Billing and Coding in Sync in the Revenue Cycle Presented By: DHA UBO Program Office Contract Support

1. Billing and Coding in Sync in the Revenue CyclePresented By:DHA UBO Program Office Contract Support 25 February 2014 @ 0800-0900 EST 27 February 2014 @ 1400-1500 EST For entry into the webinar, log into: http://altarum.adobeconnect.com/ubo.  Enter as a guest with your full name and Service or NCR MD affiliation for attendance verification. Instructions for CEU credit are at the end of this presentation. View and listen to the webinar through your computer or Web–enabledmobile device. Note: The DHA UBO Program Office is not responsible for and does not reimburse any airtime, data, roaming or other charges for mobile, wireless and any other internet connections and use. If you need technical assistance with this webinar, contact us at webmeeting@altarum.org. You may submit a question or request technical assistance at any during a live broadcast time by entering it into the “Question” field of Adobe Connect.

2. Objectives • Overview of the Revenue Cycle • Communication between Coding and Billing • Institutional Billing Guidelines • Professional Billing Guidelines • Tips for submitting clean claims • Billing Scenarios • EOB (Explanation of Benefits) and Denials • How to become a Certified Biller

3. The MHS Revenue Cycle Step 6: Institutional and Professional Coding

4. Establishing Good Communication • Each area of the Revenue Cycle works together to collect the information that pertains to the patient during their encounter • That information creates the picture for the third-party insurance company of what care and services were provided during that episode of care • Each area of the Revenue Cycle has rules and guidelines they must follow: • To register a patient • Provide services • Code for the patient care • Bill for patient’s services

5. Establishing Good Communication • When a claim is denied, the biller must review the reason • Sometimes another area of the Revenue Cycle (such as registration, coding, or the system) had incorrect information or insufficient information in order to process the claim • The biller must find out why it was returned and figure out how to fix it so that the claim will be paid • This may mean returning to the coding department to ask questions about diagnosis codes appended to the claim • Each insurance company has its own payer manual; and they often require different or additional information – such as the addition of a particular modifier or condition code • Billers and Coders need to work together to give the “story” of the encounter in the codes required by the third-party payer

6. Communication Between Coders and Billers • Accurate coding is required for proper payment from insurance companies and other payers • Build good relationships with coders so you can produce clean claims • Build good relationships with your Patient Administration Directorate (PAD) staff. If they enter incorrect information in CHCS at the front end, you may never see a claim for that beneficiary • Billers need to share and communicate with coders in order for coders to understand how coding affects the reimbursement process and is required for clean claims • Billers need to understand what a clean claim looks like. Learn the basics of coding so you can recognize when codes may or may not be correct and know why the coder used that particular code • Set up meetings and training opportunities so coders and billers can learn together

7. Billing Guidelines How do I find the billing guidelines? • Individual payer manuals (available online) • Check the UBO User Guide • It can be found on the UBO website (http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/Teleconferences.cfm) • Resources such as: The Uniform Billing Editor (gives information on what data elements are required/situational for each field locator on the UB-04) (Published by: Optum) • UBO modules entitled: • Data and Billing in Sync – UB-04/837I • Data and Billing in Sync – CMS-1500 (02/12)/837P

8. Institutional Billing Guidelines Institutional Billing Guidelines

9. UB-04 Claim Form

10. UB-04 Overview • The UB-04 is commonly referred to as the “Institutional Billing Form” • The 837I is the electronic transaction set for transmitting the information for the Institutional Claim • An on-demand, Web-based course outlining the paper and electronic data elements most commonly used for billing MHS institutional claims is available

11. UB-04 Institutional Claim Form • Training has been developed for Billers who use the UB-04 claim form/837I transaction set • The training also incorporates examples for electronic billing • Each module is interactive • To learn the required/situational data elements, select desired FL • Each FL includes examples and reference information • Course contains 7 modules: • Demographics, Institutional Information, Additional Information, Services Performed/Charging, Insurance Information, Diagnoses/Procedures, and Provider Information • At the conclusion of each module, a quiz is provided; and at the end of the course there is a final test which covers information from all 7 modules

12. Demographics Module 1 – Demographics • This module covers information obtained in the registration process • Incorrect demographic information can result in denials • Make sure all information for the patient’s episode of care is current for both address and contact information

13. Institutional Information Module 2 – Institutional Information • Institutional information relates to items such as the medical record number or the federal tax id number. • It also identifies whether the claim is an inpatient or outpatient claim • Much of the information is populated by the system • The information is used by the insurance company to identify the facility

14. Additional Information Module 3 – Additional Information • Condition Codes – these codes help determine patient eligibility and benefits and are used to administer primary or secondary insurance coverage • Occurrence Codes – these codes are used to determine liability, coordinate benefits, and administer subrogation clauses in benefit programs • Value Codes – these fields contain codes and the related dollar amounts identifying monetary data required for processing claims • These codes identify additional information about the patient and the need for medical services • These codes define significant events, insurance coverage conditions, or clinical data that can often affect payer processing and payment of the claim

15. Services Performed/Charging Module 4 – Services Performed/Charging • Information provided in this section include revenue codes, units, CPT® and HCPCS codes, descriptions, and the rate • Examples are given for inpatient, outpatient, and pharmacy

16. Insurance Information Module 5 – Insurance Information • Collecting the correct insurance information is crucial to getting the claim paid • Identifying the relationship between the patient and the holder of the insurance card is also a critical element • Identifying and billing the primary insurance payer will get the claim paid correctly

17. Diagnoses/Procedures Module 6 – Diagnoses/Procedures • This module covers the various kinds of diagnosis codes used for inpatient and outpatient coding, admitting diagnosis codes and patient’s reason for the visit • Explains and gives a listing of the POA (Present on Admission) codes • Explains what the Other Diagnosis Codes are and when to use them, such as E codes and V codes • Explains the principal procedure codes and how the data elements should be entered on the UB-04 form

18. Provider Information Module 7 – Provider Information • The information covered in this module indicates to the payer the name and identifier of the provider who was the attending, operating, or other provider during the dates of care for this claim • Explains the National Provider Identifier for the Billing Provider • Covers the attending Provider Name and Identifiers • Covers the Operating Physician name and Identifiers • Covers Other Provider Name and Identifiers

19. UB-04/837I Module Format and Functionality Modules are grouped by related sections Navigate using task bar or button

20. UB-04/837I Learning Checks and Post-Test • At the conclusion of each module, there is a narrative-based learning check • This learning check is meant to reinforce the material just covered and not every form locator is used. • At the conclusion of the 7th Module, take the Post-Test containing 10 questions for certificate • If the participant receives a score of 70+% a certificate of completion will be sent • If you would like a CEU certificate for completing the modules, you will need to send an email to the UBO.Learningcenter@altarum.org • All CEU requests will be cross-referenced and verified with the online registration. • http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/Teleconferences.cfm

21. Professional Billing Guidelines Professional Billing Guidelines

22. The CMS-1500 (02/12) Form

23. CMS-1500 • This is the form used to submit the professional charges to the third-party payer • The 837P is the electronic transaction set for transmitting the information for the Professional Claim • We take the episode of care and break it down into a series of codes that are read by the insurance payer • There are required and situational data elements that must be present on the CMS-1500 claim form/837P transaction set

24. Data and Billing in Sync - CMS-1500/837P UBO has provided training for the revised CMS-1500 form/837P transaction set • It can be found on the UBO website at this link: http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/Teleconferences.cfm • The course is broken down into 5 modules: • Insurance Information, Demographics, Diagnosis and Procedures, and Provider Information

25. Insurance Information Module 1 – Insurance Information • Covers the third-party payer(s) responsible for paying the claim • The information that identifies the patient to the payer • The relationship of the policyholder to the patient

26. Demographics Module 2 – Demographics • Name • Date of Birth • Sex • Address

27. Additional Information Module 3 - Additional Information • Covers code sets and dates required depending on the patient’s condition or type of claim being submitted

28. Diagnosis and Procedures Module 4 - Diagnosis and Procedures • Covers diagnosis codes – which identify the reason why the patient is being treated • Covers procedure codes – which identify what treatment the patient received at this encounter • Covers the charges associated with the treatment provided at this encounter

29. Provider Information Module 5 - Provider Information • Required information on the provider who treated the patient • Or provided supplies to the patient • Identifies the provider to the payer responsible for paying the claim

30. The new CMS-1500 Claim Form (02/12) • The form will be used as of 1 April 2014 • Payers will accept paper claims submitted on the new form • Updated information can be found at www.nucc.org • Both the updated claim form and updated claim manual are available (see the July 2013 Instruction Manual) • The form has been changed to accommodate the reporting and dual coding needs for both ICD-9 and ICD-10 • The form was updated to align with the changes in the 5010 837P transaction set and to accommodate upcoming ICD-10 reporting needs

31. Changes to the new CMS-1500 form • Replaced the 1500 rectangular symbol with black and white two-dimensional QR (Quick Response code) • Changed Tricare Champus to Tricare • Replaced “SSN” with “ID#” • Item Number 8 – Deleted “PATIENT STATUS” and content of field and changed title to “RESERVED FOR NUCC USE” • Item Number 9b – Deleted ‘OTHER INSURED’S DATE OF BIRTH, SEX’ – changed title to “RESERVED FOR NUCC USE” • Item 9c – deleted “EMPLOYERS NAME OR SCHOOL” – changed title to “RESERVED FOR NUCC USE” • Item 10d – changed title from “RESERVED FOR LOCAL USE” to “CLAIM CODES (designated by NUCC)

32. Changes to the new CMS-1500 form • Item Number 11b – deleted “EMPLOYERS NAME OR SCHOOL” – changed title to “OTHER CLAIM ID (designated by NUCC) • added dotted line in the left-hand side of the field to accommodate a 2-byte qualifier (Note: valid qualifiers are provided in the NUCC 07/13 Instruction Manual) • Item Number 14 – changed title to “DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP)” • removed the arrow and text in the right-hand side of the field • added “QUAL” with a dotted line to accommodate a 3-byte qualifier (Note: valid qualifiers are provided in the NUCC 07/13 Instruction Manual)

33. Changes to the new CMS-1500 form • Item Number 15 – Changed title from “IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE” to “OTHER DATE” - ADDED “QUAL” with two dotted lines to accommodate a 3-byte qualifier (Note: valid qualifiers are provided in the 07/13 Instruction Manual) • Item Number 17 – added a dotted line in the left-hand side of the field to accommodate a 2-byte qualifier (Note: valid qualifiers are provided in the 07/13 Instruction Manual) • Item Number 19 – changed title from “RESERVED FOR LOCAL USE” to “ADDITIONAL CLAIM INFO (designated by NUCC)

34. Changes to the new CMS-1500 form • Item Number 21 – added “ICD IND” and 2 dotted lines to accommodate a 1-byte indicator (Note: valid qualifiers are provided in the 07/13 Instruction Manual) • added 8 additional lines for diagnosis codes • changed labels for the diagnosis code lines to alpha characters (A-L) • removed the period within the diagnosis code lines • Item Number 22 – changed title from “MEDICAID RESUBMISSION” to “RESUBMISSION” • Item Number 30 – Deleted “BALANCE DUE” • Changed title to “RSVD FOR NUCC USE”

35. Tips for Submitting Clean Paper Claims • DO Use only original claim forms • DO Make sure claims are printed darkly • DO Remember that insurance companies scan all claim forms • Avoid folding claims, if possible • Avoid using terms such as “re-filed claim” or “second request” • Avoid handwritten claims • Don’t use all UPPERCASE letters • Don’t use punctuation or decimals • Don’t send unnecessary attachments • Don’t use staples, paperclips, or stick-on notes • Don’t mark the claim with highlighters • Don’t use circles or additional markings • Don’t attach labels or stickers • Don’t add notes or instructional assistance

36. Billing Scenario • MHS does not recognize outpatient consultation codes CPT® (99241-99245) or inpatient consultation codes (99251-99255) • Providers are required to use E&M CPT® codes depending upon whether the visit is for inpatient or outpatient • Billing Department receives a claim with the following CPT® Codes • 99243 • DX - 345.91 • This claim should be returned to have the CPT® code corrected to the correct E&M level office visit code

37. Billing Scenario • Billing department receives a claim with the following CPT® codes: • 99253 • 99251 • DX - 189.4 • This claim should be sent back to be reviewed since the MHS does not recognize inpatient consultation codes. • CPT® codes (99221-99223) should appear on the claim with modifier AI for the initial visit and CPT® (99231-99233) for any subsequent visits.

38. EOB (Explanation of Benefits) SAMPLE

39. EOB (Explanation of Benefits) • Explanation of Benefits (EOB) — A claims statement that is sent whenever a health plan is used for services or products from a healthcare provider. It shows how a patient’s benefits cover the cost of a service from a provider and what the patient owes. The EOB is not a bill. • Service/Product — The type of services or products received from a provider. • Dates of Service — The date(s) services were rendered. • Amount Billed — The full amount billed by a provider to the health plan. • Your Plan Discounts & Payments — This section details the amounts that are not patient responsibility. • PremeraNetwork Discount — The amount saved by using a provider that belongs to a Premeranetwork (or other health plan as appropriate). • Amount Paid By Your Health Plan — The portion of the charges eligible for benefits minus the patient’s copay, deductible, coinsurance, network discount and amount paid by another source up to the billed amount. • Amount Paid By Another Source — Examples of other sources include: a health funding account, other health insurance, automobile insurance, homeowners’ insurance, disability insurance, etc. This amount may not be itemized and may only show in the Totals row of the Claim Detail.

40. EOB (Explanation of Benefits) • Copay — A set amount patient’s pay for certain covered services such as office visits or prescriptions. Copays are usually paid at the time of service. • Deductible —The amount patient’s are required to pay each year for covered services before the health plan starts paying benefits. • Coinsurance — A percentage of covered expenses that patient’s pay after the deductible is met. • Amount Not Covered — The portion of the amount billed that was not covered or eligible for payment under the patient’s health plan. • Your Total Responsibility — This section details the portion of the bill that is the patient’s responsibility to pay. This amount might include the copay, deductible, coinsurance, any amount over the maximum reimbursable charge, or products/services not covered by the patient’s health plan. • Claim Notes — When present, these notes provide general information about the claim and may also provide specific explanation of activity that occurred in the Amount Not Covered, Amount Paid by Another Source, and What Your Plan Paid fields. For example, if the claim was denied because a provider submitted the same claim twice, a note would outline the claim denied as a duplicate. • Benefit Booklet Information — If applicable, contains information about why portions of a claim were denied. Retrieved From: https://www.premera.com/wa/member/manage-my-account/explanation-of-benefits/

41. Becoming a Certified Biller How to Become a Certified Biller

42. How to Become a Nationally Certified Biller • Certified Revenue Cycle Executive (CRCE) • CRCE-I(Institutional) • Patient Access • Billing • Credit/Collections • Revenue Cycle Management • CRCE-P (Professional) • Front Desk • Billing • Credit/Collections • Revenue Cycle Management • The applicant must have a minimum of four (4) years of experience in a healthcare related field. A two (2) year associate degree or a degree from an accredited university or college can be substituted for two (2) years of experience. When using an educational waiver for experience, a transcript copy must accompany the application. 

43. How to Become a Nationally Certified Biller American Association of Healthcare Administrative Management (AAHAM) • Certified Revenue Cycle Specialist (CRCS) • CRCS-I • Designed for the revenue cycle within an Institution • Hospital Environment • Must know patient access, billing and credit & collections • CRCS-P • Designed for the revenue cycle in a professional environment • Physicians office • Clinic • Must know front desk, billing, and credit & collections • Membership with AAHAM not required, although encouraged • One-year employment in the healthcare revenue cycle is recommended • Dual Certification is available • Re-certification has two options • Retake and pass the exam every three years • Joins as a national member within the year you become certified and earn CEUs • 15 hours must be earned from attending AAHAM related educational programs • The other 15 hours can be earned through other educational opportunities (i.e. UBO approved monthly webinars) • Be in good standing by 31 January of each year Retrieved From: http://www.aaham.org/Certification/CRCS.aspx

44. How to Become a Nationally Certified Biller • Certified Revenue Cycle Professional (CRCP) • CRCP-I • Patient Access • Billing • Credit/Collections • Revenue Cycle Management • CRCP-P • Front Desk • Billing • Credit/Collections • Revenue Cycle Management • CRCP-I/CRCP-P exams are available to National AAHAM members, in good standing. The applicant must have a minimum of two (2) years of experience in a healthcare related field. A two (2) year associate degree or a degree from an accredited university or college can be substituted for the two (2) years of experience. When using an educational waiver for experience, a transcript copy must accompany the application.

45. How to Become a Nationally Certified Biller American Academy of Professional Coders (AAPC) • Certified Professional Biller (CPB) • Understanding different types of insurance plans • Applying payer policy, Local Coverage Determinations (LCD), and National Coverage Determinations (NCD) for successful claim submission (Centers for Medicare and Medicaid Services) • Knowing CPT®, ICD-9-CM (ICD-10 10/01/14), and HCPCS Level II coding guidelines • Navigating the varying rules and regulations which apply to the healthcare industry, including HIPAA, False Claims Act, Fair Debt Collections Act, and Stark • Knowing the life cycle of a medical billing claim and how to improve the revenue cycle • Expertise in effective claim follow-up, patient follow-up, and denial resolution • Exam Covers • Types of Insurance • Billing Regulations • HIPAA & Compliance • Reimbursement & Collections • Coding • Case Analysis

46. How to Become a Nationally Certified Biller American Academy of Professional Coders (AAPC) cont. • Certification Requirements • We recommend having an associate’s degree. • Pay examination fee at the time of application submission. • Maintain current membership with the AAPC. • New members must submit membership payment with examination application. • Renewing members must have a current membership at the time of submission and when exam results are released. • All exams will be reported with exact scores and areas of study (65% or less). • CEUs required to maintain credentials Retrieved From: http://www.aapc.com/certification/medical-billing-certification.aspx

47. How Certification Benefits the Biller • Earning certification demonstrates a high level of achievement and distinguishes you as a leader and role model in the revenue cycle industry. The certification validates your proficiency and commitment to your profession and can play an integral role in your career strategy • Earning certification can help you by: • Giving you a competitive advantage with current and prospective employers • Granting you the recognition you deserve  • Building a network of peers in the influential group that shares your certification designation • Continuing to expand your skills and expertise through continuing education

48. How Certification Benefits the Employer • Earning certification demonstrates an individual’s expertise. It shows they possess the knowledge to meet the industry’s highest standards and the capacity to pass a rigorous certification examination. It shows commitment to their profession and ongoing career development. It also represents professionalism in the individual’s pursuit of excellence to quality of service in their career and the healthcare industry. • By hiring certified individuals and investing in certification for your staff you can: • Increase the competency of your staff • Increase quality and productivity • Build a strong team • Promote ongoing education and training • Reduce exposure to fraud and abuse

49. Summary • The MHS Revenue Cycle impacts everyone • It is crucial for billers and coders to have good communication • Understanding and knowing the coding, billing and payer guidelines help claims to get paid compliantly, accurately and timely • DHA UBO and DHA UBU have guidelines for the Services and NCR MD to follow • DHA UBO has web-based training available for both the UB-04/837I and CMS-1500/837P and provides monthly webinars on topics relevant to the MHS Revenue Cycle • The revised CMS-1500 (02/12), required by CMS, will become effective for all payers on 1 April 2014 • TPOCS will be updated to complete this version

50. Thank You Questions?