Transcript Slide 1

CHAPTER
1
Introduction to Health
Information Technology
and Medical Billing
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1-2
Learning Outcomes
When you finish this chapter, you will be able to:
1.1
1.2
1.3
1.4
1.5
Explain why the use of technology in healthcare is
increasing.
Describe the functions of practice management
programs.
Identify the core functions of electronic health
record programs.
List the steps in the medical documentation and
billing cycle that occur before a patient encounter.
List the steps in the medical documentation and
billing cycle that occur during a patient encounter.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1-3
Learning Outcomes (continued)
When you finish this chapter, you will be able to:
1.6
1.7
1.8
List the steps in the medical documentation and
billing cycle that occur after a patient encounter.
Discuss how the HIPAA Privacy Rule and Security
Rule protect patient health information.
Explain how the Health Information Technology for
Economic and Clinical Health (HITECH) Act and the
Affordable Care Act (ACA) promote health
information technology and explore new models of
delivering healthcare.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1-4
Key Terms
• accountable care
organization (ACO)
• adjudication
• Affordable Care Act
(ACA)
• audit trail
• clearinghouse
• coding
• Current Procedural
Terminology (CPT®)
• diagnosis
• diagnosis code
• documentation
• electronic data
interchange (EDI)
• electronic health record
(EHR)
• electronic medical
records (EMRs)
• electronic prescribing
• encounter form
• explanation of benefits
(EOB)
• HCPCS
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1-5
Key Terms (continued)
• health information
exchange (HIE)
• health information
technology (HIT)
• Health Information
Technology for
Economic and Clinical
Health (HITECH) Act
• Health Insurance
Portability and
Accountability Act of
1996 (HIPAA)
• HIPAA Privacy Rule
• HIPAA Security Rule
• International
Classification of
Diseases, Ninth
Revision, Clinical
Modification (ICD-9-CM)
• International
Classification of
Diseases, Tenth
Revision, Clinical
Modification (ICD-10CM)
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Key Terms (continued)
• meaningful use
• medical documentation
and billing cycle
• National Health
Information Network
(NHIN)
• National Provider
Identifier (NPI)
• patient-centered medical
home (PCMH)
• patient information form
• personal health records
(PHRs)
1-6
• practice management
programs (PMPs)
• procedure
• procedure code
• protected health
information (PHI)
• regional extension centers
(RECs)
• remittance advice (RA)
• revenue cycle
management (RCM)
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.1 The Increasing Use of Technology in
Healthcare
1-7
Healthcare costs are rising for several reasons:
• The use of new medical technologies
Procedures and treatments have increased patient survival and
the cost of medical care.
• The aging population
As the population ages, spending on healthcare rises.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.1 The Increasing Use of Technology in
Healthcare (continued)
1-8
• Technology is being used to track patient
treatments and outcomes, which leads to the
development of quality standards.
• Technology makes it possible for primary care
providers and specialists to confer while looking
at the same CT scan on a computer, even when
they are miles apart.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.1 The Increasing Use of Technology in
Healthcare (continued)
1-9
• Health information technology (HIT)
is technology that is used to record, store, and
manage patient healthcare information.
• Technology is used to perform these tasks:
– clinical tasks such as recording vital signs or ordering
medications,
– administrative tasks such as scheduling appointments
or creating insurance claims.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.2 Functions of Practice Management
Programs
1-10
• A practice management program (PMP) is a
software program that automates many of the
administrative and financial tasks in a medical
practice including:
–
–
–
–
–
–
Verifying insurance eligibility and benefits.
Organizing patient and payer information.
Generating and transmitting insurance claims.
Monitoring the status of claims.
Recording payments for payers.
Generating patients’ statements, posting payments, and
updating accounts.
– Managing collections activities.
– Creating financial and productivity reports.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.2 Functions of Practice Management
Programs (continued)
1-11
• Creating and Transmitting Claims
– One of the most important functions of a PMP is to
create and transmit healthcare claims.
– The PMP collects information from various
databases. A database is simply an organized
collection of information about the patient, the
provider, the health plan, the facility, and more.
• Monitoring Claim Status
– Monitoring claim status is necessary to ensure prompt
payment of claims.
– A PMP is used to follow up on the status of claims.
An electronic message can be send to the health
plan.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.2 Functions of Practice Management
Programs (continued)
1-12
• Receiving and Processing Payments
– A PMP receives a document that lists the amount that
has been paid on each claim and reasons for
nonpayment or partial payment of claims.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs
1-13
• An electronic health record (EHR) is a
computerized lifelong healthcare record for an
individual that incorporates data from all
providers who treat the individual.
• Documentation is a record of healthcare
encounters between the provider and the
patient.
• An electronic medical record (EMR) is the
computerized record of one physician’s
encounter with a patient over time.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs (continued)
1-14
• Personal health records (PHRs) are private,
secure, electronic files that are created,
maintained, and owned by the patient.
• The Institute of Medicine suggests that an EHR
include:
1.
2.
3.
4.
5.
6.
7.
8.
Health information and data elements
Results management
Order management
Decision support
Electronic communication and connectivity
Patient support
Administrative support
Reporting and population health
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs (continued)
1-15
• Health Information and
Data Elements
– Demographic information
(address, phone numbers,
patient name)
– Clinical information about
the patient’s past and present
health concerns (problem list,
signs and symptoms,
diagnosis, procedures,
treatment plan, medications
list, allergies, diagnostic test
results, radiology results,
health maintenance status,
and advance directives)
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs (continued)
1-16
• Results Management
– Computerized results can be accessed by multiple
providers when and where they are needed.
• Order Management
- Staff members in different offices and facilities can
access orders which eliminates unnecessary delays
and duplicate testing.
• Decision Support
– An EHR gives physicians immediate access to clinical
research on diagnosis, treatment, and medications.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs (continued)
1-17
• Electronic Communication and Connectivity
– Physicians, nurses, medical assistants, referring
doctors, testing facilities, and hospitals can
communicate with one another through a number of
mechanisms within the EHR.
• Patient Support
– The EHR offers patients access to educational
materials and instructions for tests, as well as the
ability to report home monitoring.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs (continued)
1-18
• Administrative Processes
– PMPs and EHRs streamline billing, scheduling, and
other administrative tasks.
• Reporting and Population Management
– EHRs also enhance reporting capabilities to make it
easier to comply with federal, state, and private
reporting requirements.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs (continued)
1-19
• Advantages of Electronic Health Records
– Safety
•
•
•
•
•
Reduced medication and physician order errors
Instant alerts about patient allergies and drug interactions
Alerts when medications are unsafe
No risk of records being lost due to a natural disaster
Improved communication related to an outbreak of a disease
– Quality
• Patients are reminded about preventive care screenings.
• Patients are able to monitor chronic disease at home and
report results via the Internet.
• Patients can review data about quality and performance of
providers prior to obtaining healthcare.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.3 Functions of Electronic Health
Record Programs (continued)
1-20
• Advantages of Electronic Health Records (continued)
– Efficiency
• Improved workflow in the physician practice or hospital
• Speedy delivery of diagnostic test results
• Ability for two or more people to work with a patient’s record
at the same time
• Never need to search for a misplaced or lost patient chart
• Summary of patient’s health information available at a glance
• Reduced time to refill prescriptions through electronic
prescribing
• All information available in one place
• Payment for services received more quickly
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.4 The Medical Documentation and
Billing Cycle : Pre-Encounter
1-21
• Medical
documentation
and billing
cycle – a
10-step process
that results in
timely payment
for medical
services
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.4 The Medical Documentation and
Billing Cycle : Pre-Encounter
1-22
• Step 1: Preregister Patients
– Gather the following information to preregister patients
before the office visit.
•
•
•
•
Name
Contact information; address and phone number
Reason for visit
Patient status (new or established)
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.5 The Medical Documentation and
Billing Cycle: Encounter
1-23
• Step 2: Establish Financial Responsibility
– Determine whether the patient has insurance and
obtain the identification number, plan name, and
name of policyholder. If the patient does not have
insurance, establish the patient’s planned method of
payment.
• Step 3: Check In Patients
– A patient information form is a form that includes a
patient’s personal, employment, and insurance data
needed to complete an insurance claim.
– Verify identity by photocopying or scanning the
patient’s insurance card and photo ID.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.5 The Medical Documentation and
Billing Cycle: Encounter (continued)
1-24
• Step 3: Check in Patients (continued)
– Distribute Financial Policy and Privacy Policy.
– Collect time-of-service payments.
• Step 4: Review Coding Compliance
– Diagnoses and Procedures
• A diagnosis is the physician’s opinion of the nature of the
patient’s illness or injury.
• Procedures are the medical services provided.
• Coding is the process of translating a description of a
diagnosis or procedure into a standardized code.
– A diagnosis code is a standardized value that
represents a patient’s illness, signs, and symptoms.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.5 The Medical Documentation and
Billing Cycle: Encounter (continued)
1-25
• Step 4: Review Coding Compliance (continued)
– A procedure code is a code that identifies a medical service
and is obtained using the Current Procedural Terminology
(CPT). The CPT is the standard classification system for
reporting medical procedures and services.
– HCPCS codes are codes used for supplies, equipment, and
services not included in the CPT codes.
– ICD-9-CM is the source of the diagnosis codes used for
reporting until October 1, 2014, and ICD-10-CM will be used
beginning October 1, 2014.
– An encounter form is a list of common procedures and
diagnoses for a patient’s visit.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.5 The Medical Documentation and
Billing Cycle: Encounter (continued)
1-26
• Step 5: Review Billing Compliance
– Each charge, or fee, for a visit is represented by a
specific procedure code.
– The provider’s fees for service are listed on the
medical practice’s fee schedule.
– Medical billers use their knowledge to analyze what
can be billed on healthcare claims.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.5 The Medical Documentation and
Billing Cycle: Encounter (continued)
1-27
• Step 6: Check Out Patients
– Medical codes have been assigned and checked.
– Types of charges usually collected at the time of
service include:
•
•
•
•
•
•
Previous balance
Copayments or coinsurance
Noncovered services
Charges of nonparticipating providers
Charges for self-pay patients
Deductibles
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.6 The Medical Documentation
and Billing Cycle: Post-Encounter
1-28
• Step 7: Prepare and Transmit Claims
– Once patient and transaction information is entered
into the PMP, the software is used to create insurance
claims.
– A clearinghouse is a company that collects
electronic insurance claims from medical practices
and forwards the claims to the appropriate health
plans.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.6 The Medical Documentation and Billing1-29
Cycle: Post-Encounter (continued)
• Step 8: Monitor Payer Adjudication
– When a claim is received by a payer, it is reviewed
following a process known as adjudication—a series
of steps designed to judge whether it should be paid.
– The document explaining the results of the
adjudication process is called a remittance advice
(RA) or explanation of benefits (EOB).
• Each payment, RA and EOB is checked to see that:
– All procedures are listed on the claim.
– Unpaid charges are explained.
– Codes match the claim.
– Payment is as expected.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.6 The Medical Documentation and
Billing Cycle: Post-Encounter (continued)
1-30
• Step 9: Generate Patient Statements
– Statements list the services performed and the
remaining balance that is the responsibility of the
patient.
• Step 10: Follow Up Payments and
Collections
– Revenue cycle management is managing the
activities associated with a patient encounter to
ensure that the provider receives full payment for
services .
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.7 The Impact of Legislation: HIPAA
1-31
• The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) contains a
number of rules, including:
– HIPAA Electronic Transaction and Code Sets
standards
– HIPAA Privacy Rule
– HIPAA Security Rule
– Final Enforcement Rule
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.7 The Impact of Legislation: HIPAA
(continued)
1-32
• HIPAA Electronic Transaction and Code Sets
standards
– These describe an electronic format that providers
and health plans must use to send and receive health
care transactions.
– The electronic transmission of data is called
electronic data interchange (EDI).
– Payment may be via electronic funds transfer (EFT).
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.7 The Impact of Legislation: HIPAA
(continued)
1-33
• Claim Formats
– The HIPAA-standard X12-837 Health Care Claim, or
837P for short
– The CMS-1500 (08/05) paper claim
• The National Provider Identifier (NPI) is a tenposition numerical identifier consisting of all
numbers.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.7 The Impact of Legislation: HIPAA
(continued)
1-34
• HIPAA Privacy Requirements
– The HIPAA Privacy Rule protects individually
identifiable information about a patient’s health and
payment for healthcare that is created or received by
a healthcare provider.
– Rule mandates that
• A set of privacy practices are adopted.
• Patients are notified about their privacy and how their
information can be used or disclosed.
• Employees are trained to understand the privacy practices.
• A staff member is appointed as the privacy official.
• Patient records that contain health information are secured.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.7 The Impact of Legislation: HIPAA
(continued)
1-35
• Protected health information (PHI) is information about
a patient’s health or payment for healthcare that can be
used to identify the person.
• The HIPAA Security Rule regulates the protection of
individually identifiable information about a patient’s
health and payment for healthcare that is created or
received by a healthcare provider.
• An Audit Trail is a report that traces who has accessed
electronic information, when information was accessed,
and whether any information was changed.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.8 The Impact of Legislation:
HITECH and ACA
1-36
• The Health Information Technology For
Economic and Clinical Health Act (HITECH)
provides financial incentives to physicians and
hospitals to adopt EHRs and strengthens HIPAA
privacy and security regulations.
– Act introduced additional privacy and security
regulations, including:
• Breach notification
• Monetary penalties
• Advanced enforcement
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.8 The Impact of Legislation: HITECH
and ACA (continued)
1-37
• Meaningful Use is the utilization of certified
EHR technology to improve quality, efficiency,
and patient safety in the healthcare system.
• Regional Extension Centers (RECs) are
centers that offer information, guidance, training,
and support services to providers transitioning to
an EHR system.
• A Health Information Exchange (HIE) is a
network that enables the sharing of healthrelated information among provider
organizations according to nationally recognized
standards.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.8 The Impact of Legislation: HITECH
and ACA (continued)
1-38
• The National Health Information Network
(NHIN) is a common platform for health
information exchange across the country.
• The Affordable Care Act (ACA) is federal
legislation that includes provisions designed to
increase access to healthcare, improve the
quality of healthcare, and explore new models of
delivering and paying for healthcare.
• An accountable care organization (ACO) is a
network of doctors and hospitals that shares
responsibility for managing the quality and cost
of care provided to a group of patients.
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
1.8 The Impact of Legislation: HITECH
and ACA (continued)
1-39
• The patient-centered medical home (PCMH) is
a model of primary care that provides
comprehensive and timely care to patients, while
emphasizing teamwork and patient involvement.
– Core Features include
•
•
•
•
•
•
•
Personal Physicians
Clinician Directed Medical Practice
Whole Person Orientation
Coordinated/Integrated Care
Quality and Safety
Enhanced Access
Payment
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.