BILLING

1
BILLING CODING

• How to Ensure Efficiency

Tammy W. Norville, RMC Primary Care Systems
Specialist March 3, 2011
2

• The North Carolina Office of Rural Health and
  Community Care (ORHCC) helps communities get
  low-cost access to medical care.  Since it was
  created in 1973, ORHCC has opened 86 rural health
  centers across the state.   Currently, ORHCC
  supports 28 rural health centers with funding and
  technical support.  ORHCC also helps to place
  medical, psychiatric, and dental providers in
  communities throughout the state.  Rural
  hospitals, as well as many statewide medical
  facilities that treat poor and uninsured
  residents, may receive help through grant funds. 
  Qualifying patients may take advantage of drug
  companies free and low-cost drug programs
  through ORHCCs medication assistance program.

3
Road Map

• Preamble Claims Management Cycle
• Part 1 What is Efficiency?
• Part 2 Billing Coding
• Part 3 Conclusion Questions

4
Preamble

• Claims Management Cycle

5
Claims Management Revenue Cycle Components

• Registration
• Clinical Documentation
• Check-Out
• Coding
• Billing
• Insurer
• Collections
• Paid in Full!!

6
Our Focus

• Coding
• Code Verification Review
• Pre-auth, Pre-cert or Pre-determination
• Billing
• Claim Generation
• Claim Review
• Collections
• Collections/Claim Follow-Up
• Posting Payments
• Appealing Claims

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Part 1

• What is Efficiency???

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Definitions

• The quality or degree of being efficient
• Effective operation as measured by a comparison
  of production with cost (as in energy, time and
  money)
• The ratio of the effective or useful output to
  the total input in any system

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Definitions

• The ratio of the useful energy delivered by a
  dynamic system to the energy it supplies
• The degree to which this quality is exercised

10
Word Play

• Time to have a little fun!!!

11
What are a few

• Synonyms

• Antonyms

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Tammys Picks

• Synonyms

• Antonyms

• Edge
• Effectiveness
• Productiveness
• Competence

• Ineffectiveness
• Ineffectualness
• Unproductiveness
• Incompetent

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Question

• How do you know if something is efficient?

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The Take-Away

• Know the process
• Know your role

15
Let us pause for a commercial

• A brief moment to meditate on FQHC/RHC
  Reimbursement
• (Sappy music playing in the background..)

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FQHC/RHC Reimbursement

• Applies to Medicare and Medicaid Patients ONLY
• Payment for these Core Visits are on an ALL
  INCLUSIVE RATE PER VISIT created by dividing a
  practices total allowable costs by its total
  FQHC/RHC visits. In addition, other Medicaid
  FQHC/RHC services are reimbursed on a
  fee-for-service basis and are reconciled to cost
  at the end of the year.

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FQHC/RHC Reimbursement

• Under the FQHC/RHC program, the practice is
  allowed to break even on the cost of providing
  FQHC/RHC services to Medicare and Medicaid
  patients.
• The FQHC/RHC program does not affect
  reimbursement for private insurance and self-pay
  patients.

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Part 2

• Billing Coding

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What is a CodingPersons Job?

• To capture what a Provider did (the service they
  provided the patient) and why they did it based
  on the ICD-9 codes selected and documented by the
  Provider.

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What is a BillingPersons Job?

• Submit timely and accurate claims the first time
  get it paid!!

21
Tell Me What You Think

• What does your coding/billing staff look like?
• How is it set up?
• Do you have the tasks separated?

22
Reality Check!!

• Why is the information in the previous discussion
  relative/important??

23
Coding Overview

• Coding is the translation of services,
  procedures, events, circumstances and patient
  conditions into numeric designations which must
  be fully represented as documentation in the
  medical record.

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Coding Overview (cont)

• Components of appropriate documentation
• North Carolina Medical Board Requirements
• Coding Requirements CPT Manual
• Procedures must be supported by appropriate
  diagnosis codes establishing medical necessity.

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Types of Codes

• Level I CPT Procedures
• Level II HCPCS Healthcare Common Procedural
  Coding System drugs, supplies, Prosthetics,
  vision
• ICD-9 Diagnoses Volumes 1 and 2 Volume 3
  Hospital only
• RBRVS Resource Based Relative Value Scale Fee
  schedule broken down into parts
• CCI Correct Coding Initiative Updated
  quarterly

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Coding Documentation - CPT

• Chief Complaint
• History of Present Illness
• Review of Systems
• Past, Family, Social History
• Exam 1995 Rules Rule!
• Medical Decision Making
• Time - Sometimes

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The Billing Process

• Data Entry
• Electronic Insurance Claims Processing
• Insurance Provider Enrollment
• Insurance Contract Negotiation
• Insurance Claim Follow-Up
• Payment Posting
• Patient Invoicing
• Reporting Analysis

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Whats The Big Deal?

• Inefficiencies in coding and/or billing may
  result in
• Loss of revenue
• Refunds
• Fines
• Accusations of Fraud
• Medicare OIG Men in Black

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Who Cares, Anyway?

• Other than the insurance companies that are
  paying claims including Medicare and Medicaid
• Baltimore Statistical Office
• (aka, the National Center for Health Statistics)
• EVERY claim goes through this office without
  common knowledge. All ICD-9 codes are tracked
  including trending to physician and extracted.
  This information is disseminated to appropriate
  agencies (ex, CDC).

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RAC Program Mission

• "To reduce Medicare improper payments through
  efficient detection and collection of
  overpayments, the identification of
  underpayments, and the implementation of actions
  that will prevent future improper payments.

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RAC AUDITS!!!

• The Centers for Medicare and Medicaid Services
  (CMS) awarded Connolly Healthcare the contract to
  provide recovery audit services mandated by the
  Tax Relief and Health Care Act of 2006 for Region
  C. The Recovery Audit Contractor (RAC) program is
  a cost containment effort aimed to reduce
  improper payments within Medicare programs as
  well as identify process improvements to reduce
  or eliminate future improper payments.

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Region C RAC

• Connolly Healthcare is tasked with auditing
  Region C, which consists of the following states
  AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN,
  TX, VA, WV and the territories of Puerto Rico and
  U.S. Virgin Islands.

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Reality Check!!

• Signs of Inefficiency

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Biller/Coder Skill Issues

• Incorrect/Inaccurate demographic/eligibility
  information
• Inaccurate or lack of coding
• Incomplete claims
• Lack of supporting documentation
• Poor communication with payer
• Not billing for services rendered
• No follow-up on A/R balance claims

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How Many Days in A/R?

• On average, how long does it take any given payer
  to remit payment from the date of claim
  processing?

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Total A/R Over 90 Days

• How much (or what percent) of your total Accounts
  Receivable (A/R) had a date of service/date of
  first billing greater than 90 days ago?

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• 5 Steps to
• Increased Efficiency

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Tip 1

• Know your team ask for their help
• Strengths
• Weaknesses
• Areas needing education
• Areas of expertise
• Communicate with the team regularly!!
• Claims Processing Review Discussion

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Tip 2

• Review your internal claims process
• Are claims submitted accurately to the correct
  payer within the required timeline? Eligibility
  verification prior to visits?

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Tip 3

• Review and reconcile claims payments
• Are claims payments received from payers? Are
  the payments accurate? Are they posted to patient
  accounts appropriately? Are denials, delays or
  reductions addressed? Are appeals used when
  appropriate?

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Tip 4

• Run Review Monthly Reports
• Collection
• EOB/ERA for each claim
• Production by user

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Tip 5

• Know your payer fee schedules
• Are claims payments received from payers
  correct? Are the payments accurate? Are they
  posted to patient accounts appropriately?
• Do you maintain all health insurance contracts
  centrally and review regularly?

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More Information

• The American Medical Association is sponsoring
  the Heal the Claims Process campaign.
• www.ama-assn.org/go/healthatclaim
• For educational material
• www.ama-assn.org/go/pmc

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Other Ideas?

• Tell me what you think!

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Part 3

• Why is this important??
• What does the future hold??

46
If were inefficient now

• What happens when we have to implement an
  entirely new coding system?
• Goodbye, ICD-9!!!
• Hello, ICD-10!!!

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Goodbye ICD-9!

• ICD-9-CM is outdated
• Technology has changed
• Categories are full
• Not descriptive enough
• Reimbursement would enhance accurate payment
  for services rendered
• Quality would facilitate evaluation of medical
  processes and outcomes

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What do we need for a new coding system?

• Flexibility to quickly incorporate emerging
  diagnoses and procedures
• Exact enough to identify diagnoses and procedures
  precisely

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Hello, ICD-10!!!

• Incorporation of much greater specificity and
  clinical information which results in
• Improved ability to measure health care services
• Increased sensitivity when refining grouping and
  reimbursement methodologies
• Enhanced ability to conduct public health
  surveillance
• Decreased need to include supporting
  documentation with claims

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Development Background

• The new system is intended to replace ICD-9-CM
  Volume 3 for reporting inpatient procedures
• ICD-10 has been around for years
• 1995-1996 First draft of
• ICD-10-PCS completed
• 1996-1998 Training and Testing
• 1998 Present ICD-10-PCS updated annually

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Major Development Goals

• Improve accuracy and efficiency of coding
• Reduce training effort
• Improve communication with physicians

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Essential Attributes

• Completeness
• All substantially different procedures have a
  unique code
• Expandability
• The structure of the system allows incorporation
  of new procedures as unique codes

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Essential Attributes

• Standardized terminology
• Includes definitions of terminology used
• While the meaning of specific words can vary in
  common usage, ICD-10-PCS defines a single meaning
  for each term used in the system.

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General Principles

• Diagnostic information is not included in the
  code description
• A not elsewhere classified option is allowed
  for new devices and substances
• All substantially different procedures are defined

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Code Structure

• Codes are comprised of seven components.
• Each component is called a character
• All codes are seven characters long
• Individual units for each character are
  represented by a letter or number
• Each unit is called a value
• 34 possible values for each character
• Digits 0-9
• Letters A-H, J-N, P-Z

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System Structure 16 Sections

• Medical and Surgical
• Obstetrics
• Placement
• Administration
• Measurement and Monitoring
• Extracorporeal Assistance Performance
• Extracorporeal Therapies
• Osteopathic

• Other Procedures
• Chiropractic
• Imaging
• Nuclear Medicine
• Radiation Oncology
• Physical Rehabilitation and Diagnostic Audiology
• Mental Health
• Substance Abuse Treatment

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Potential Implementation Issues

• Budgeting
• Personnel training
• Working with medical staff to ensure appropriate
  documentation available to reap the benefits of
  greater specificity
• Hardware and software changes
• Data conversion

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Potential Systems Applications Affected (AHIMA)

• Encoding software
• Case mix systems
• Medical record abstracting
• Billing systems
• Registration and scheduling systems
• Accounting systems
• Decision support systems
• Clinical systems
• Utilization management
• Quality management

• Case management
• Clinical protocol
• Test ordering systems
• Performance measurement systems
• Medical necessity software
• Disease management systems
• Provider profiling systems
• Aggregate data reporting

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Timing

• OCTOBER 1, 2013
• Start preparations for implementation now
• Estimate time frames for making needed software
  changes
• Educate Team coders, billers, providers, etc.

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Web Resources

• CMS
• General ICD-10 Information
• http//www.cms.hhs.gov/ICD-10
• Complete version of ICD-10-PCS updated annually
• User manual
• Mapping between ICD-9-CM and ICD-10-PCS
• PowerPoint speaker slides
• Technical paper explaining system
• ICD-10-PCS Coding System and Training Manual
• http//www.cms.hhs.gov/ICD9ProviderDiagnosticCodes
  /08_ICD10.asp

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Web Resources

• CMS
• ICD-10-PCS Files
• http//www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp
• ICD-10-CM Coding System
• http//www.cms.hhs.gov/ICD10/03_ICD_10_CM.asp

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Web Resources

• AHA
• Central Office ICD-10 Resource Center
• http//www.ahacentraloffice.org/ICD-10
• AHIMA
• ICD-10 General Information
• http//www.ahima.org/icd10
• Implementation preparation Checklist

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The Take-Away

• What is the current impact of inefficiency on
  your organization ?

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The Take-Away

• What may be the future impact of inefficiency on
  your organization?

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The Take-Away

• What are your plans to deal with inefficiency in
  your organization?

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Web Resources

• http//www.cms.hhs.gov/
• Centers for Medicare Medicaid Services
• Coding/Documentation Requirements
• RAC Audits/Requirements
• HIPAA 5010 Implementation
• ICD-10 Implementation

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Web Resources

• http//www.ncmedboard.org/
• NC Medical Board
• http//www.mgma.com/
• Medical Group Management Association
• http//www.google.com/
• Google
• When in doubt, Google it!!

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Questions/Comments??

• Thank you for your participation!!

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Contact Info

• Tammy Norville
• Primary Care Systems Specialist
• tammy.norville1_at_dhhs.nc.gov
• Cell [phone]
• Office [phone] x 229