Clinical Documentation &
Revenue Management:
Capturing the Services
Overview
Prepared and Presented by
Linda Hagen and Mae Regalado
Presentation Outline
1. Context: Quality of Care, Revenue
Optimization, and Compliance
2. Tools: Records, Systems, Templates,
and Billing Forms
3. Process: Clinical Documentation and
Coding
4. Question & Answer
Context
• Why is it important to revenue
management that we capture enhanced
clinical information?
• Who finds it important?
• What can happen if we do not capture
enhanced clinical information?
Clinical Documentation:
Capturing the Services you Provide
• Complete and Consistent
– Capturing clinical documentation including all relevant
diagnostic data within the treatment record improves
the quality of care
– Up-to-date and accurate clinical information –
diagnostic and related to specific services provided
enables improved billing and cash flow
– Timely, accurate clinical records improve clinical and
financial audit results
Clinical Documentation
• While billing is important, providers should not focus
strictly upon capturing diagnostic and service data for
reimbursement purposes only
• Improved accuracy in the reporting of severity of
illness and morbidity/mortality measures are critical to
the overall quality of care and treatment outcomes
• More accurate data supports value-based
performance reporting as well as efforts aimed at cost
effectiveness/efficiency.
Clinical Documentation
• Other Goals for Clinical Documentation:
– Accurately capturing and reflecting the patient’s true severity of
illness, clinician’s judgment, clinical decision-making in support
of medical necessity
– Enhancing interdisciplinary care team performance
– Improving assessments, interventions and outcomes.
Sample Copy of CMS-1500
Billing Form
Sample Copy of UB04Billing
Form
Coding
Accurate Coding is a priority for all healthcare
providers and it is important to improve coding
accuracy and ensure compliance with
government regulations.
There are two schools of thought on coding:
• Some consultants recommend that clinicians do it, and
others say that a billing person can handle it, using
boxes checked off on a super bill.
Coding
• Kinds of Coding
– HCPCS
– CPT
– ICD-9
– DSM-IV
– NPI
CPT
Current Procedural Terminology (CPT)
• CPT is maintained by the American Medical
Association (AMA). The CPT code set accurately
describes medical, surgical, and diagnostic services
and is designed to communicate standardized
information about medical services and procedures
among physicians, coders, patients, accreditation
organizations, and payers for administrative, financial,
and analytical purposes.
CPT: Units of Service
• Units of service must be entered where
appropriate. Examples of CPT codes requiring
units of service include:
– CPT 90853, 96100, 96105, 96110, 96111,
96115, 96117, 96152, 96153, 96154, 96155.
HCPCS
Healthcare Common Procedure Coding System (HCPCS)
• Describes the specific items and services provided. HCPCS
coding is necessary for Medicare and Medicaid and other health
insurance programs to ensure that claims are processed in a
consistent manner. With the implementation of HIPAA, use of the
HCPCS for transactions involving health care information became
mandatory
Coding: Modifiers
Modifiers
• Modifiers are two-digit codes appended to
procedure codes such as CPT and/or HCPCS
codes, to provide additional information about the
billed procedure.
• In some cases, addition of a modifier may directly
affect payment.
ICD-9
ICD-9
• Diagnosis codes are used to group and identify diseases,
disorders, symptoms, and medical signs, and are used to measure
morbidity and mortality.
• The International Classification of Diseases , 9th Edition (most
commonly known by the abbreviation ICD-9) provides codes to
classify diseases and a wide variety of signs, symptoms, abnormal
findings, complaints, social circumstances, and external causes of
injury or disease.
• Under this system, every health condition can be assigned to a
unique category and given a code, up to six characters long.
ICD-10
ICD-10 Transition on October 1, 2013
• ICD-10 codes must be used on all HIPAA transactions, including
outpatient claims with dates of service, and inpatient claims with
dates of discharge on and after October 1, 2013.
• Otherwise, your claims and other transactions may be rejected,
and you will need to resubmit them with the ICD-10 codes. This
could result in delays and may impact your reimbursements, so it
is important to start now to prepare for the changeover to ICD-10
codes.
UB04
What are UB04 Revenue Codes?
• The UB-04 billing form, is a uniform institutional provider bill
suitable for use in billing multiple third party payers. Because it
serves many payers, a particular payer may not need some
data elements.
• The National Uniform Billing Committee (NUBC) maintains lists
of approved coding for the form. All items on the form are
described.
• UB04 Field: 42 - Revenue Code (Required) The provider
enters the appropriate revenue codes to identify specific
accommodation and/or ancillary charges.
What is a Super Bill?
• Unique to every provider depending
upon service mix and payer agreements
• Quickly capture clinical services in
“layman’s terms” that clinicians readily
understand
• Allows billing staff to rapidly convert
checked boxes to correct codes and
modifiers
• Quickly identify errors
Super Bill
• Super Bills need to include the following
basic information:
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•
•
•
•
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Patient demographic information
Insurance information
Treating clinician information
Diagnostic information
Service information, including cost
Release authorization
Example Super Bill
Next Steps
• Obtain and review billing manuals from
payers (Medicaid, Medicare, insurance
companies)
• Contact provider relations with questions
• Contract with a consultant to help set up
your billing process
• Outsource your billing to a third party
Thank You! Questions?
888-898-3280
www.ahpnet.com