BILLING & CODING
How to Ensure Efficiency
Tammy W. Norville, RMC
Primary Care Systems Specialist
March 3, 2011
The North Carolina Office of Rural Health and
Community Care (ORHCC) helps communities get lowcost access to medical care. Since it was created in
1973, ORHCC has opened 86 rural health centers
across the state. Currently, ORHCC supports 28
rural health centers with funding and technical
support. ORHCC also helps to place medical,
psychiatric, and dental providers in communities
throughout the state. Rural hospitals, as well as
many statewide medical facilities that treat poor
and uninsured residents, may receive help through
grant funds. Qualifying patients may take advantage
of drug companies’ free and low-cost drug programs
through ORHCC’s medication assistance program.
Road Map
Preamble – Claims Management Cycle
Part 1 – What is Efficiency?
Part 2 – Billing & Coding
Part 3 – Conclusion & Questions
Preamble
Claims Management Cycle
Claims Management Revenue
Cycle Components
Registration
Clinical Documentation
Check-Out
Coding
Billing
Insurer
Collections
Paid in Full!!
Our Focus
Coding –
Code Verification & Review
Pre-auth, Pre-cert or Pre-determination
Billing –
Claim Generation
Claim Review
Collections –
Collections/Claim Follow-Up
Posting Payments
Appealing Claims
Part 1
What is Efficiency???
Definitions
The quality or degree of being efficient
Effective operation as measured by a
comparison of production with cost (as in
energy, time and money)
The ratio of the effective or useful output
to the total input in any system
Definitions
The ratio of the useful energy delivered by a
dynamic system to the energy it supplies
The degree to which this quality is exercised
Word Play
Time to have a little fun!!!
What are a few…
Synonyms
Antonyms
Tammy’s Picks
Synonyms
Edge
Antonyms
Ineffectiveness
Effectiveness
Ineffectualness
Productiveness
Unproductiveness
Competence
Incompetent
Question
How do you know if something
is efficient?
The Take-Away
Know the process
&
Know your role
Let us pause for a commercial…
A brief moment to meditate on
FQHC/RHC Reimbursement
(Sappy music playing in the background…..)
FQHC/RHC Reimbursement
Applies to Medicare and Medicaid Patients
ONLY
Payment for these Core Visits are on an ALL
INCLUSIVE RATE PER VISIT created by
dividing a practice’s total allowable costs
by it’s total FQHC/RHC visits. In addition,
other Medicaid FQHC/RHC services are
reimbursed on a fee-for-service basis and
are reconciled to cost at the end of the
year.
FQHC/RHC Reimbursement
Under the FQHC/RHC program, the practice
is allowed to “break even” on the cost of
providing FQHC/RHC services to Medicare
and Medicaid patients.
The FQHC/RHC program does not affect
reimbursement for private insurance and
self-pay patients.
Part 2
Billing & Coding
What is a Coding
Person’s Job?
To capture what a Provider did (the
service they provided the patient)
and why they did it – based on the
ICD-9 codes selected and
documented by the Provider.
What is a Billing
Person’s Job?
Submit timely and accurate claims the
first time – get it paid!!
Tell Me What You Think
What does your coding/billing staff
look like?
How is it set up?
Do you have the tasks separated?
Reality Check!!
Why is the information in
the previous discussion
relative/important??
Coding Overview
Coding is the translation of services,
procedures, events, circumstances and
patient conditions into numeric
designations which must be fully
represented as documentation in the
medical record.
Coding Overview (con’t)
Components of appropriate documentation
– North Carolina Medical Board Requirements
– Coding Requirements – CPT Manual
Procedures must be supported by
appropriate diagnosis codes – establishing
medical necessity.
Types of Codes
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Level I – CPT – Procedures
Level II – HCPCS – Healthcare Common
Procedural Coding System – drugs, supplies,
Prosthetics, vision
ICD-9 – Diagnoses – Volumes 1 and 2
Volume 3 Hospital only
RBRVS – Resource Based Relative Value
Scale – Fee schedule broken down into
parts
CCI – Correct Coding Initiative – Updated
quarterly
Coding Documentation - CPT
Chief Complaint
History of Present Illness
Review of Systems
Past, Family, Social History
Exam – 1995 Rules Rule!
Medical Decision Making
Time - Sometimes
The Billing Process
Data Entry
Electronic Insurance Claims Processing
Insurance Provider Enrollment
Insurance Contract Negotiation
Insurance Claim Follow-Up
Payment Posting
Patient Invoicing
Reporting & Analysis
What’s The Big Deal?
Inefficiencies in coding and/or billing may
result in:
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•
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•
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Loss of revenue
Refunds
Fines
Accusations of Fraud
Medicare – OIG – “Men in Black”
Who Cares, Anyway?
Other than the insurance companies that are paying
claims – including Medicare and Medicaid
Baltimore Statistical Office
(aka, the National Center for Health Statistics)
EVERY claim goes through this office without common
knowledge. All ICD-9 codes are tracked – including trending
to physician – and extracted. This information is
disseminated to appropriate agencies (ex, CDC).
RAC Program Mission
"To reduce Medicare improper
payments through efficient detection
and collection of overpayments, the
identification of underpayments, and
the implementation of actions that
will prevent future improper
payments.”
RAC AUDITS!!!
The Centers for Medicare and Medicaid Services
(CMS) awarded Connolly Healthcare the contract
to provide recovery audit services mandated by
the Tax Relief and Health Care Act of 2006 for
Region C. The Recovery Audit Contractor (RAC)
program is a cost containment effort aimed to
reduce improper payments within Medicare
programs as well as identify process improvements
to reduce or eliminate future improper payments.
Region C – RAC
Connolly Healthcare is tasked with
auditing Region C, which consists of
the following states:
AL, AR, CO, FL, GA, LA, MS, NC,
NM, OK, SC, TN, TX, VA, WV and
the territories of Puerto Rico and
U.S. Virgin Islands.
Reality Check!!
Signs of Inefficiency
Biller/Coder Skill Issues
Incorrect/Inaccurate
demographic/eligibility information
Inaccurate or lack of coding
Incomplete claims
Lack of supporting documentation
Poor communication with payer
Not billing for services rendered
No follow-up on A/R balance claims
How Many Days in A/R?
On average, how long does it take any
given payer to remit payment from
the date of claim processing?
Total A/R Over 90 Days
How much (or what percent) of your
total Accounts Receivable (A/R) had a
date of service/date of first billing
greater than 90 days ago?
5 Steps to
Increased Efficiency
Tip #1
Know your team & ask for their help
Strengths
Weaknesses
Areas needing education
Areas of expertise
Communicate with the team regularly!!
Claims Processing & Review Discussion
Tip #2
Review your internal claims process
Are claims submitted accurately to
the correct payer within the required
timeline? Eligibility verification prior
to visits?
Tip #3
Review and reconcile claims payments
Are claims payments received from
payers? Are the payments accurate?
Are they posted to patient accounts
appropriately? Are denials, delays or
reductions addressed? Are appeals
used when appropriate?
Tip #4
Run & Review Monthly Reports
Collection
EOB/ERA for each claim
Production by user
Tip #5
Know your payer fee schedules
Are claims payments received from
payers correct? Are the payments
accurate? Are they posted to patient
accounts appropriately?
Do you maintain all health insurance
contracts centrally and review
regularly?
More Information
The American Medical Association is
sponsoring the “Heal the Claims
Process” ™ campaign.
www.ama-assn.org/go/healthatclaim
For educational material:
www.ama-assn.org/go/pmc
Other Ideas?
Tell me what you think!
Part 3
Why is this important??
What does the future
hold??
If we’re inefficient now…
What happens when we have to
implement an entirely new coding
system?
Goodbye, ICD-9!!!
Hello, ICD-10!!!
Goodbye ICD-9!
ICD-9-CM is outdated
–
–
–
–
Technology has changed
Categories are full
Not descriptive enough
Reimbursement – would enhance accurate
payment for services rendered
– Quality – would facilitate evaluation of medical
processes and outcomes
What do we need for a new
coding system?
Flexibility to quickly incorporate
emerging diagnoses and procedures
Exact enough to identify diagnoses and
procedures precisely
Hello, ICD-10!!!
Incorporation of much greater specificity
and clinical information which results in
– Improved ability to measure health care
services
– Increased sensitivity when refining grouping
and reimbursement methodologies
– Enhanced ability to conduct public health
surveillance
– Decreased need to include supporting
documentation with claims
Development Background
The new system is intended to replace ICD9-CM Volume 3 for reporting inpatient
procedures
ICD-10 has been around for years
1995-1996
First draft of
ICD-10-PCS completed
1996-1998
Training and Testing
1998 – Present ICD-10-PCS updated annually
Major Development Goals
Improve accuracy and efficiency of
coding
Reduce training effort
Improve communication with physicians
Essential Attributes
Completeness
All substantially different procedures
have a unique code
Expandability
The structure of the system allows
incorporation of new procedures as
unique codes
Essential Attributes
Standardized terminology
Includes definitions of terminology used
While the meaning of specific words can vary
in common usage, ICD-10-PCS defines a
single meaning for each term used in the
system.
General Principles
Diagnostic information is not included in the
code description
A “not elsewhere classified” option is allowed
for new devices and substances
All substantially different procedures are
defined
Code Structure
Codes are comprised of seven components.
Each component is called a “character”
All codes are seven characters long
Individual units for each character are
represented by a letter or number
Each unit is called a “value”
34 possible values for each character
Digits 0-9
Letters A-H, J-N, P-Z
System Structure –
16 Sections
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Medical and Surgical
Obstetrics
Placement
Administration
Measurement and
Monitoring
Extracorporeal
Assistance &
Performance
Extracorporeal
Therapies
Osteopathic
Other Procedures
 Chiropractic
 Imaging
 Nuclear Medicine
 Radiation Oncology
 Physical Rehabilitation
and Diagnostic
Audiology
 Mental Health
 Substance Abuse
Treatment

Potential Implementation
Issues
Budgeting
 Personnel training
 Working with medical staff to ensure
appropriate documentation available
to reap the benefits of greater
specificity
 Hardware and software changes
 Data conversion

Potential Systems & Applications
Affected (AHIMA)
Encoding software
 Case mix systems
 Medical record
abstracting
 Billing systems
 Registration and
scheduling systems
 Accounting systems
 Decision support
systems
 Clinical systems
 Utilization
management
 Quality management
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Case management
Clinical protocol
Test ordering systems
Performance
measurement systems
Medical necessity
software
Disease management
systems
Provider profiling
systems
Aggregate data
reporting
Timing
OCTOBER 1, 2013
Start preparations for implementation
now
Estimate time frames for making
needed software changes
Educate Team – coders, billers,
providers, etc.
Web Resources
CMS
General ICD-10 Information
http://www.cms.hhs.gov/ICD-10
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Complete version of ICD-10-PCS – updated annually
User manual
Mapping between ICD-9-CM and ICD-10-PCS
PowerPoint speaker slides
Technical paper explaining system
ICD-10-PCS Coding System and Training Manual
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10
.asp
Web Resources
CMS
ICD-10-PCS Files
http://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp#
ICD-10-CM Coding System
http://www.cms.hhs.gov/ICD10/03_ICD_10_CM.asp#
Web Resources
AHA
Central Office ICD-10 Resource Center
http://www.ahacentraloffice.org/ICD-10
AHIMA
ICD-10 General Information
http://www.ahima.org/icd10
Implementation preparation Checklist
The Take-Away
What is the current
impact of inefficiency
on your organization ?
The Take-Away
What may be the
future impact of
inefficiency on your
organization?
The Take-Away
What are your plans to
deal with inefficiency
in your organization?
Web Resources
http://www.cms.hhs.gov/
Centers for Medicare & Medicaid
Services
Coding/Documentation Requirements
RAC Audits/Requirements
HIPAA 5010 Implementation
ICD-10 Implementation
Web Resources
http://www.ncmedboard.org/
NC Medical Board
http://www.mgma.com/
Medical Group Management Association
http://www.google.com/
Google
**When in doubt, Google it!!**
Questions/Comments??
Thank you for your
participation!!
Contact Info
Tammy Norville
Primary Care Systems Specialist
tammy.norville1@dhhs.nc.gov
Cell: (919) 215-0220
Office: (919) 733-2040 x 229