Transcript Behavioral Emergencies - Vista Unified School District

Medical Office Administration
2nd edition
Brenda A. Potter, CPC
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Chapter 10
Medical Billing
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Billing Process
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Charges and payments must be properly
processed
Process starts at registration of patient
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Complete information for billing obtained at
registration
Registration form
Registration information verified for established
patient
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3
Superbill
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Also known as encounter form, charge clip,
fee slip, service record
Lists patient’s billing information
Details patient’s procedures and diagnosis
Often computerized
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4
Billing Process
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5
What Does the Doctor Charge?
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Depends on the patient’s medical condition
Other charges often associated with a
patient’s visit
Amounts should be an estimate
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6
Charges for Minors
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Charges must be billed to adult (unless minor
is emancipated)
In case of divorce, court will decide which
parent is responsible for a minor’s bill
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7
Missed Appointments
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Physicians usually do not charge
May charge if appointment time was lengthy
Charging is ethical as long as patient was
notified in advance
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8
Assignment of Benefits
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Insurance benefits are sent directly to
physician’s office
Office will receive funds more quickly with
assignment
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9
Fee Schedule
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Details how much each procedure costs
Fees usually reviewed annually
Fees vary regionally and nationally
Some insurance programs have maximum
allowed amounts
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10
Medical Coding
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Assigns a numeric or alphanumeric code to a
procedure or diagnosis
Standardized codes make communication
easier between physicians and insurance
companies
Easier, faster processing of insurance claims
Coding is used to gather statistics
Knowingly misrepresenting by overcoding
constitutes fraud
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11
Procedure Coding
Current Procedural Terminology – CPT
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Codes copyrighted by American Medical
Association (AMA)
Updated annually
HCPCS (HCFA Common Procedure Coding
System)
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Level I – CPT codes for physician services
Level II – codes for nonphysician services
(medical equipment and supplies)
Level III – no longer used
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12
Format of CPT Manual
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Six sections
Index
Appendices
Manual in numerical order with the exception
of E&M codes
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13
Basics of Procedure Coding
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Procedures located in index by
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Condition
Anatomical site
Name of procedure
Synonym, eponym, or abbreviation
Procedures verified in one of six sections of
manual
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14
Evaluation and Management (E&M)
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Includes codes for physician’s visits in various
locations or for special services such as
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Office
 Hospital
 Nursing home
 Emergency room
 Consultation
 Preventative care
 Critical care
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15
Anesthesia
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Codes may be used by anesthesiologist,
nurse anesthetist, or physician administering
anesthesia
Location and type of procedure are needed to
identify anesthesia code
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16
Surgery
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Largest section of CPT
Divided by medical specialty
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17
Radiology
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Includes x-ray, ultrasound, CT, MRI,
mammography, radiation oncology, nuclear
medicine
Some studies may specify use of contrast
medium
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18
Pathology and Laboratory
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Laboratory can test various body substances,
such as blood, urine, feces, sputum
Surgical pathology
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19
Medicine
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Vast assortment of codes
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Vaccines and administration
Psychiatry
Ophthalmology
Cardiology exams
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20
Modifiers
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Used to identify special circumstances for a
procedure
Listed in front of CPT
Defined in guidelines and appendix
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21
HCPCS Level II
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Used for billing supplies and nonphysician
services
Alphanumeric – One letter followed by four
numbers
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22
Table of Drugs and Chemicals
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Part of HCPCS Level II codes
Used to identify the supply of a medication
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23
Diagnosis Coding
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ICD-9-CM – International Classification of
Diseases, 9th Revision, Clinical Modification
Developed by World Health Organization
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24
Format of ICD-9-CM Manual
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Consists of three volumes:
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Vol. 1 – Tabular List of Diseases
Vol. 2 – Index of Diseases
Vol. 3 – Index and Tabular List of Procedures
(used only to identify facility services, not
physician services)
Updated annually
Must use codes from current year
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25
Conventions
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Symbol or an abbreviation
Used to identify special circumstances when
coding
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26
Outpatient Guidelines
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ICD-9 has specific guidelines on diagnosis
coding in an outpatient setting
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27
Basics of Diagnosis Coding
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Diagnosis first located in index (Vol. 2)
Diagnosis then verified in tabular list (Vol. 1)
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28
Late Effects
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Something that has happened to a patient
after acute phase of disease
No specific time frame
Residual is what occurs as a result of a late
effect
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29
V Codes
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Used to identify reasons for having a health
encounter such as
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Physical examinations
Screening for certain diseases
Immunization
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30
E Codes
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External Case of Injury and Poisoning
Identify circumstances of an injury
Not normally used in outpatient setting
Cannot be listed as first diagnosis
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31
Table of Drugs and Chemicals
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Not same as HCPCS table
Identifies causes of adverse effects of drugs
and other chemicals
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32
Vol. 3 – Procedures
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Used to record facility’s portion of procedure
or service
NOT used in place of CPT
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33
Compliance
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Ensuring government regulations are met
Incorrect coding is an example of
noncompliance
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34
The Coding Profession
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Certifications
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CPC – Certified Professional Coder
CCS – Certified Coding Specialist
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35
Computerized Bookkeeping Systems
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Procedure code database holds current price
of procedures
Diagnosis code database contains current list
of diagnoses
Both codes are then placed on insurance
claim form
Reports can help track
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Current and past due accounts
Financial picture of practice
Insurance claim information
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36
Pegboard System for Billing
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One-write system
One sheet logs the business transactions of a
practice
Low cost, but time-consuming
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37
Credit
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Paying for a charge at a later time
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38
Federal Equal Opportunity Act
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Unlawful to discriminate when granting credit
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39
Billing Patients
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Each month, statement should be sent to
guarantor
Cycle billing spreads workload out over
month
Aging accounts helps determine which
accounts need attention for collection
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40
Collection
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Assistant should always obtain permission
from the patient’s physician before pursuing
collection
Find out why patient has not paid bill
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41
Collection Guidelines
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Physician should establish collection
guidelines
Aggressive tactics not appropriate
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42
Fair Debt Collection Practices Act
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Protects debtors from unfair practices of debt
collectors
Debt collectors cannot
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Use threats of violence
Use offensive language
Misrepresent themselves
Contact debtor at social events
Call a third party more than once
Debt collectors must
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Call at convenient hours (between 8 AM and 9 PM)
Stop contacting a debtor if debtor states he has an attorney
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43
Collection Methods
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Dunning message on monthly statement
Telephone collection
Collection letters
In-person collection
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44
Agency Collection
or Small Claims Court
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Agencies may be costly
Small claims court may have limits
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45
Medical Debt
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Bills can become astronomical
Many bankruptcies involve medical debt
Some offices may employ special credit
counselors
Charitable sources may be available
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46
Confidentiality
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All medical billing information is confidential
Account information should not be given
without patient’s permission
Release of information is required for filing
insurance claims
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47
Billing Fraud
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Knowingly and willfully billing for something
that did not occur
Provider fraud
Patient fraud
Punishable by law
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48
Identify Theft
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Patient registering under false name
Patient using someone else’s insurance
Ask for identification from patients
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49
Fee Splitting
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Physician cannot receive anything of value in
exchange for referrals
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50
Estate Claims
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Limited amount of time to collect for charges
incurred by a deceased patient
Varies from state to state
Legal notices identify personal representative
of patient’s estate
Claims cannot be made after time limit
expires
Allow reasonable time after death before
sending bill
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51
Medical Records

Patients with past due accounts may not have
medical records withheld
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52