Medical record number is assigned to the patient during the registration process
Chapter 5
Accounts
As explained in chapter 4 in medical record number is assigned to the patient during the registration process. The purpose of the medical record number is to facilitate identification of the patient as unique from other patients. Functionally it also allows the system to capture and store demographic data about the patient separate and apart from the individual encounter data
For users of the individual encounter data, the medical record number also allows the user to identify all encounters under one record number. Individual encounter data are collected in separate accounts. So a patient should have only one medical record number but may have many account numbers the medical record number attaches to the demographic data and the account number attaches to the clinical and financial data associated with the specific encounter. For post discharge storage and retrieval purposes, individual accounts are usually maintained in separate folders and filed by medical record number. Similarly in an electronic health record environment patient data can be referenced by medical record number and by account number. When reviewing electronic patient data it is important to ensure that one is referring the correct time period answer us because some data such as laboratory values may display even though the data is associated with a different account number. It is also important to remember that the way data is displayed on an electronical dashboard does not necessarily reflect on how the data was collected patient account data laboratory data nursing notes and medication orders may be configured to stay on the same screen even though they are collected at different times and by different individuals and are actually stored in separate tables in the EHR system therefore when an query for data be sure to ask for the exact data by name not by screen on what you have seen the data displayed. Account documentation supports the claim for the individual encounter therefore the documentation for each account must stand on its own merits and must match the charges in the claim all diagnostic and therapeutic data should be collected in a manner that tracks directly to the claim.
Types of accounts
There are two types of patients in patients and outpatients. The fundamental difference between the two types of patients is the physician’s order to admit. A physician orders and inpatient admission when the patient’s condition requires at least in overnight stay and 24-hour nursing care. Inpatient length stay is measured in days counting the day of admission and not counting the day of discharge. In addition to 24-Hour nursing care, inpatients also receive room and board and are located in an area of the hospital specifically designed to accommodate such services. Reasons changes and medicare payment rule this change seeks to establish a clearer demarcation between inpatient and outpatient services. Particularly as outpatient status relates to the centers for Medicare and Medicaid services Observation services rule. For fiscal year 2016 CMS further clarified that stays briefer than 2 days would be reviewed on a Case by case basis and emphasized that the physician’s judgment and documentation supports the medical necessity of an impatient admission. To a hospital and outpatient is any patient who has not been admitted. More specifically all patients are associated with certain departments such as clinic, laboratory radiology same Day surgery and emergency. Out patient services are measured by encounters or a single encounter contain several visits or services. For example an outpatient encounter may include a visit to the laboratory for blood test and a visit on the same day to radiology for an x-ray this encounter would be captured in one account if those visits took place on different days the patient would be registered for two different accounts because one account is typically used or outpatient services that take place on the same day. There are a number of exceptions to this general rule emergency department encounters for example may cross over from one day to the next resulting in different dates for the beginning and end of this is not a problem because the period represents one episode of service. We are current encounters such as those for physical therapy or chemotherapy may be captured in one account and build periodically usually monthly until the patient is just charged from the service. It is important to keep charges for these recurring encounters separate from mother encounters that may occur during the same time period. For example a laboratory visit would not be included in an unrelated reoccurring account for physical therapy services. Another type of outpatient is the observation patient. Observation patients are technically outpatients because they have not been admitted to inpatient status. However they received room and bored and continuous nursing care some hospitals maintain a distinct observation units or specific observation beds. Other hospitals integrate the observation patients with the impatience this latter arrangement can be confusing for patients who sometimes assume that they are impatience because they are on a nursing unit. As mentioned earlier in this chapter one of the reasons for the CMS two -midnight rule is to make a clearer distinction between impatience and observation status the important distinction is that the physician order for outpatients in nursing units will State observation status one way to ensure correct patient status is to include patient status on a physician order form for initial orders. Another distinction is that the length of stay of an observation patient is measured in hours regardless of the duration of the observation the encounter is represented by one account. The status of the patients stay does not always remain the same type sometimes the status changes from outpatient to inpatient or vice versa. The change might occur as medical necessity dictates or due to clerical error for example a patient’s encounter May starts in the Ed during which the physician decides to order an inpatient admission. This is not a new encounter in this case the patient type changes from outpatient to inpatient and the certain outpatient accounts would need to be included in the inpatient bill if they occur within the 3-day payment window CMS 2014 a accurate billing win a change in patient type has occurred is most easily accomplished by combining the accounts. On the other hand if the physician orders observation status but the registration enters the patient as an inpatient this clinical error must be corrected to build the account correctly and either prevent the change in patient status has an effort on data collection for example room and board changes must be documented for an inpatient stay.
Impact on data collection
Correct classification of the patient at registration and throughout the encounter is critical for data collection and Ed outpatients account is expected to contain an evaluation and management charge for emergency services that expresses the level of complexity and intensity of service if the patient is subsequently admitted to inpatient status then the daily room and board charges will be added to the account delay in changing the patient status from outpatient to inpatient may result in missed charges for example a patient arrives in the Ed at noon at 9:00 p.m. The physician writes the order for the patient to be admitted as an inpatient if the patient status is not changed until the next morning the account will miss the overnight posting of room charges for the first day of service. If not corrected the bill will fail because the room charges do not match the length of State another key factor affected by the patient type is the pre-authorization for services. Some payers require prior or concurrence authorization for services before the facility can bill for those services. An authorization for a computed tomographic (ct) scan of the brain would not necessarily encompass and immediate subsequent cerebral endarterectomy and an inpatient stay. Therefore solid lines of communication are necessary between the clinical departments and patient access so that changes in patient type are properly recorded and if necessary authorized by the payer.
Complete documentation
The extent to which various providers and caregivers most document healthcare services is the subject of State facility licensure regulations as well as joint commission payer and facility guidelines over and above the regulatory and institutional requirements are the professional standards that caregivers must follow within their own discipline for revenue cycle purposes the documentation must reflect the medical necessity for the charges and the charges should include what is documented. For example the need for a transfusion is reflected in documentation of blood loss anemia the targets will include the diagnostic blood test the blood type and Cross match and the transfusion charge itself. When there is discrepancy between charges and documentation the paper may deny the bill.
Impact of hybrid records
Documentation to support the claim must be accessible and transmittable in a format acceptable to the payer. Prayers frequently requests copies of health records to review the documentation if the payer wants a complete health record all components must be accessible and printable for the p pair in a fully electronic environmental specific documentation requested can be exported in a usable format either printed in a record format for mailing converted in an electronic document or transmitted electronically through the interface such as hl7 in a fully and paper environment specific pages of the record can be photocopied. A true hybrid record which has both electronic and paper components increases the difficulty of releasing information. To ensure accurate and complete documentation clinician must be trained to document services in the correct place. For example if history and physical reports are to be dictated and signed electronically then all physicians should do so consistently. Having similar reports in both hard copy and electronic format is confusing in addition to release of information concerns the documentation requirements for clinical personnel must be clear from charting to authorization.
Clinical documentation improvement
Clinical documentation improvement is a process and organization undertakes to improve clinical specificity and documentation so that the clinical documentation is clear for reimbursement purposes. Clinicians are taught to document their investigation of a patient complaint the clinicians point of view the clinicians point of view however is not always consistent with the classification system used to convert the clinical data to classification format anemia is an example of this issue as illustrated in table 5.1 the international classification of diseases 10th revision clinical modification makes more than two dozen classifications for anemia available to the coder in health information management however the physician documentation often consist of only one word anemia. Further complicating the communication between physician and coder is the implementation of Medicare and severity diagnosis related groups for inpatient prospective payment system the severity adjusted methodology has increased the need for specificity and detail in position documentation that clinicians are not necessarily trained to provide. For example traditionally physicians document cognitive heart failure however severity adjusted msdrgs increase the weight of certain visit only in the presence of additional clarification of diastolic or systolic cognitive heart failure is a comorbidity /complication in many cases. The addition of a cc or MCC can bump the case into a higher weighted msdrg which increases the reimbursement. In addition to the reimbursement implications increase specificity also facilitates Care Management and epidemological studies.
Analysis
Audits claims denials and recurring edits are good places sister when identifying areas that need improvement. In clinical documentation improvement achieving excellence facilities are advised to use comparative data to benchmark their data and to use coded data to evaluate certain performances as well as ongoing CDI program success. For example assuming comparative data are available CDI programs can compare staffing against discharges percentage of cases reviewed on a timely basis percentage of cases for which documentation clarifications were recommended and percentage of documentation clarifications that were affected prior to discharge. These comparisons are also useful in longevitably within the program to set goals and demonstrate performance improvement. While documentation clarification is certainly supports medical necessity and coding specificity such clarification may also result in diagnosis related group changes. Therefore tracking the percentage of reviewed cases that result in a change in drg can be benchmarked and the associated change in expected revenue is a tangible result that can help demonstrate the impact of the program on the revenue cycle.
Education
Although the ostensibly purpose of a CDI program is to improve physician documentation it is in reality a method to improve communication which is the primary purpose of documentation by documenting The physician is communicating with the nurse for clinical care and other physicians in the course of diagnosing and planning treatment for the patients. Documentation improvement facilitates those relationships as well as communication with case management coders and pears the more clearly and succinctly The physician communicates the better able these parties are to respond appropriately. Although to complete discussion of CDI programs is beyond the scope of this text it should be noted that a robust query process is extremely helpful in post discharge communication between physicians and coders.
Tracking
To measure the success of a CDI program one must evaluate it in the context of the goals of the program. And a minimum one would expect use of a CDI program to improve coding accuracy and reduce claims denials for medical necessity. Of course administration would tend to expect an increase in case mix index because the results in increased reimbursement any measure of success to be tracked should be identified and recorded prior to implementation of the program to ensure accurate evaluation of the program.
Charges
The services the patients receive must be trapped. Departments need to know how many procedures were performed supplies were used and patients were seen. Patient accounting needs to know how much to bill the patient or other payer. The pair wants to know whether the services rendered match what was authorized or otherwise payable. Consequently a detailed list of services and charges must be accumulated in the account. The anatomy of a charge consists of the date of service the responsible department a description of the service and the volume and price for the service. An example is shown in table 5 3 in this example the charge for the complete blood count with different laboratory test was entered on the date of service the level charge of Ed visit level 3 was entered the next day and the radiatorology charge was entered 4 days later.
Charge description master
Similar to a grocery store which keeps detailed records of every possible item to be sold so that purchases can be scanned at checkout they provide our must also maintain a list of every possible charge that could go into the account. This master list is called the charge master or charge description master CDM is a database of all the supplies and services provided to patients and the corresponding charges for those items. The key field in the database is the charge code the unique identifier for each charge. Other fields in the CDM provide additional detail. The CDM enables the facility to capture and record patient charges efficiently as they are incurred. In addition to capturing charges for billing the CDM can provide data for budgeting by providing statistics on volume for both individual departments as well as services. Chargers can also be compared to actual cost of providing a services to determine the profitability of given services and department . An example of a charge description Master is shown in table 54 the structure and maintenance of the CDM depends on the system used but the basic components are similar various pairs may have different requirements regarding payments of specific charges in the CDM database for example certain pairs may end selected items in the CM to be non-payable. Also some pairs recognize certain healthcare common procedure coding system hcpcs codes as opposed to CPT codes and the specification needs to be noted by pair and the CDM to Bill payers correctly. The specific charge requirements for inpatient charges versus outpatient charges may also differ. Some charges inheritantly go together such as those for the injection of a vaccine. There is one code for the vaccine itself and another for the injection. The facility may choose to set up one code that explodes into two chargers a convention that is more administerable efficient for staff who are responsible for recording all charges. In other words the user enters one code and the system post the multiple charges that are associated with that activity. Exploding charges will not work in all settings or for all players but it is an option for some organizations. The concept of exploding charupdo used when hospital bills out both the facility and the physician charges. Medicare allows split bill ing by hospitals for facility and physician charges and which the UB captures the facility component with a revenue code and the modifier signifying the claim is only for facility charges while the CMS 1500 captures The physician charges
Charge Master maintenance
The chargemaster requires continual maintenance to ensure that the documentation and billing are accurate. The CDM must be updatable and because prices and other details change over time the CDM must accommodate not only the current charge detail but also historical detail. The finance department can use the CDM to increase charges and thus increase revenue. Charge increases are generally made on an annual basis but they can be made as frequently as necessary to align the CDM with charges within their given market. Changes to charges in the CDM require a complex analysis whether performed internally or outsourced to a consulting firm of charge volume for each service line including reimbursement rates by payers that allow for a percentage of build or build eligible inpatient or outpatient charges as a reimbursement methodology this analysis must also incorporate any managed Care CDM increase the threshold contract provision clauses. These causes often have a threshold or charge increase limit of 3% to 5% further most states Medicaid and managed Medicaid programs require that a hospital notify the payer within a specific time. Got a CDM increase is taking place for example no less than 60 days prior to the intended effective date. Medicaid will then calculate a new cost to charge ratio that the hospital will be paid for outpatient services. Medicaid generally does not allow any CDM increases. CDM policies should be verified with each state’s Medicaid division. The CCR is based on the outpatient portion of the Medicaid cost report that was discussed in detail in chapter 2. As of January 1st 2016 claims must distinguish place of service which designates that services were rendered in an on-campus hospital outpatient setting from POS code 19 which Disney’s that services were rendered in and off campus hospital outpatient setting furthermore these POS codes must have any necessary modifiers to signify that the claim is for the physician component only. Prior to January 4th 2016 only POS code 22 was used for both scenarios. This change was implemented to facilitate Medicaid and other payers need for greater specificity in the hospital setting. Well Medicare does not distinguish between the on campus and off campus settings for payment purposes other pairs sisters Medicaid do however Medicare does not make the on-campus versus off-campus distinction which is based on the hospital’s Medicare participation documentation of which sites is the main site and which sites are ancillary or satellite for administrative purposes. This recent POS change highlights why revenue cycle practitioners need to pay close attention to CMS transmittables as updates to the patients access modules or systems and billing module or systems as well as staff education are required to address such changes. Maintenance of the CDM is a multidisciplinary activity for example the him department knows the clinical codes the patient accounts department knows what the general billing edit issues are for the facility the pharmacy department knows the drug and their cost the finance department knows the associated charge formulas and general ledgers codes and managed Care knows the payer billing policies. Pharmacy staff cannot realistically update the radiology department’s data nor can finance staff update charges without knowledge of underlining cost. To coordinate the update efforts a single department usually the budgeting and reimbursements or managed Care department within the finance division should be assigned responsibility for ensuring timely updates. The finance department then should enlist the assistance of other disciplines including him. Updated frequency depends on the data elements to be updated but the CDM certainly should be updated whenever underlining cost or codes change. For example pharmacy charges may be updated every time inventory is replenished the entire CDM must be reviewed at least annually. Many hospitals use CM committees or teams consisting of members from department hospital wide to establish and maintain an accurate charge Master description ambulatory payments classification and drg reimbursement methodology and healthcare technology are changing rapidly requiring the CDM be revised on a continual basis. A team approach will maximize reimbursement and make maintenance process more efficient and effective then an individual approach by implementing change quickly and ensuring that all departments affected by the change receive adequate advance notice. At an absolute minimum a CDM must be updated and it will lead to reflect the cpt/hcps code updates which have typically taken place each January 1st most healthcare facilities add delete and or change services frequently and prefer to update the CDM continually thus the CDM maintenance team meets regularly often monthly. A CDM team will require that a facility expand resources therefore incurring cost. And you charge Master team should be appointed I carefully selecting interdepartmental clinical and hospital managers. Employees end users and technical staff may also be included on a permanent or an ad-hoc basis. Team members should be carefully selected for their specific knowledge and expertise as well as their vested interest in the specific charges. Representatives from laboratory radiology him and patient financial services as well as staff from clinical areas such as surgery are important to include. Remember education and course training are important first steps for each and every member. For example clinical directors and finance personnel are typically unfair recurring policies and procedures and him personal will need to acquire a more thorough understanding of billing activities and systems every team member needs to know which cpt/hcpcs codes is our automatically assigned by the information system based on a charge code. Soft Coding refers to hcpcs code assignment and subsequent data entry into the billing system by him coders after record review. For the soft-coated records the team should have a master list of who codes various types of claims. Clarification in this area will produce double billing Miss coding and subsequently pay your denial and lowers the facilities risk for fraud and abuse charges. Another important component in maintaining the facilities CDM is reviewing the claim denials. Organizations need to develop a comprehensive system for investigation correcting claim denials often a facility corrects these problems on an individual Case by case basis. Through appropriate auditing analyst and communication the source of the problem can be identified and corrective action taken. In many cases the source of the problem can be traced back to the CDM and the amount of time expended by billing and h I m personnel correcting these problems is eliminated by making the appropriate CDM updates or changes. Communication and information sharing among team members are also important to improve efficiency and reduce work redundancy. One of the disadvantages of a poorly selected team or committee is that it can take longer to make decisions and implement changes this is the antithesis of one of the major goals for using the team approach. Therefore the leader or chair of the team should have a strong leadership in project management skills. The leader must coordinate all team activities such as scheduling meetings assigning individual member task ensuring that the project is completed as scheduled and following up on any implementations or recommendations. The leader must also establish formal lines of communication to distribute information regarding proposed changes both within the committee and among important departments that may not have team representation. The leader must also establish communication lines to disseminate important information contained in Medicare bulletins and transmissible and the ncci. A specific procedure including request forms should be established to allow department directors to submit charge master change request for new deleted or revised procedure and services.
Bundling issues
Charges for echocardiograms are a good example of the type of routine CVM changes that a facility might need prior to January 2009 echocardiograms with Doctor wave spectral display and color flow velocity were charged using three separate codes
93307 echocardiography transthoracic
93318 Doppler echocardiography pulse wave and or continuous wave with spectral display
93325 Doppler echocardiography color flow velocity
Each procedure had a separate charge code and the facility might have opted to set up a single charge that exploded into the three charges if there were numerous cases in which all three procedures were done. As of January 1st 2009 a comprehensive code 93306 was added to CPT to bundle all three procedures. The facility would then have had to make the old exploding charge obsolete as of January 1st 2009 and create a new charge code for the bundled service the individual codes are still valid so those would remain for services after the effective date use of the exploding charge to produce the three codes would be incorrect and the claim would fail. Another example of unbundling is the potential conflict between the codes associated with CDM charges hard coding charges and the codes assigned in the HM department soft coated churches generally the him coder assigns a specific CPT code for a surgical procedure whereas the surgical department may have entered codes to reflect charges for the surgical suite and an individual items used. In some cases however a procedure may be added to the charge in the clinical area. For example radiology codes including interventional radiology maybe assigned in the radiology department or attached to the CDM. The HRM code or must be alert to this potential duplication which would result in double billing for the same procedure. Another type of error can occur if both a CVM code and an HRM code are validate assigned. Because some multiple codes cannot be billed together or require a combination code or modifier this Bill welfare if the unbundling is not corrected situations like this should appear on a pre billing error report so that the air can be evaluated and corrected before building occurs. The him department is logical area to undertake this evaluation because the Earth can be corrected and and the coder remediated as needed. Claims processing an error reports are discussed in more detail and chapter 7
Timelessness
Chargers must be recorded for the date of service which in turn must take place during the dates of service stated on the uniform bill churches that are recorded for dates outside the ub04 range will cause the bill to fail. Charges that are recorded after the date of service are late charges. Since one of the main purposes of a bill hold is to capture late charges it is acceptable although not best practice to record charges up to the end of the bill hold period. Charges recorded after the bill hold period are problematic as discussed in chapter 6.
Another issue with respect to timelessness is the handling of claims around the time of coding changes. In the previous echocardial graphic bundling example an account with a discharge date of December 31st 2008 would be correctly billed with the exploding charges and a claim with a discharge date of January 1st 2009 would be correctly build with the hat bundle code. However due to Bill hold requirements both charges could theoretically drop and bill on the same day in January internal controls to ensure timely recording of charges are critical for efficient revenue cycle management clinical departments that have difficulty ensuring that charges are posted on a timely basis should examine their workflow. Lean mythologies for performance improvement or optimal in this scenario. The goal is to develop a process that yields the highest degree of timelessness and accuracy in charge capture with the fewest steps and least amount of effort for instance consider a manual charge capture system that requires multiple individuals to list individual charges by hand on a pick list or other paper charge capture form. Barcoding supplies and scanning them for use at point of care can reduce error and minimize effort in the clinical area. However this is for such a system is time-consuming and the cost can be prohibited the cost justification must take into consideration the time saving and charge capture as well as the reduction in time required to make corrections and rebill.
Accuracy
The existence of a charge code does not inherently mean that using that code is correct in every situation. Clinical department personnel who are responsible for charging must be educated as to the appropriate charges for services. Going back to the previous echocardiography bundling example personnel who were unaware of the CPT code charge would continue to drop the out of date charges until they were informed otherwise. Furthermore the quantities of individual charges must be correct which places additional responsibility on the clinical department management to ensure that charges are not only complete but accurate. Compliance with correct coding guidelines and correct spelling guidelines is inherently part of the charging responsibility.
Internal controls
In any industry internal controls must be in place to safeguard assets and to ensure compliance with policies and procedures. Internal controls may be designed to prevent the theft of cash or to ensure that a patient receives the correct medication. The three major categories of internal controls are preventative detective and corrective controls.
Preventative controls
Preventative controls are implemented at the front end of the process they are specifically designed to stop an incorrect or inappropriate activity. For example computer data entry validation of a date would prevent someone from entering 13 for a month or 45 for a day preventative controls in patient access help register identify missing and potential erroneous data in many cases preventative controls are time-consuming and not cost-effective. If every registrator had to stop and correct every single error or emission at the point of registration the number of patients who could be registered in a day would be quite small. Preventative controls are typically developed and implemented for critical process points in which the era would cause a failure of the function or other major problem. For example three-point patient identification is preventative control that helps stop the administration of medication to the wrong person. It preventative controls are not cost effective or practical than defective and corrective controls must be developed and implemented to find and fix errors..
Detective controls
Detective controls are put in place to find errors that may have been made during a process. Routine coding quality audits and registration on its are examples of detective controls. Detective controls can be more cost effective than preventative controls in finding errors partly because the detective process is specifically designed to find specific errors India. Detective controls are appropriate when errors can be found before they result in a failure of the function or other major problem. Therefore the most efficient detective controls in the revenue cycle process take place prior to billing. Once the bill has dropped the cost of reviewing and correcting errors increases. Because detective controls only find errors they must be accompanied by corrective controls to fix errors.
Corrective controls
Corrective controls are designed to fix problems that have already occurred. They are most often associated with a preceding and detective control that identified the problem. In the revenue cycle process corrective controls apply to any modification of the demographic financial or clinical data that results in a more accurate claim. Corrective controls apply to registration activities such as completing a registration as well as obtaining pay your authorization for the encounter if the authorization was not done before registration. The process for completing health record post discharge is also a corrective control. From a billing perspective there are a few errors that cannot be corrected before the claim is sent to the payer. One error that cannot be corrected in the completion of the service that will not be reimbursed errors that cannot always be corrected include theft of assets and theft data. Otherwise errors that are detected can be corrected and doing so within the bill hold period is less costly than trying to make corrections retrospectively. An important application of detective and corrective controls is the review and reconcilation of orders.
Reconcile orders
Clinical departments that are responsible for executing orders such as radiology laboratory and pharmacy must reconcile the number and type of orders with the actual services provided. This reconcile should be done daily. Daily reconciliation facilitates early detection of open orders duplicate orders and missing orders. All clinical services must be proceeded by a physician order which may be documented electronically or by paper script failure to detect and control errors at the stage will result in missing charges delayed billing rebilling or denials for medical necessity.
Open orders
Open orders are orders that have been placed but have not been completed for example The physician rights in order for an x-ray of the foot. The nurse takes the order from the physician order sheet conveys the order to radiology and marked it complete on the order sheet. However radiology has three additional steps perform the order record the charge for the test and provide results of the examination. There are several controls in place on the clinical side to ensure that ordered test are performed.
Not the least of these controls is the physician who having ordered an x-ray is looking for the results.
Canceled orders
Sometimes ours are canceled perhaps because the patient is discharged her to the execution of the order the medical necessity of the test is reevaluated or the patient refuses to test or drug. Both the ordering department and the receiving department must ensure that the orders are canceled in the organization’s computer system. Failure to cancel an order in a timely manner will result in wasted time effort and sometimes supplies as the receiving department attempts to fulfill the order.
Results
The results of the order are the clinical documentation that supports the charge. Just because the test was ordered does not mean that it was completed. The physician order is a clue to look for the test results not proof that the test occurred. The results documentation is critical for defense of reimbursement denials. Therefore the least of information personal in the him department should ensure that they are knowledgeable regarding the storage and retention of the test results. If test results are in the HER how are they printed or downloaded for release to a payer? If they are retained in the testing department how accessible are they? If the test was ordered and it seems to have been performed but the results are not in the expected place is there a backup method for determining whether the test was really performed and obtaining the results? For example there may be an ancillary system in the department that maintains all tests results these are questions that needed to be answered so that the appropriate documentation can be obtained quickly.
Back end reporting
The dnfb report is one of the most important kpi monitored by revenue cycle teams. This report is reviewed to identify the number of accounts that are past the bill hold period because of late charges the number of accounts that need to be combined based on specific Medicare or pay rules and the number of accounts that cannot be billed out because him needs additional documentation from a department or the physician to finish coding the record. Through complete documentation is key to him ability to code an account for billing. Missing documentation accounts for a large percentage of accounts being on the dnfb past the close of the bill hold period. A late charge report should be generated daily and showed with the individual clinical areas to resolve any late charge issues. If late charges are included on the kpi dashboard the dollar amount would be captured at a high level the total charges by number of days out from date of service. But if a more significant issue exists there may be a need to report by department and number of days out with total charge the designated person in each clinical department should explain and justify the late charges. If the late charges are not resolved within the bill hold. Then a corrected claim needs to be submitted by patient financial services. This correction will cause the account to readjustigate within the hospitals reimbursement or contract management system to ensure that the expected reimbursement is accurately reflected in the system. Late charges need to be handled in this manner so they make it into the account the account can then be updated to correctly reflect open accounts receivable. Running daily reports will allow the revenue cycle team to determine which clinical areas need updated training on charge entry or may simply need a backup plan for when the designated charge entry person is out of the office. As previously mentioned if late charge is are entered after the bill hold period the delay will cause claims management issues for patient financial services. Carve out reports are another area of significant importance to the revenue cycle team. these reports hope to ensure that all high cost drugs and implantable our captured on the claim. This documentation is particularly important not just for cost analyzes but also because this item may be separately payable depending on the payer. The reports should be run by internal clarification of disease 10th revision procedure coding system code. If they charge is coded to a document that a pacemaker was implanted then there should be a corresponding charge with revenue code 275 for the high cost implant the pacemaker in the past charts had to be manually audited to capture missing high cost items that are curved out in the payer contracts. Looking at accounts based on coding done by him allows for a lesser degree of manual intervention. Carve out reports should be run for all payers but special attention should be given to those payers that additionally paid the hospital for high cost drugs or implant often there is a threshold associated with the carved out items in the contract. Contract wording varies but the following represents typical language high implants build out under revenue codes 271 through 279 that crossed the hospital more than 10,000 per item will be paid x percent of invoice cost in addition to the negotiated for denim. Because these items cost the hospital substantial sums the facility will want to be reimbursed at a minimum for the items cost an addition to the pre denim. The second part of this kpi is whether or not the facility was paid correctly. This topic will be discussed further in chapter 7.
Compliance related reports
Revenue cycle team should review which rules for Medicare and Medicaid and other payers affect the hospital’s reimbursement. Reports are needed to track those CMS rules that other national and state-based payers currently have in place or are trying to adopt through contract or policy and procedure changes including the following the 3-day payment window readmission within 30 days and hospital acquired conditions. The 3-day payment went over requires that a hospital include in the inpatient bill any outpatient services related to the inpatient admission that have occurred at the facility within 3 days of the admission or discharge. If a hospital uses one name and one tax identification number for it’s free standing surgery center or physical therapy center and it’s mean acute Care facility then all inpatient care and outpatient services directly related to the impatient diagnosis need to be included on the admission bill. The 3-day payment window is not a rule many providers agree to allow payers to implant for commercial product loans. Readmission must also be included in compliance related reports. CMS is the process of adopting a readmission within 30 days of inpatient stay roll through the readmission reduction program. With the goal of reducing readmission hospitals have begun to dedicate employees in their case management or Care Management departments to identify and tracking patients who have been re-emitted for the same condition within 30 days of discharge. Readmission reports can be used to identify patients who may not have been identified priority discharge in need of post-discharge tracking by discharge follow-up nurses or social workers tracking is intended to ensure that patients are compliant with their doctor’s home care instructions and may involve ensuring patients take their medication or 10 schedule follow-up visits as part of this readmission reduction program Medicare provides a list of diagnosis that fall within the 30-day readmission rule including acute exasperation of chronic obstructive pulmonary disease total hip arthroplasty and total knee arthro blasty. Reports that include the designated diagnosis should be generated daily to ensure that accounts have been combined as needed prior to billing. They also allow the hospital to track the cost that parents are not reimbursing. Medicare does not allow hospitals to increase the drg payment for a hospital stay associated with certain HAC such as a traumatic fracture that was not presented at admission. Medicare has initiated a HAC reduction program as part of the affordable Care act some managed Care payers are taking it this will one step further and denying all payment on the account with specified HAC report is based on the specific codes that signify the patient has a HAC. CMS has published a list of those conditions and most commercial payers are also incorporating that list into their contracts to negatively impact reimbursement. The h a c reports should be shared with the chief nursing officer and chief & operation officer as well as verse management leadership to confirm that the hospital is making any necessary changes to ensure patient safety and reduce the incident of hacs the revenue cycle team needs to be aware of expected reimbursement losses do to hacs. The HAC reports provide an opportunity to Incorporate clinical leadership into the revenue cycle team discussions. The CNO or c o o can’t explain to the revenues cycle team what correction active is being taken to reduce HAC and therefore increase reimbursement to the hospital.
Special considerations for specific practice settings
All settings have much the same transaction flow registration the patient examine him or her document relative data or services and treat but documentation and charge capture issues very based on the building requirements and the volume of transaction in the particular setting. Whereas inpatient documentation and orders are typically completed as a single case outpatient documentation can be less finite. For example inpatient test results are typically reviewed and acted on during the episode of care but physician office visits may be complete in the absence of such documentation. Further physician offices likely do not have volumes of open orders to review at the end of the day.
Inpatient settings
Whether the patient is an inpatient or an outpatient is a key issue in the inpatient setting. Although the definitions are clear the actual documentation does not always reflect the level of clarity or direction that is necessary to make a definite decision. Historically acute care hospitals have bustled with unclear documentation such as an order to admit for observation which created ambiguity as to whether the patient was an impatient or an outpatient. The evolving to midnight rule should assist with resolving this issue. Further the medical necessity that drives the level of care is not always well documented. Clinical documentation programs are proving valuable in this regard. Timing of charge caption can be problematic in light of the volume of charges that are posted and the decentralization of the review and validation of daily charges hence the need for internal controls order reconcile and back and monitoring of activities.
Outpatient settings
For outpatient services maintenance of the CDM is a key issue. When setting up the charge the proper revenue code must be assigned as well as the correct cpt/hcpcs code. Changes to cpt/hcpcs must be identified and the CDM must be updated accurately. Proving medical necessity can be problematic because physician scripts do not always contain the appropriate icd-10-cm code. Patient access register to not be expected to realize that act scan is not justified but unspecified anemia. Without front and medical associated especially for Medicare patients these errors will not be caught until the bill drops unless the outpatient services department takes a proactive role in identifying and correcting these errors. Since the department needs a medical reason for the test in the first place it seems reasonable that they should also look for admitting codes to see whether they make sense. Timely resolution of this issue will hope the bill drop faster.
Physician practices
Physicians typically maintain one record per patient accounts not a necessarily reflected in the record. If the records are stored in a problem oriented format it may be difficult to pull together the documentation to support a particular claim. N e h r solves these problems. Charge capture in a physician’s office absent and HER may be supported by an encounter form also known as a super bill. A document on which the physician can check off the patient’s diagnosis and procedures performed including office visit time. Physician billing for inpatient services may require copies of parts of the impatient record. The home department must have policies and procedures in place to handle the documentation request from physicians for copies of progress note. In an EHR physicians can potentially download the documentation themselves. However if this documentation is still in paper format the photocopying may be a burden to him. The hospital must identify the scope of this issue and determine what arrangements best suits all parties concerned.
READ CHAPTER 5 ABOVE AND THEN ANSWER QUESTIONS 1-2
1.It is January 10th and your coding manager has just brought you a list of accounts that cannot be finalized because the CPT codes attached to the charges are not valid. Your HIM systems were updated for the January 1st CPT code changes. What is the problem and how will you fix it?
2.It is suggested in chapter 5 that back-end reporting should be reviewed in order to monitor compliance with specific billing rules. One such report is to monitor the CMS 3-day payment window. What data would you want to have on a report to monitor this rule and how often would you run it?
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