Charge Capture via EMR vs. Manual Charge Entry

Transcription

1 Charge Capture via EMR vs. Manual Charge Entry National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD FAX

2 Agenda Introduction Clean Claim ICD to CPT Linkage Front Desk Who & What Claim Critical Data Front Desk Capture Demographic Capture Eligibility CBO Feedback Manual Charge Entry What s Involved & Who Does It? Production Benchmarking EMR/EHR Capture Why & Who Unbeatable Efficiency Summary

3 Clean Claims Objective: Paid all the money anticipated on first claim submitted CMS Billing Formats: 1500 (ANSI 837p; Part B/Professional) UB-04 (ANSI 837i; Part A/Facility and NGS) Top Reasons for Non-Payment Demographic Issues Eligibility Prior-Authorization Medical Necessity (ICD) First Pass Rate: Clearinghouse (EDI) Level Report Clean Claim Rate: Post Pay Adjudication

4 ICD to CPT Linkage Example A ICD Codes In Order of Provider s Perceived Acuity: 1. Abscess: Acne: Warts: Psoriasis: Rendered Services: Linked ICD to CPT A (Level 3, established patient) 1, 2, 3, & 4 B (Any benign lesion destruction) 3 C (I&D, Simple) 1

5 ICD to CPT Linkage Example B ICD Codes In Order of Provider s Perceived Acuity: 1. Otalgia Cerumen Impaction Hearing Loss Strep Throat Rendered Servies: Linked ICD to CPT A (Level 3) 1, 2, & 3 B (Wax removal) 2 C (Rapid Strep) 4 D (Audiometry) 3

6 ICD to CPT Linkage Example C ICD Codes in order of Provider s Perceived Acuity 1. Pelvic Pain: Exposure to STI: V Negative Urine PT: V Condyloma: ASCUS Pap: Oral Contraceptive Management: V25.01 Rendered Services Linked ICD (Above) A (Level 4 Established Patient Visit 1, 6 B (Destruction of Vulvar Lesions, Extensive) 4 C (Urine Pregnancy Test) 3 D. Q0091 (Pap Conveyance) 5 E (Venipuncture RPR billed by outside lab) 2

7 Front Desk: Who are these people? Entry Level Position New to healthcare Limited Education (formal) Pay (Living wage?) Training (Initiation by Fire) Result: High Turnover Improve Retention? Elevate awareness Job Share Career path options Organizational impact Key Tasks: Collect money ( Patient $) Check-in & Check-out Self-Pay: Charge entry and Payment post Demographics capture Eligibility verification Health coverage expert Public relations & marketing Billing functions FPL determination Retail sale Financial reconciliation

8 Front Desk: Clinic Operational Duties Fluid job description small business Patient exam room placement Food/Drink order/coordinator HIPAA (PHI) & Payer of Last Resort Awareness Phone, fax, and mail management Pulling and replacing charts What happens if successful? Promotion Leave for better opportunity (i.e., more $) Consider broad-banding option

9 Front Desk: Eligibility Verification Every patient, every time no excuses Morning of visit (12 AM resets status) Primary Modus Operandi (MO): WWW Secondary: telephone Five payers = 75-80%+ of payments Focus on these (favorites on MS Explorer) Written Protocols (e.g., pictures of ID Cards & web site screen shots) Key Rules: 1. No exceptions check top five payers for EVERYONE 2. No proof of coverage, pay cash (See Rule 1) 3. Balance Due policy (See Rule 1) 4. Compliance with Payer of Last Resort Billing staff feedback (Clearinghouse Reports) by clinic

10 Front Desk: Eligibility Continued Rejected EDI Analysis **EDI: Electronic Data Interchange 55% Denial due to Eligibility Issues

11 Front Desk Feedback: Sample CBO Communication

12 Front Desk Feedback: Clearinghouse Report

13 Manual Charge Entry: Front Desk Charge Entry To do or NOT What is charge entry Capture of HCPCS (e.g., CPT or what was done) and ICD-9 (Why patient was seen) for each patient encounter At Centralized Billing Office (CBO) NOT Front Desk TOS Full Self-pay (not partial): Only charge entry Why?? Not Simply Data Entry National Correct Coding Initiative (NCCI or CCI) Charges (RVU based? No, how will they know order?) Ranked & linked ICD to CPT Modifier utilization NEVER JUST DOING BILLING CANNOT BE EXPERT Time from DOS to Charge Entry if not same day, to CBO Time to Enter a Charge: 30 to 40 seconds each 40 per hour, 6 hours per day, 5 day week = 1,200 4 weeks per month, 48 per year (4 weeks off) = 57,600 If automated no real front desk responsibility other than check out EMR/EHR: Never easy or seamless but WILL automate charge entry Handheld: Medaptus, PatientKeeper, other PDA options

14 Manual Charge Entry: Front Desk Charge Entry, If You Must HCPCS (e.g., CPT) versus ICD-9 (CM) (CPC/CCS-P NOT required) Use of Modifier -25 Billing Must REGULARLY Communicate/Interact with Charge Entry Staff: Reasons claims fail validation (EDI) which may be fixed at charge entry Reasons for payer claim denials based on Explanation of Benefit (EOB) Use of Modifier -25 Use of Modifiers -51 versus -59 versus -22 Establishment of Medical Necessity for most claims (via accurate ICD-9) Necessary ranking & linking of HCPCS and ICD Unique payer rules around immunization/injections Core Provider encounters versus not (e.g., R.N. administration of Gardasil versus doctor) Global Surgical Days (Packaged services vs. not) Link Compensation to Timeliness of charge entry (no more than one business day) Accuracy of charge entry First pass rate through EDI (e.g., clearinghouse)

15 Manual Charge Entry: Central Billing Office (CBO) Optimal Decrease Variability Increase Quality Check & balance to avert embezzlement Focused Coding & Billing Expertise Medicare/Medicaid encounter rate expertise Unique commercial requirements MCO specific coding/billing Immediate Feedback from Team (EOB) Decreased Churn/Turnover (Vs. Front Desk) CHC Billing is VERY Unique Most Cost Effective Option Training of front desk vs. Limited billing staff All billing staff in one place vs. How many clinics? Lost money & liability from inexperienced front desk

16 Charge Entry (or Payment Posting) CE/PP =18-28% of Process Encounters equals visits equals units Manual Charge Entry: Production Benchmarking Full Time Equivalent is FTE Just entering charges, FTE should manage 60,000 visits annually (easily) NOTE: Daily Units- 6 40/hour

17 Automated Charge Entry: Why & Who Time Savings maybe Provider reluctance Automated Manual takes 30 to 90 seconds for one entry $10,000 EOB in minutes Feature of EMR/HER Already paid for Accuracy Coding & Demographics Employed Providers Upside (additional): Privacy Accountability Efficiency Downside Little to no motivation Dislike for coding/billing Enforceability Diminished access (for patients)

18 Automated Charge Entry: EMR/EHR Not What You Think How optimal is your EMR/EHR and/or PM situation? 40-80% of Medical Practices have no HIT* <4% Fully Integrated EMR/Practice Management* National Ambulatory Medical Care Survey ( ) 1.8 Billion Ambulatory Visits 14 of 17 Quality Indicators no significant difference Quality of care NOT improved *CDC & POMIS Report 2008 *Robert Wood Johnson Foundation HIT in US, Where We Stand 2008 ** Archives of Internal Medicine;

19 Automated Charge Entry: EMR/EHR Not What You Think

20 Summary Charge Entry is a skill even if automated Must remember critical role of front desk process (demographics & eligibility) ICD to CPT Link = Medical Necessity Benchmarks are critical EMR/EHR is NO panacea Automation is not always automatic Stay educated and informed

21 Disclaimer: 1. The guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding/billing decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Neither NACHC nor Priority Management Group, Inc. accepts any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter may have a significant financial interest/relationship with the organization that provides this product/service.

22 Speakers: Ray Jorgensen, MS, CPC, CHBME Raymond T. Jorgensen is President and CEO of Priority Management Group, Inc. (PMG). Ray is responsible for oversight of consulting operations as well as coding, reimbursement, and payer related issues for the out-sourced billing component of PMG s services (more than one million annual encounters). He has personally trained thousands of providers from over 35 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles. Ray s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer s objectives and process unlike other medical business consultants groomed from the provider side. BA from The College of the Holy Cross (Worcester, MA) MS from Northeastern University (Boston, MA) CPC from the American Academy of Professional Coders (Salt Lake City, UT) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)

23 Speakers: Caroline Peucker, CPC, CPC-H, CPC-I PMG s Vice President, Consulting and Compliance Caroline has more than 25 years experience in the physician billing and coding industry. Her extensive experience includes serving as the Vice President, Coding and Compliance, Manager of coding and Billing Operations Manager for physician billing companies that serviced a wide range of specialties and practice types. She has broad experience with hospital-based physician and private practice where she was integral to coding and compliance education and training for clinical providers, practice and billing office staff members. She has performed and managed chart audits with objective of both compliance and optimizing reimbursement through correct coding and thorough documentation. Caroline holds a Bachelor of Science degree in Health Service Administration from Providence College. She is an AAPC certified coder and PMCC instructor.

24 Speakers: Robert Skeffington, CHBME Robert Skeffington, a founding partner and Executive VP of Sales and Marketing for Priority Management Group, Inc. (PMG). Responsible for PMG s overall business development strategy, Robert also works with staff to assess the impact of Health Care Reform on PMG and its hundreds of clients. Robert works diligently to enhance relationships with the National Association of Community Health Centers, state and regional CHC organizations, and individual community health sites. In addition to his role in PMG Billing, Robert also leads marketing and sales efforts for PMG Consulting which provides CHC centric education, operational assistance, and training services around revenue cycle management, coding, and other health care finance related matters. During his more than 17 years in health care Robert has worked with CHCs in the 48 contiguous states with an exclusive focus on revenue cycle management for the past 12 years with PMG. He is a speaker for NACHC and other regional CHC associations on a variety of health care revenue cycle related topics. BS from Salve Regina University (Newport, RI) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)

25 Contact Information Priority Management Group, Inc. (PMG) 700 School Street Pawtucket, RI P: F: Raymond Jorgensen, President & CEO Robert Skeffington, CHBME, Partner and Co-founder Caroline Peucker, Vice President, Consulting and Compliance