Third Party Reimbursement Training

1. Third Party Reimbursement Training

2. Julia Hidalgo, ScD, MSW, MPHPositive Outcomes, Inc.Harwood MDwww.positiveoutcomes.netjulia.hidalgo@positiveoutcomes.net(443) 203 - 0305

3. Planning Committee • Aubrey Arnold • Gayle Corso • John Eaton • Theresa Fiano • William Green • Deidre Kelly • Syd McCallister AHCA • Heidi Fox HRSA HAB Project Officers • Johanne Messore • Yukiko Tani TPR Trainers • Curt Degenfelder • Marilyn Massick • Michael Taylor

4. Ground Rules • I do not represent HRSA, CMS, or AHCA • Let me know if you do not understand • We can share our feelings at the end of each section • You will be rewarded for staying awake • Shut off your electronic devices • A 15 minute break means 15 minutes!

5. Overview of Today’s Session • Overview regarding organizing patient/client charts, basics of billing, developing billing systems • Additional training modules and materials are available on website • Real life examples will be used • Resources for more in-depth information are identified • Each section includes training and discussion • Train the trainer approach is used • Please follow-up by email with additional questions • Focus of the training is on beginning to intermediate skills • Advanced training and TA are available

6. What is third party reimbursement (TPR)? Patient 1st Party Provider 2nd Party services Insurer Medicaid Medicare 3rd Party $ $ TPR is receiving payment from a source other than the patient for services provided to patients by a provider. This other source is the “third party”

7. Constructing an Effective TPR Strategy

8. HRSA Grant Funding Versus TPR • The CARE Act is considered by the HIV/AIDS Bureau to be the payer of last resort • This requirement is subject to audit • CARE Act grantees have been audited • Grantees and subgrantees should not rely on grant funds as their sole source of revenue • HRSA grant funds are finite because they are capped in annual appropriations • TPR is driven by patient service and volume • Funds from TPR should be used in addition to HRSA grant funds

9. The Role of a Grantee’s Sponsoring Organization • Communicate the availability and value of TPR • Grantees and subgrantees (i.e., contractors) should agree upon billing and collections responsibilities and procedures • Grantees should request periodic accounting of collected TPR payments, as appropriate • These payments should be reported as grant income • Grant income should be retained by direct service provider grantees or contractors • Grantees should develop and implement clear, adequately documented processes for CARE Act invoices for Title I and Title II

10. Documenting CARE Act and Other Funded Services

11. Health and Case Management Record Basics The record is the core element of a visit or other unit of service • It is a systematically organized record of a patient’s total care • Everyone who records progress of care in the record should follow the same note writing format • Policies and procedures dictate its organization and use • Creates a verifiable record of services provided for third party payers and other interested parties (QI, accreditation, etc.)

12. Health and Case Management Record Basics • The record is the primary instrument for planning care • Forms the basis to bill and pay for care • Documentation in the record can be reviewed by third party payers • Records are legal documents that assist in protecting the interests of the patient, facility, and providers • They are considered to be more reliable than an individual’s memory about events • They can be used in court or for other legal matters • They can protect you in a law suit

13. Record Documentation • Documentation provides the who, what, when, where, why, and how of patient care • Regardless of the complexity of documentation, records must be comprehensive enough to meet regulatory, licensing, accreditation, legal, research, and patient care needs and purposes • Record notes must be comprehensive enough to support evaluation and management code assignment

14. Record Contents • Date and time of service • Place of service • Chief complaint/presenting problem • Objective findings • List of tests/labs that are ordered and lab results • Diagnoses • Therapies administered and medications provided or prescribed • Preventive services provided • Disposition and patient instructions • Provider’s name and title • Length of the visit (e.g., minutes required to document time-specific procedures)

15. Minimum Records Processes • Develop and implement a process addressing the use of standard forms including • Responsible parties for form development and revision • Form approval process • Definition of timeframe for periodic review and revisions of forms • Consistent use of forms across sites

16. CMS/AMA General Principles of Record Documentation • An individual record is established for each person receiving care • The patient’s name should appear on every page with their unique identifier (patient record number) • The record should be complete and legible • Documentation of each encounter should include • Reason for the encounter • Relevant history and physical examination findings • Prior diagnostic test results • Assessment, clinical impression, or diagnosis • Care plan • Date and legible identity of the observer

17. CMS/AMA General Principles of Record Documentation • If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred • Past and present diagnoses should be accessible to the treating and/or consulting physician • Appropriate health risk factors should be identified • The patient’s progress, response to, and changes in treatment and diagnosis should be documented • The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record • If it’s not legible, it’s not there • If it’s not there, it wasn’t done

18. Universal Record Standards • All clinical information pertaining to a patient is kept in the record and must be readily available any time the facility is open • Multiple sites • Filing systems • Records elsewhere – radiology, counseling, etc. • Standards apply across all settings and are compiled from JCAHO, NCQA, AAAHC, Medicare, and Medicaid

19. Universal Record Standards • Information should be recorded by the provider at the time of care • At least on the same day • The longer the delay, the lower the quality of the entry • All staff should use the same set of approved abbreviations and symbols • All entries must be dated, timed, chronological, legible, and signed in non-erasable blue or black ink by the provider with his/her credentials noted after their name • No blank spaces in between entries • Corrections can only be made with a new entry-cross out and initial

20. Reimbursement and Records • Physicians and mid-level providers can make entries in the record and may generate charges during a patient visit • All payers have specific guidelines about how to submit claims for non-physician charges • Some payers may credential non-physicians to allow charges to be submitted under their own provider number • Others only allow billing under a physician • Whatever the rules, besure that your health record documentation backs up the billing

21. Reimbursement and Records • Charges can be generated based on office visits, consultations, procedures, diagnostic tests, X-rays, injections, vaccinations, and/or supplies • Supporting documentation (including who provided the service) has to be located in the progress notes, laboratory reports, X-ray reports, or diagnostic service reports • If services are provided in multiple sites (e.g., exam room and lab), charges have to be collected and organized for billing purposes • A data collection form is the best way to do this

22. Why set-up record policies and procedures? • Maintaining record policies and procedures is essential to protect your program and patients • Licensing and accrediting bodies, as well as governmental entities, require them • Your policies and procedures dictate how health information will be maintained and protected • Your policies set the basis for your legal record

23. Minimum Record Policy Elements • Confidentiality policies and procedures • Chart organization: sections, forms, and their order in the chart • Including specifications of what constitutes a complete record • Record maintenance, storage, retrieval: access to and archiving, backing up, security, and destruction • Patient compliance: informed consent and authorization to release information • Health record documentation practices: who, how and when; entry authentication; correcting the record • Sanctions or progressive discipline policy for staff who do not make proper entries into records

24. Set Your Record Audit Policy • Internal record audits should be performed as part of your program’s QA procedures • Internal review allows problems to be identified and corrected before someone else does it for you • Record internal audit policies should address • Audit content • Auditors • Audit timeframes, breadth, and scope • Levels of review • Audit types • Qualitative or quantitative deficiency analysis • Detailed audit process

25. Records Policy Implementation • When policies are developed, be sure • Input on the content has been received from all levels of staff, as appropriate • Staff are trained on the content and retrained annually • Maintain training session attendance records • All new employees should be oriented upon hire • All staff training should be documented • Staff should have easy access to relevant policies • Computer access is ideal

26. Step-by-Step Billing Process

27. Billing Process Schedule Appointment Provide Care Verify/Auth Register/ Determine Eligibility Coding Generate & Sign Bill Contact Payer Submit Bill No No Payment? Pend/Denial? Yes Yes Deposit Correct Post Payment Re-submit Bill Patient if applicable Charge Entry

28. Components of Bill Generation • Schedule appointment • Collect as much patient information as possible • On-site registration • Collect and verify outstanding patient demographic and insurance information • Conduct financial screening, as necessary • Create or have patient health record available • Generate encounter form • Provider encounter form • Provider completes encounter form and health record, both of which go to coding

29. Components of Bill Generation • Coding a claim • Coder verifies record notes, assigns appropriate codes, completes encounter form, and forwards it to billing department • Generating a bill • Billing department books appropriate service charge and produces bill based on completed encounter form • Submitting a claim • Bills are aggregated to form a claim, claim is attached to transmittal sheet identifying included bills, and both are submitted to third party payer

30. Common Billing Forms • The CMS1500 is the standard form used to bill all third party payers for professional services • It must be completed accurately • Timely collection of third party reimbursement depends on this form • The CMS1450 (UB-92) is the billing form used for hospital-based outpatient care

31. CMS1500 – Top of Form

32. CMS1500 – Bottom of Form

33. Code Sets • Coding transforms descriptions of diseases, injuries, conditions, and procedures from words to alphanumerical designations • The purpose of coding is to utilize code sets (ICD-9-CM, CDT, CPT, DSM, HCPCS, DSM) to classify patient encounters • The actual code set used is determined by • Healthcare setting • Regulatory agency • Reimbursement system • Approved HIPAA transaction code sets • ICD-9-CM, HCPCS and CPT are the primary coding systems that are used to determine reimbursement in the United States and selected under HIPAA

34. International Classification of Diseases (ICD) • ICD-9-CM has two volumes of diagnosis codes and one volume of procedure codes • Resources for ICD • Coding Clinic is a newsletter containing coding advice • It is published quarterly and helps you keep up to date with ICD-9-CM • Coding Clinic is agreed upon by a wide variety of parties and is considered authoritative • Call 1-800-261-6246 to subscribe

35. Sample ICD-9-CM Codes

36. Current Procedural Terminology (CPT) • Owned by the AMA and designed to facilitate communications between physicians, mid-level practitioners, and third party payers • Codes represent procedures and services performed by clinicians and some codes for other staff • Contains evaluation and management (E/M) codes • To help with CPT coding, the AMA publishes a monthly newsletter called CPT Assistant • Call 1-800-621-8335 for subscription, or go to http://www.ama-assn.org/catalog • CMS, Medicare carriers, and fiscal intermediaries publish transmittals and bulletins about CPT coding to guide you in their use

37. Sample CPT Codes

38. Healthcare Current Procedural Coding System (HCPCS) • HCPCS Level II Codes represent supplies, materials, injectable medications, DME, and services • Used mostly for ambulatory care and is a three level system • Level I is the CPT code • Level II codes are developed and maintained by CMS and updated quarterly • They are used primarily for reporting purposes in ambulatory care claims processing • Level III codes are for new procedures, devices, and services not in Levels I and II • Defined by fiscal intermediaries and vary by location or payer • HCPCS – useful information at www.cms.gov

39. Sample HCPCS Codes

40. Other HIPAA Standard Code Sets • Code on Dental Procedures and Nomenclature, Second Edition (CDT-2) • Developed and maintained by the American Dental Association to record dental procedures • Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) • Developed and maintained by the American Psychiatric Association to code diagnoses made by mental health and substance abuse treatment providers • National Drug Codes (NDCs) • Developed and maintained by the Food and Drug Administration to report prescription drugs in pharmacy transactions and some claims by health claim professionals

41. Coding Process • The process of who does the coding may vary among settings • However, the function of assigning codes does not change • Providers and coders take clinical information (e.g., diagnostic terms, procedure descriptions) and assign a code to each one according to official rules • Coders would take this clinical information from the provider’s portion of the health record • The provider is responsible to record proper information • Coding professionals do not make assumptions or use personal preferences • Coding guidelines absolutely prohibit this

42. Coding Tips • Documentation must substantiate the bill • The note should back up the code chosen, and vice versa, or you can lose reimbursement • Coding is a joint effort between the clinician and coder to achieve complete and accurate documentation, code assignment, and diagnostic and procedural coding • ICD codes labeled “not elsewhere classified (NEC)” or “not otherwise specified (NOS)” should be used only when the documentation in the record does not provide adequate information to assign a more specific code

43. More Coding Tips • Code to the highest level of specificity when applying codes (i.e., use the 4th or 5th digit if they exist) • Do not code diagnoses documented as “probable,” “suspected,” or “rule out” as if the diagnosis is established • Guidelines for these were developed for inpatient reporting and do not apply to outpatients • You have to code the symptoms, signs, abnormal test results, or other reason for visit if no diagnosis is established at that time • When no definite condition or problem is documented at the conclusion of a patient care visit, the coder should select the documented chief complaint or symptom

44. Evaluation and Management (E/M) Coding • All physicians, regardless of specialty, may use any E/M service code • History, examination, and medical decision-making are the key elements when determining a level of service • There are different codes for new and established patients • E/M codes encompass wide variations in skill, effort, time, responsibility, and medical knowledge required for diagnosis and treatment • Includes private/clinic “office” visits or hospital-based outpatient visits and other types of services provided by physicians and mid-level providers

45. Coding and Reimbursement • Coding errors can result in delayed, incorrect, or no payment • With the added scrutiny of the Office of Inspector General and others, it is increasingly more important to minimize errors that can result from incomplete documentation or inappropriate use of codes • Patient records have to include documentation for medical care, diagnostic tests, procedures and all other services submitted for payment

46. Coding Audit Triggers On Medicare’s Current Hit List • Excessive use of higher-level E/M codes—too much use of 99215 • Billing for consultations on established patients for minor diagnoses that do not support this level of service • Billing for excessive repetition of lab tests when results are typically normal for that patient • Upcoding and overutilization billing for office visits, especially when services were not medically necessary

47. TPR Collections: Step-by-Step

48. Billing Process Schedule Appointment Post Payment Deposit Contact Payer Register/ Determine Eligibility Submit Bill Pend/Denial? Payment? Verify/Auth Correct Provide Care Re-submit Coding Bill Patient if applicable Charge Entry Generate & Sign Bill No No Yes Yes

49. Collecting Third Party Payments • Remittance Advice (RA) • Third party payer forwards a RA to billing provider • RA is usually accompanied by an Explanation of Benefits (EOB) form and a check for paid bills • Deposit payment – deposit payment immediately upon receipt • Post payment – payments made on outstanding amounts should be posted to patient accounts

50. Collecting Third Party Payments • Bill secondary payer • As appropriate, bill secondary payer (s) for remaining patient balances (or coordination of benefits) • Bill patient • After payment from a secondary payer is received, bill patient accordingly • Analyze pended and denied bills • Analyze RAs and EOBs to identify and resolve correctable billing errors • Resubmit corrected bills