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Introduction to Physician Professional Claims and Billing. Brody School of Medicine East Carolina University. How does a Physician medical insurance claim begin?. At a minimum an insurance claim begins with: A patient A provider A service rendered to a patient.

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introduction to physician professional claims and billing

Introduction to Physician Professional Claims and Billing

Brody School of Medicine

East Carolina University

how does a physician medical insurance claim begin
How does a Physician medical insurance claim begin?
  • At a minimum an insurance claim begins with:
    • A patient
    • A provider
    • A service rendered to a patient
ways that patient contact occur
Ways that patient contact occur:
  • An Appointment
  • A Walk-in
  • Urgent/Emergency visit
  • Scheduled Admissions
  • “Rounds” ( hospital daily care, consultations, nursing home visits, home visits., etc)
  • Scheduled Procedures/Surgery
when appointments are made
When appointments are made:
  • Identify the patient type (new vs established)
  • The nature of the visit should be identified, i.e. sick visit, annual physical, etc.
  • Notification of insurance status: the patient should alert the provider regarding any insurance coverage or changes in coverage
new patient vs established patient
New patient -vs.- Established patient
  • New patient is one that has not received any face to face professional services from the provider or another provider of the same specialty in the same group practice within the last 3 years
  • Established patient has received face to face services within the last 3 years by the provider/provider specialty of the same group…
          • CPT Evaluation and Management Guidelines
patient sees the provider
Patient Sees the Provider
  • The provider must clearly document in the health record
    • Any patient history, exam and medical decision making as applicable
    • Procedures performed
    • Tests ordered or performed
    • Any independent interpretations
    • Any referrals or instructions to the patient &/or office/ancillary staff
    • Consultations: who requested, exam/findings, response to referral source
claim creation information required on a claim
Claim Creation: Information Required on a Claim
  • Patient identifying information
  • Patient insurance information
  • Patient Diagnoses(ICD-9-CM)
  • Patient Services/Procedures(CPT-4/HCPCS)
  • Provider information
  • Site of Service information (office, inpatient hospital, home, etc)
initiating a claim for a non hospital setting
Initiating a claim for a non-hospital setting
  • Patient data is provided via schedules, visit logs or other information surrounding encounters
  • Encounter forms or charge tickets are utilized by providers to communicate the services provided to the bill following scheduled visits or other encounters
  • Physicians or other professional clinical staff will select the diagnoses/services best describing the patient encounter (most clinics) OR
  • Professional coding staff will review and/or select the diagnoses/services as documented in the patient record
initiating a claim for a non hospital setting continued
Initiating a claim for a non-hospital setting continued…
  • Settings in which the provider completes the encounter form or charge document will submit the completed forms for charge entry
  • Settings in which the encounter form/charge document is submitted to a coder will require completion by the coder. The coder will review the documentation and select the appropriate ICD-9-CM and CPT codes for the service.
initiating a claim for a hospital based setting option 1
Initiating a claim for a hospital based settingOption 1
  • Physicians or other professional clinical staff will select the diagnoses/services best describing the patient encounter
  • Diagnoses and services are communicated to professional coding staff via an encounter document
  • Encounter documents are verified for accuracy and completeness
  • Encounter documents are batched for billing
  • Services are randomly picked by the coder for review to verify services are billed as documented in the medical record
initiating a claim for a hospital based setting option 2
Initiating a claim for a hospital based settingOption 2
  • Professional coding staff track patient encounters via census listings and service logs provided by the facility or physician office
  • Coding staff will then identify potential encounters performed by their assigned physician group
  • Coding staff will review medical record documentation for the applicable services that corresponds with information found via census and visit logs
  • ICD-9-CM and CPT service will be coded and recorded on the appropriate encounter document for billing
  • Encounter documents are subsequently batched for billing
initiating a claim for a hospital based outreach setting
Initiating a claim for a hospital based outreach setting
  • Physicians or other professional clinical staff are responsible for notifying coding staff of services rendered at outreach locations
  • Providers will select the diagnoses/services best describing the patient encounter
  • Diagnoses and services are communicated to professional coding staff via an encounter document
  • Encounter documents are verified for accuracy and completeness and in some cases coded by the coding staff
  • Encounter documents are batched for billing
charge entry
Charge Entry
  • Claims may be entered by Patient Access Services Staff in some of the clinical areas
  • Claims may be entered centrally by Clinical Financial Services
  • Some coding staff have been trained to enter services that they have coded
information found on cms 1500
Information found on CMS 1500
  • Patient identification
  • Patient insurance data
  • Services and diagnosis (ICD-9-CM/CPT/HCPCS)
  • Provider information
  • Authorization to file a claim
  • Authorization for payment allowance
  • Information related to patient’s current illness or hospitalization
  • Charges
  • Payments (as applicable)
slide18
TES
  • TES (Transaction Editing System) is a billing interface that contains claim edits to help identify service information that does not contain all of the required billing information
  • Claims or “invoices” that are missing information or have a deficiency will suspend in the TES system for a responsible user to correct
  • Individuals that are responsible for correcting data include coding staff, patient access services staff and insurance staff
claimsmanager
Claimsmanager
  • A billing edit interface that focuses on coding content including but not limited to the following:
    • Invalid diagnosis/procedures
    • Bundling rules
    • Coverage of services (medical necessity)
  • Coding staff are responsible for the correction/evaluation of coding edits that are suspended by Claimsmanager
a word about fraud and abuse
A word about fraud and abuse…

Fraud and Abuse Guidelines

  • Fraud: “Intentional” deception or misrepresentation that someone makes knowing it is false, that could result in an unauthorized payment.
  • Abuse: “Actions that are inconsistent with accepted sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the [Medicare] program thru improper payment.”
coding and billing as an identified potential risk area for fraud and abuse
Coding and billing as an identified potential risk area for fraud and abuse
  • Billing for items or services not rendered or not provided as claimed (fraud)
  • Submitting claims for equipment, medical supplies and services that are not reasonable and necessary (abuse)
  • Double billing resulting in duplicate payment (abuse)
  • Billing for non-covered services as covered (fraud)
coding and billing as an identified potential risk area for fraud and abuse1
Coding and billing as an identified potential risk area for fraud and abuse
  • Knowing misuse of provider identification numbers, which results in improper billing (fraud)
  • Unbundling (assigning multiple codes for a service that is covered by a single comprehensive code) (fraud)
  • Failure to properly use coding modifiers (fraud)
  • Clustering (selection of the same level of E/M service repetitively) (abuse)
  • Upcoding or coding at a higher level of service than actually provided (fraud and abuse)
tips to prevent fraud and abuse related to coding
Tips to prevent fraud and abuse related to coding:
  • Never make changes to a diagnosis code or CPT code on a claim or edited invoice without evaluating the documentation first
  • Use the correct version of ICD-9-CM/CPT/HCPCS based on the date of service
  • ICD-9-CM codes should be selected to the highest specificity based on documentation
  • Select the CPT code which best describes the service performed. For services that do not have a specific CPT code to describe, use the unlisted code from the appropriate category
  • When using a CPT modifier, make sure the combination with the CPT code is appropriate
tips to prevent fraud and abuse related to coding1
Tips to prevent fraud and abuse related to coding:
  • When using a CPT modifier, make sure the combination with the CPT code is appropriate
  • Use a comprehensive CPT code if available in reporting a procedure or surgery. Never use multiple codes to describe a service when a single comprehensive code is available
  • Familiarize yourself and stay up to date on payer coverage policies that you frequently code
  • Communication: keep providers well informed regarding documentation and coding requirements
commitment to compliance
Commitment to Compliance
  • If you have questions about:
    • Billing
    • Documentation and Coding
    • Fraud and Abuse
    • BSOM code of Conduct

Contact the Brody School of Medicine Compliance Office at 744-5200

commitment to compliance1
Commitment to Compliance
  • Two methods to report compliance concerns:
  • Brody School of Medicine email:
    • BSOMcompliance@ecu.edu (you may remain anonymous)
  • Brody School of Medicine Hotline:
    • 1-866-515-4587 24 hours a day/7days a week (you may remain anonymous)