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Weekly Overview

Week Five

Overview

Week Five summarizes the fundamental concepts addressed throughout this course. You will explore in-depth the coding systems used (ICD-10, CPT, HCPCS) and discuss the relationship between medical documentation, coding, and billing. Also, you will compare inpatient and outpatient hospital services. An inpatient hospital service must have a physician’s admission order; whereas, an outpatient hospital service, which includes emergency department services, observations, lab tests, or X-rays, does not have a written physician’s admission order.

What you will cover

1. Summarizing the Medical Billing Process

a. Compare inpatient and outpatient service.

1)

2) Inpatient hospital service

a) Equipped for patients to stay overnight and are admitted through registration

b) Inpatient care may be provided for special populations

1) Skilled Nursing Facilities (SNF)

a) Provides skilled nursing or rehabilitation services

b) Helps with recovery after a hospital stay

c) Care given by licensed nurses under the direction of a physician

2) Long-term care facilities

a) Nursing homes that provide custodial care

b) Patients with chronic disabilities and prolonged illnesses

3) Outpatient hospital service

a) Often called ambulatory care

b) Covers health services that do not require an overnight hospital stay

1) Ambulatory Surgical Unit (ASU)

a) Same day surgery performed in a separate part of the hospital

2) Ambulatory Surgical Center (ASC)

a) Same day surgery performed at a free standing facility

3) Emergency Room (ER)

a) Emergency services provided to patients that present to the hospital on their own or by ambulance

4) Observation (OBS)

a) Patient kept in the hospital to run additional test and monitor progress

5) Laboratory

6) Radiology

c) Covers services provided in a patients’ home by a home health agency (HHA)

1) Physical therapy

2) Skilled nursing

3) Occupational therapy

4) Speech therapy

5) Help with activities of daily living (ADLs), such as bathing and eating

6) Hospice care

a) Caring for people with terminal illnesses

b) Person is not expected to live longer than six months

c) Care is given in the patient’s home or a special hospice

b. Relate ICD, CPT and HCPCS to the medical billing process.

1) Medical codes

a) Describes diagnoses and treatments

b) Determines costs and reimbursement

c) Codes must be assigned prior to billing

d) Codes must be current and valid and pass through edits for appropriateness

2) ICD

a) Codes are used to describe a patient’s diagnosis including symptoms, diseases or disorders

b) Used to establish medical necessity for patient visits

c) Communicates to insurance companies the reason for the visit

d) Codes have to be accurate for the medical office to receive proper insurance reimbursement.

e) All inpatient and outpatient facilities are required to use ICD code sets on claims submitted to Medicare.

f) Failure to code properly can result in fines, sanctions, or decreased revenue

3) CPT

a) Physicians use these codes to describe the services they provide

b) If CPT code is not listed on the claim form, the physician is not paid by the health plan

c) Outpatient or professional physician and practitioner offices use CPT code sets to identify procedure codes

4) HCPCS

a) Used to report supplies, equipment, and devices provided to patients

b) Outpatient or professional physician and practitioner offices use HCPCS code sets to identify procedure codes

c) Used to identify services not included in the CPT codes such as:

1) Ambulance services

2) Durable Medical Equipment (DME), i.e. wheel chairs and hospital beds.

3) Prosthetics

4) Orthotics

5) Supplies used in a doctor’s office

c. Discuss the relationship between medical records documentation and billing.

1) Medical Records

a) Facts, findings, and observations about a patient’s health history

b) Contains communications with and about the patient

c) Begins with a patient’s first contact and continues through all treatments

d) Traces the course of care

e) Legal documents and can be used as a physician’s defense against medical negligence accusations from the patient

f) Medical records must include:

1) Patient’s full name

2) Social Security number

3) Date of birth

4) Full address

5) Marital status

6) Home and work telephone number

7) Employer information as applicable

8) Copies of all communications with patient

a) Letters

b) Telephone calls

c) Faxes

d) Email messages

e) Patient’s response

f) Note of the time, date, and topic of call

g) Physician’s response

9) Copies of all prescriptions

10) Patient signed documents

a) Authorization to release information

b) Advanced directive if applicable

11) Medical allergies and reactions

12) Up-to-date immunization record

13) Previous and current diagnosis, test results, health risks, and progress

14) Copies of referral or consultation letters

15) Hospital admissions and release documents

16) Missed appointments or cancellations

17) Request for information about the patient and a detailed log of to whom the information was released

2) Documentation

a) Patient’s health record is organized in chronological order

b) Includes a patient’s health history, tests, and results

c) Comprehensive documentation to show the physician has followed medical standards of care

d) Must include every patient encounter

e) Documentation should include

1) Patient’s name

2) Encounter date and reason

3) Appropriate history and physical examination

4) Review of all tests that were ordered

5) Diagnosis

6) Plan of care or notes on procedures or treatments that were given

7) Instructions or recommendations that were given to the patient

8) Signature of the provider who saw the patient

3) Office of Inspector General (OIG)

a) ocr/hipaa/

b) Has authority to investigate suspected fraud cases

c) Can audit physician and payor records

d) Performs examinations to see if documentation matches the billing

e) Reviews accounting records

f) Can file fraud and abuse charges against a practice

4) NPI numbers

a) National provider identification number

b) Issued to all providers by Centers for Medicare & Medicaid Services (CMS)

5) Authorization codes

a) Required when the health plan requires prior authorization or approval for services

6) Place of service codes

a) Place of service rendered

b)

7) Diagnosis codes: Week Two review

8) Primary and secondary insurance

a) Primary coverage is through a health plan

1) Patients are covered usually for the longest period of time

b) The secondary coverage may be a second plan held by a spouse or dependent

1) This plan will provide reimbursement after the primary coverage has been exhausted

9) Birthday rule

a) Used to determine which health plan is primary or secondary

b) The birthday of the parent that occurs first in the calendar year is the primary insured

10) Recognize situations where encounters forms should be reviewed with the physician

a) Old codes

b) Medical necessity is needed

c) Missed charges or codes

d) Incorrect procedure

e) Office visit level charge

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