Information Management (HIM) staff?
Dynamic (soft) coding
Which billing and claims preparation is used by noninstitutional providers and suppliers to submit claims to Medicare and many other payers?
Which billing and claims preparation is used by institutional providers and suppliers to submit claims to Medicare and most other payers?
CMS 1450 or UB-04
What is claims editing (scrubbing)?
Providers and payers use to edit claims
Under claims editing (scrubbing) what do providers want?
-Want maximum payment
-Shortest reimbursement time
Under claims editing (scrubbing) what do payers want?
-Pay accurate amount due
-Delay payment within required guidelines