Computer Billing- chapter 8-10

third-party relationship
the patient (policyholder) is the first party, and the physician is the second party
third-party payer
the plan agrees to carry some of the risk of paying for the services
private or government organization that insures or pays for health care on behalf of beneficiaries
preferred provider organization (PPO)
managed care network of health care providers who agree to preform services for plan members at discounted fees
preferred provider organizations
most popular type of health plan, PPO contracts with physicians, hospitals, clinics, and pharmacies to provide a network of care providers for its beneficiaries
Three types of transactions recorded in the pm/ehr
charges, payments and adjustments
the final step of the charge capture process is patient checkout which involves : receipts to the patient for all payments, scheduling any follow up appointments, providing referrals and providing patient education material
revised annually—-the national center for health statistics and the centers for medicare and Medicaid services[cms] release ICD-9-CM updates called the ADDENDA twice a year
reporting encounters
current codes must be used for reporting encounters as of the date they go into effect and in valid[deleted] codes must not be used
is a proprietary code set, meaning that it is not available for free to the public rather the information must be purchased either in print or electronic format from the American medical association [AMA] which issues revised CPT codes each year
The annual changes are released by the AMA on OCT. 1 and are in effect for procedures and services provided after JAN. 1 of the following year
Claim scrubber
software that checks claims to permit error corrections
Code linkage
clinically appropriate connection between a provided service and a patients condition or illness
adding new procedure codes
the process of adding new procedure codes to the database begins with selecting Procedure/payment/adjustment codes on the list menu [the p/p/a list dialog box lists codes already in the database] When the new button is clicked the p/p/a dialog box Is displayed. the dialog box contains three tabs: general, amounts, and allowed amounts.
amounts tab
the amounts tab shows the amount charged for the procedure as listed in the practices fee schedule. the amount entered in field A is the normal charge for the selected procedure additional charges [b-z] may be used to record special pricing.
allowed amounts tab
the allowed amounts tab lists the amount each insurance carrier pays for the particular code. the columns in this dialog box list the following : insurance name, code, modifiers, and amount
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
incorrect billing practice of breaking a panel or packeage of services/procedures into component parts
medically unlikely edits [MUE]
units of services edits used to lower the mediocare fee-for-services paid claims error rate
CPT modifiers: description and common use in main text sections: -25
significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service
CPT modifiers: description and common use in main text sections: -52
reduced services : less then 8 mins
Real time claim adjudication [RTCA]
process used to contact health plans electronically to determine visit charges
Real time claim adjudication [RTCA] part 2
the information transmitted by the health plan allows the practice to: verify that the services are covered under the policy, know the patients financial responsibility for the visit and collect it NOTE: The RTCA does not generate a real time payment, the payment usually follows within 24 hrs
CLAIM MANAGEMENT in medisoft network prof
insurance claims are created, edited, and submitted for payment within the Claim Management are of MNP, after claims are created they are either transmitted electronically or printed and mailed
navigator buttons
the upper right corner ot the claim management dialog box contains 5 [FIVE] navigator buttons that simplify the task of moving from one entry to another —- The last claim button makes the last claim in the list active…the bottom of the claim management dialog box contains a number of buttons that are used for various functions
navigator buttons : EDIT
opens a claim for editing
is accessed by clicking the create claims button in the claim management dialog box. The dialog box provides several filters to customize the creation of claims
claim filters
the following filters can be applied within the create claims dialog box : transaction dates chart numbers, primary insurance, billing codes, case indicator, location, ASSIGNED [ the assigned provider is the patients regular physician]. attending, enter amount.
transaction tabs
the transaction tab lists information about the transaction included in the claim: DIAGNOSIS [the diagnosis code for the listed transaction is displayed] date form, document, PROCEDURE [ the procedure box displays the procedure code for a performed procedure], AMOUNT [in the amount box the dollar cost of a service is displayed].
submitting claims
claims that have been created in Medisoft network professional [MNP] are submitted using the REVENUE MANAGEMENT feature. Physician practices use revenue management to electronically transmit claims to clearing houses as well as directly to payers [VIA MAIL]