9.1 List the six steps in the charge capture process. 9.2 Explain the purpose of auditing diagnosis and procedure code assignment. 9.3 Discuss the effect of health plans’ rules on billing. 9.4 Describe the use of CPT/HCPCS modifiers to communicate billing information to health plans. 9.5 Discuss strategies to avoid common coding/billing errors. 9 -2 © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill Learning Outcomes (Continued) When you finish this chapter, you will be able to:

9.6 Explain the difference between posting charges from a paper encounter form and posting charges from an electronic encounter from. 9.7 Identify the types of payments that may be collected following a patient’s visit. 9.8 Identify the steps needed to create walkout receipts. 9.9 Describe the use of a patient education feature in an electronic health record. 9 -3 © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill Key Terms • accept assignment • addenda • adjustments • bundled code • CCI column 1/column 2 code pair edits • CCI edits • CCI modifier indicator • CCI mutually exclusive code (MEC) edits • charge capture 9 -4 • charges • claim scrubbing • code linkage • compliant billing • Correct Coding Initiative (CCI) • global period • medically unlikely edits (MUEs) • modifier • MultiLink codes © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill Key Terms (Continued) • package • payments • place of service (POS) code • query • real -time claim adjudication (RTCA) • self -pay patients • unbundling • walkout receipt 9 -5 © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.1 Overview: Charge Capture Process 9 -6 • Charge capture — process of recording billable services • The six steps of the charge capture process:

– Step 1: Access encounter data. – Step 2: Audit coding compliance. – Step 3: Review billing compliance. – Step 4: Post charges. – Step 5: Calculate, collect, and post time -of -service (TOS) payments. – Step 6: Check out patient. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.1 Overview: Charge Capture Process (Continued) 9 -7 • Charges — amount a provider bills for performed health care services • Payments — money paid by patients and health plans • Adjustments — changes to a patient’s account © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.2 Coding Compliance 9 -8 • Physician practices audit medical coding to ensure maximum appropriate reimbursement – Codes/claims must be current and accurate for reimbursement. – Code linkage and medical necessity must be shown. • Addenda — updates to ICD -9 -CM • Claim scrubber — software that checks claims to permit error correction • Code linkage — clinically appropriate connection between a provided service and a patient’s condition or illness © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.3 Billing Compliance 9 -9 • Health plans and government payers reimburse practices according to their own negotiated or government -mandated fee schedule. – Health plans issue many billing rules that govern what will and will not be covered. – Medical practices must comply to be reimbursed. • Compliant billing — billing actions that satisfy official requirements • Package — combination of services included in a single procedure code © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.3 Billing Compliance (Continued) 9 -10 • Bundled code — two or more related procedure codes combined into one • Global period — days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package • Correct Coding Initiative (CCI) — computerized Medicare system that prevents overpayment • CCI edits — CPT code combinations that are used by computers to check Medicare claims © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.3 Billing Compliance (Continued) 9 -11 • Unbundling — incorrect billing practice of breaking a panel or package of services/procedures into component parts • CCI column 1/column 2 code pair edits — Medicare code edit in which CPT codes in column 2 will not be paid if reported for same day of service, for the same patient, and by the same provider as the column 1 code © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.3 Billing Compliance (Continued) 9 -12 • CCI mutually exclusive code (MEC) edits — edits for codes for services that could not have reasonably been done during one encounter • Medically unlikely edits (MUEs) — units of service edits used to lower the Medicare fee -for – service paid claims error rate © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.4 Modifiers 9 -13 • Modifier — number appended to a code to report particular facts – Communicates special circumstances involved with procedures. – Tells the health plan that the physician considers the procedure to have been altered in some way. – There are both CPT and HCPCS modifiers. • CCI modifier indicator — number showing whether the use of a modifier can bypass a CCI edit © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.5 Strategies to Avoid Common Coding/Billing Problems 9 -14 • Compliance errors can result from incorrect code selection or billing practices. • Strategies for compliance include:

– carefully defining bundled codes and knowing global periods, – using modifiers appropriately, and – following the practice’s compliance plan, especially the guidelines about physician queries. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.5 Strategies to Avoid Common Coding/Billing Problems (Continued) 9 -15 • Place of service (POS) code — designates location where medical services were provided • Query — request for more information from a provider © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.6 Posting Charges in Medisoft Network Professional 9 -16 • Process of posting charges differs when using a paper encounter form versus an EHR. • Posting charges from a paper encounter form:

– Click the New button in the Transaction Entry dialog box. – Complete the required fields. – Apply the payment in the Charges Area of the Transaction Entry dialog box. – Save the charges using the Save Transactions button. • MultiLink codes — groups of procedure code entries that relate to a single activity © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.6 Posting Charges in Medisoft Network Professional (Continued) 9 -17 • Posting charges from an EHR:

– Transactions from an EHR do not need to be manually posted in the Transaction Entry dialog box. – After electronic encounter form data is reviewed and edited (if necessary), it is posted and automatically appears in the Transaction Entry dialog box. – Unprocessed transactions can be posted from the Unprocessed Charges dialog box or from the Unprocessed Transactions Edit dialog box. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.7 Posting Patient Time – of – Service Payments 9 -18 • Practices routinely collect payment for the following types of charges at the time of service:

– Previous balances – Copayments or coinsurance – Noncovered or overlimit fees – Charges of nonparticipating providers – Charges for self -pay patients – Deductibles for patients with consumer -driven health plans (CDHPs) © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.7 Posting Patient Time – of – Service Payments (Continued) 9 -19 • Accept assignment — participating physician’s agreement to accept allowed charge as full payment • Self -pay patients — patients with no medical insurance • Real -time claim adjudication (RTCA) — process used to contact health plans electronically to determine visit charges © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.8 Creating Walkout Receipts 9 -20 • Walkout receipt — report that lists the diagnoses, services provided, fees, and payments received and due after an encounter • To create a walkout receipt in MCPR:

– Click the Print Receipt button in the Transaction Entry dialog box; the Open Report window appears. – Click the OK button; the Print Report Where? Dialog box is displayed. – Make a selection, and click the Start button. – Click the OK button to send the report to its destination. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 9.9 Printing Patient Education Materials 9 -21 • It may be appropriate to give patients education materials during checkout in order to:

– help patients better understand their diagnoses and treatments, and – provide instructions following an office procedure. • The patient education feature of MCPR provides a built -in set of patient education articles that can be printed and given to patients.