How is the claim management dialog box displayed in medisoft

Health Information System Electronic Health Record Week 5

Administrative and Structural Analysis of an Electronic Health Claim Management: Chapters 9 &10

Objective: In this assignment you are request to you will describe, analyze and apply process of creating claims, locating specific claim, methods used to submit electronic claims, and the claim determination process used by health plans.

ASSIGNMENT GUIDELINES (10%):

Students will judgmentally evaluate the readings from Chapter 9 and 10 on your textbook and from the article assigned for week 5. The Purpose of this Administrative and Structural Analysis of an Electronic Health Claim Management is to describes the potential benefits of EHRs that include clinical outcomes (eg, improved quality, reduced medical errors), organizational outcomes (eg, financial and operational benefits), and societal outcomes (eg, improved ability to conduct research, improved population health, reduced costs). Despite these benefits, studies in the literature highlight drawbacks associated with EHRs, which include the high upfront acquisition costs, ongoing maintenance costs, and disruptions to workflows that contribute to temporary losses in productivity that are the result of learning a new system. Moreover, EHRs are associated with potential perceived privacy concerns among patients, which are further addressed legislatively in the HITECH Act. Overall, experts and policymakers believe that significant benefits to patients and society can be realized when EHRs are widely adopted and used in a “meaningful” way.

You need to develop a 4 page paper long including title page and references page reproducing your understanding and capability to relate the readings to claim management. Each paper must be typewritten with 12-point font and double-spaced with standard margins. Follow APA format when referring to the selected articles and include a reference page.

EACH PAPER SHOULD INCLUDE THE FOLLOWING:

1. Introduction (25%) Provide a brief synopsis of the meaning (not a description) of each Chapter and articles you read, in your own words.

2. Your Strategies (50%)

a. Briefly compare the CMS-1500 paper claim and the 837 electronic.

b. Discussion the information contained in the claim management dialog box

c. Analyze the method used to submit electronic claims.

d. Discuss the use of the PM/HER to monitor claims.

3. Conclusion (15%)

Briefly summarize your thoughts & conclusion to this assignment and your appraisal of the articles and Chapter you read. How did these articles and Chapters impact your thoughts about Claim Management? How this Administrative Analysis help you in relation to Claim management in Medisoft.

Evaluation will be based on how clearly you respond to the above, in particular:

a) The clarity with which you present and analyzed the strategies;

b) The depth, scope, and organization of your Administrative Analysis paper; and,

c) Your conclusions, including a description of the impact of these articles and Chapters on any Healthcare Organization.

ASSIGNMENT DUE DATE:

The assignment is to be electronically posted no later than noon on Sunday, December 1, 2019.

Learning Outcomes

When you finish this chapter, you will be able to:

9.1 List the six steps in the charge capture process.

9.2 Explain the purpose of auditing diagnosis and

procedure code assignment.

9.3 Discuss the effect of health plans’ rules on billing.

9.4 Describe the use of CPT/HCPCS modifiers to

communicate billing information to health plans.

9.5 Discuss strategies to avoid common coding/billing

errors.

9-2

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Learning Outcomes (Continued)

When you finish this chapter, you will be able to:

9.6 Explain the difference between posting charges from

a paper encounter form and posting charges from an

electronic encounter from.

9.7 Identify the types of payments that may be collected

following a patient’s visit.

9.8 Identify the steps needed to create walkout receipts.

9.9 Describe the use of a patient education feature in an

electronic health record.

9-3

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Key Terms

• accept assignment

• addenda

• adjustments

• bundled code

• CCI column 1/column 2

code pair edits

• CCI edits

• CCI modifier indicator

• CCI mutually exclusive

code (MEC) edits

• charge capture

9-4

• charges

• claim scrubbing

• code linkage

• compliant billing

• Correct Coding Initiative

(CCI)

• global period

• medically unlikely edits

(MUEs)

• modifier

• MultiLink codes

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Key Terms (Continued)

• package

• payments

• place of service (POS)

code

• query

• real-time claim

adjudication (RTCA)

• self-pay patients

• unbundling

• walkout receipt

9-5

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9.1 Overview: Charge Capture Process 9-6

• Charge capture—process of recording billable

services

• The six steps of the charge capture process:

– Step 1: Access encounter data.

– Step 2: Audit coding compliance.

– Step 3: Review billing compliance.

– Step 4: Post charges.

– Step 5: Calculate, collect, and post time-of-service

(TOS) payments.

– Step 6: Check out patient.

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9.1 Overview: Charge Capture Process

(Continued) 9-7

• Charges—amount a provider bills for performed

health care services

• Payments—money paid by patients and health

plans

• Adjustments—changes to a patient’s account

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9.2 Coding Compliance 9-8

• Physician practices audit medical coding to

ensure maximum appropriate reimbursement

– Codes/claims must be current and accurate for

reimbursement.

– Code linkage and medical necessity must be shown.

• Addenda—updates to ICD-9-CM

• Claim scrubber—software that checks claims to

permit error correction

• Code linkage—clinically appropriate connection

between a provided service and a patient’s

condition or illness

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9.3 Billing Compliance 9-9

• Health plans and government payers reimburse

practices according to their own negotiated or

government-mandated fee schedule.

– Health plans issue many billing rules that govern what

will and will not be covered.

– Medical practices must comply to be reimbursed.

• Compliant billing—billing actions that satisfy

official requirements

• Package—combination of services included in a

single procedure code

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

9.3 Billing Compliance (Continued) 9-10

• Bundled code—two or more related procedure

codes combined into one

• 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

• CCI edits—CPT code combinations that are

used by computers to check Medicare claims

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

9.3 Billing Compliance (Continued) 9-11

• Unbundling—incorrect billing practice of

breaking a panel or package of

services/procedures into component parts

• CCI column 1/column 2 code pair edits—

Medicare code edit in which CPT codes in

column 2 will not be paid if reported for same

day of service, for the same patient, and by the

same provider as the column 1 code

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9.3 Billing Compliance (Continued) 9-12

• CCI mutually exclusive code (MEC) edits—

edits for codes for services that could not have

reasonably been done during one encounter

• Medically unlikely edits (MUEs)—units of

service edits used to lower the Medicare fee-for-

service paid claims error rate

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

9.4 Modifiers 9-13

• Modifier—number appended to a code to report

particular facts

– Communicates special circumstances involved with

procedures.

– Tells the health plan that the physician considers the

procedure to have been altered in some way.

– There are both CPT and HCPCS modifiers.

• CCI modifier indicator—number showing

whether the use of a modifier can bypass a CCI

edit

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9.5 Strategies to Avoid Common

Coding/Billing Problems 9-14

• Compliance errors can result from incorrect

code selection or billing practices.

• Strategies for compliance include:

– carefully defining bundled codes and knowing global

periods,

– using modifiers appropriately, and

– following the practice’s compliance plan, especially

the guidelines about physician queries.

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9.5 Strategies to Avoid Common

Coding/Billing Problems (Continued) 9-15

• Place of service (POS) code—designates

location where medical services were provided

• Query—request for more information from a

provider

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9.6 Posting Charges in Medisoft

Network Professional 9-16

• Process of posting charges differs when using a

paper encounter form versus an EHR.

• Posting charges from a paper encounter form:

– Click the New button in the Transaction Entry dialog

box.

– Complete the required fields.

– Apply the payment in the Charges Area of the

Transaction Entry dialog box.

– Save the charges using the Save Transactions

button.

• MultiLink codes—groups of procedure code

entries that relate to a single activity

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9.6 Posting Charges in Medisoft

Network Professional (Continued) 9-17

• Posting charges from an EHR:

– Transactions from an EHR do not need to be

manually posted in the Transaction Entry dialog box.

– After electronic encounter form data is reviewed and

edited (if necessary), it is posted and automatically

appears in the Transaction Entry dialog box.

– Unprocessed transactions can be posted from the

Unprocessed Charges dialog box or from the

Unprocessed Transactions Edit dialog box.

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9.7 Posting Patient Time-of-Service

Payments 9-18

• Practices routinely collect payment for the

following types of charges at the time of service:

– Previous balances

– Copayments or coinsurance

– Noncovered or overlimit fees

– Charges of nonparticipating providers

– Charges for self-pay patients

– Deductibles for patients with consumer-driven health

plans (CDHPs)

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9.7 Posting Patient Time-of-Service

Payments (Continued) 9-19

• Accept assignment—participating physician’s

agreement to accept allowed charge as full

payment

• Self-pay patients—patients with no medical

insurance

• Real-time claim adjudication (RTCA)—

process used to contact health plans

electronically to determine visit charges

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9.8 Creating Walkout Receipts 9-20

• Walkout receipt—report that lists the

diagnoses, services provided, fees, and

payments received and due after an encounter

• To create a walkout receipt in MCPR:

– Click the Print Receipt button in the Transaction Entry

dialog box; the Open Report window appears.

– Click the OK button; the Print Report Where? Dialog

box is displayed.

– Make a selection, and click the Start button.

– Click the OK button to send the report to its

destination.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

9.9 Printing Patient Education Materials 9-21

• It may be appropriate to give patients education

materials during checkout in order to:

– help patients better understand their diagnoses and

treatments, and

– provide instructions following an office procedure.

• The patient education feature of MCPR provides

a built-in set of patient education articles that

can be printed and given to patients.