Him- Billing And Coding For Health Services

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Claim

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—A request by a provider for payment for services provided to a beneficiary.

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Charge description master (CDM)

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—A list of all items for which a firm has established specific prices.

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For most healthcare firms there are two basic categories of claims

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the Uniform Bill 2004 (UB-04) and the Centers for Medicare & Medicaid Services (CMS) 1500.

The UB-04 is the claim form used for most hospitals to report claims for both inpatient and outpatient services. The CMS-1500 is used primarily for physician and professional claims.

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Copayments

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—Requiring the patient to pay part of his or her healthcare bill. These payments are used to prevent overutilization of services.

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Deductible

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—A set amount the patient is responsible for paying before third-party coverage begins. These are used to prevent overutilization of services

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From the financial perspective, three activities are especially important in the billing and collection process

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insurance verification

computation of copayment or deductible provisions that may be applicable for the patient.

The third activity in this registration process relates to financial counseling

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Financial counseling

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—Staff at the healthcare firm can advise the patient regarding eligibility for discounts through the firm’s charity care policy or governmental programs such as Medicaid. Staff can help patient to complete the necessary documents required for coverage.

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International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

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—The ICD-9-CM is a diagnosis and procedure classification system. ICD-9-CM codes are the basis for grouping patients into diagnosis-related groups.

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HCPCS

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Procedures, not diagnosis

ICD-9 procedure codes are required for procedure reporting for hospital inpatients, whereas HCPCS codes are used for procedure reporting by hospitals for outpatient services and also by physicians

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The three greatest concerns in billing are:

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• Capture of charges for services performed

• Incorrect billing

• Billing late charges

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Charge capture

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—Actual paper documents or charge slips are used to identify services performed. These charge slips are then posted to a patient’s account in a batch-processing mode by data processing or the business office.

Alternatively, an order entry system could be used that may involve direct entry of charges to the patients account through a computer terminal.

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Charge explosion

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—A system used to better organize charge entry for selective services. One code is used, which then explodes into the list of supply codes used for that surgery.

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Charge code

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—Reflected in the order entry system or the charge slips and also represented on the firm’s charge master (also known as CDM). There is a unique charge code for each service procedure, supply item, or drug in the CDM.

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Every charge master usually has the following six common elements:

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• Charge code

• Item description

• Department number

• Charge/price

• Revenue code

• CPT/HCPCS code

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Static coding

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—Direct coding of HCPCS codes into the charge master. Also referred to as “hard coding.”

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Dynamic coding

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—When codes are left off the charge master and entered later by Health Information Management personnel. Also referred to as “soft coding."

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DRGs and APCs are assigned based on

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data in the UB-04

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MCC

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Major Complications or Comorbidities

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Medicare payment for hospital outpatient services shifted to APC payment in

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2000

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for an APC to be assigned...

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A HCPCS code must be present.

Multiple HCPCS codes may map to one APC code, but any given HCPCS code maps to one and only one APC.

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NationalCorrect Coding Initiative edits

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identifypairs of services that normally should not be billed by the same physician forthe same patient on the same day

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The National Correct Coding Initiative includes two types of edits:

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Comprehensive/component edits identify code pairs that should not be billed together because one service inherently includes the other.

Mutually exclusive edits identify code pairs that, for clinical reasons, are unlikely to be performed on the same patient on the same day

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CMS has designated a series of specific edit checks that are used in determining hospital outpatient claim status.

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These edit checks are referred to as outpatient code edits (OCE) and at the time of this writing included 83 specific edit checks.

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Each OCE results in one of six different dispositions. The dispositions help to ensure that all fiscal intermediaries are following similar procedures. There are four claim-level dispositions:

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Rejection: Claim must be corrected and resubmitted.

Denial: Claim cannot be resubmitted but can be appealed.

Return to provider: Problems must be corrected and claim resubmitted.

Suspension: Claim requires further information before it can be processed.

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There are two line item–level dispositions:

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• Rejection: Claim is processed but line item is rejected and can be resubmitted later.

• Denial: Claim is processed but line item is rejected and cannot be resubmitted.

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