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Hospital invoice sample for Supervision

chapter 19 hospital outpatient and inpatient billing the learning objectives for lesson 19 is one explain the revenue cycle of hospital claims two manage the discharge not final build report three discuss the seven two hour rule four explain utilization management and its role in the hospital reimbursement system five explain the charge master six explain the international classification of diseases tenth revision procedure coding system the ic10 bcs seven explain the role of the ic10 pcs in hospital billing eight explain the role of current procedural terminology in hospital billing nine explain the role of healthcare common procedural coding system 10 assign the president on admission indicator and 11 explain the reimbursement methods used when receiving reimbursement for medicare hospital services admissions procedure to maintain a quality of standard of care it's important to first identify the standards of patient care and develop a strategy to meet those standards the joint commission tjc american hospital association the aha and centers for medicare and medicaid services cms provide guidance to hospitals to meet quality patient delivery goals these organizations have established specific procedure guidelines that hospitals must follow to ensure quality patient care for pre-admission tests such as laboratory tests x-rays and electrocardiogram also known as ekgs or ecgs admitting procedure for major insurance programs some services require prior approval from the insurer before they can be performed this is known as pre-authorization private insurance either group or individual and you need to know the commercial insurance and managed care on emergency inpatient admissions the managed care program should be notified the next working day or within 48 hours and then an authorization number must be obtained that's usually called a retro off in non-emergency to hospitals with a managed care contract what must the physician do to obtain authorization for the length of this hospital stay is you want to refer to the primary care physician admitting requirements will differ amongst insurance companies between medicare and medicaid the treatment authorization form is required for medicaid patients pre-approval is not required for medicare patients but they but their admittance should be certified by aeps tricare what is need to be obtained to a civilian hospital is a pre-certification and workers comp says employees do not carry workers compensation insurance cards what must happen before a hospital or a physician's insurance claim can be submitted an injury report must be complete and submitted to the workers compensation insurance company and the state industrial accident board before the hospital or physician's claim can be submitted pre-admission testing routine blood and urine work when a laboratory panel of tests is performed each separate test must be itemized and must show the clinical benefit for each test performed based on the patient's diagnosis diagnostic studies laboratory tests chest x-rays electrocardiography also known as your ekg or ecg and this is all part of what the pre-admission testing is the 72-hour rule if patient receives diagnostic tests and hospital outpatient services within 72 hours of admission to a hospital all such tests and services are combined with inpatient services pre-admission services become part of the diagnostic related group the drg payment to the hospital and may not be billed separately and if this rule is not followed fraud and abuse may be considered exceptions to the 72-hour rule services provided by home health agencies hospice nursing facilities and ambulance services physicians professional portion of a diagnostic service and pre-admission testing at an independent laboratory when the laboratory has no formal agreement with the health care facility utilization review the ur process determines whether admissions are justified the process also anticipates length of stay and concludes the expected discharge date the department conducts an admission and concurrent review and prepares a discharge plan on all cases utilization review you are companies exist for self-insured employers third party administrators and insurance companies quality improvement organization program these are composed of licensed doctors of medicine or osteopathy actively engaged in the practice of medicine or surgery while working under federal guidelines these physicians evaluate others positions on the quality of professional care as well as other factors they take into consideration in mission review readmission review procedure reviews day outliner review cost outlier review drg's validation and transfer review coding hospital diagnosis and procedures the diagnosis codes come from the ic9cm or ic10cm the procedure codes come from the current procedural terminology cpts or the healthcare common procedure coding system hey pics ic9cm volume 3 or icd-10-pcs the principal diagnosis is the first listed diagnosis it's the reason patient is seeking medical care and on outpatient claims it's known as a reason for the encounter the principal diagnosis is subject to 100 review these are arteriosclerosis heart disease ashd diabetes melias without complications right or left bundle branch block or coronary atherosclerosis [Music] coding inpatient procedures the coding structure in icd-10-pcs is significantly different than the ic9cm volume 3. ic 10 pcs code drafts can be downloaded for free from the cms website character definitions because of the detailed nature of the ic10 pcs coding set the successful coder must understand the procedures and the type of operation performed the exact body part and the surgical approach use the alphabetical index and tabular index when coding from the ic10 pcs the definition characters as character 1 is the medical section character 2 is the body system such as your respiratory intercommentary cardiovascular character 3 is the root operation character four is the body part character five is the approach character six is the device and character seven is the qualifier tabular index and the alphabetical index the tabular index is organized first by section and then by body part it prevents coders from choosing erroneous codes the alphabetical index is not advisable to rely on this index for accurate coding you never ever code straight from the index coding hospital outpatient procedures the cpt codes are updated each year billing software must be updated with new codes to receive maximum reimbursement your hippix level 1 cpt coding system that means that you must use your up-to-date cpts use hit picks to obtain medical procedural codes for medicare and some non-medicare patients on an outpatient hospital insurance claims that are not in the cpt code burke use modifiers as noted in cpt and hitpic guidelines modifiers modifiers are two-digit alphanumeric codes that modify or provide more detailed information on the procedure refer to appendix a at the cpt manual for a full list of all the modifiers charge description master the charge master database must be kept current and accurate to obtain proper reimbursement and must be regularly audited the master charge list is the charge description list is a computer file unique to each hospital that accommodates the charges for items and services that may be provided to patients revenue codes usually lines up with specific lines on the cms 1450 or the ub004 the form used for inpatient claims the services and procedures are checked off and coded internally and data included is the procedure codes the charge and the revenue code electronic claims submission paper claims submission is prohibited except under the following conditions small provider claims roster billing of inoculations covered by medicare claims for payment under a medicare demonstrated topic that specifies claims to be submitted on paper medicare secondary payer claims claims submitted by medicare beneficiaries dental claims claims for services and supplies furnished outside the u.s disruption of electricity or communication connections claims from providers that submit fewer than 10 claims on average during a calendar year reimbursement methods ambulatory payment classification is a method based on procedure rather than diagnosis services are associated with a specific procedure or visit and bundle together bad leasing capitation or percentage of revenue capitation is reimbursement to the hospital on a per member per month basis then reimbursement methods could be case rate the contracted rate drgs differential by day in hospital differential by service type fee for service fee schedule flat rate per dm percentage of accrued charges the periodic interim payments the pips and cash advances relative value studies or scale the rvs and resource-based relative value scale usual customary and reasonable the ucr withhold managed care stop-loss outliers charges discounts in the form of sliding skill and sliding skills for discounts and per diems and what is a slight a sliding scale a is a form of discount with a limit in which the percentage amount increases based on hospital numbers example could be the number of bed days per year hard copy billing is used for insurance companies that are not capable of receiving electronic claims receiving payment is after receipt of payment patient sent net bill listing any owed deductibles coinsurance amounts and charges not covered pre-determining payment now the difference between cost-based systems and the prospective payment system the pps is that cost-based systems were efficient because the amount charged varied physician to physician even though the same service was rendered and the amount charged often didn't take into account the variables such as where the physician practiced malpractice insurance rates and the amount of work it was designed to increase reimbursement for sicker patients medicaid tricare and other private insurance companies develop their own pps medicare severity diagnosis related groups the ms drgs the drg based two-tiered system is used for reimbursement to hold down rising health care the drgs is a prospective payment structure on which hospital fee reimbursements are based the msdrg group diseases possible related diseases and medical treatment into a single code clinical outliners their unique combination of diagnosis and surgeries causing high costs for very rare conditions the long length of stay or day outliners no longer apply low volume drgs and then inliners are hospital case that falls below the mean average or expected length of stay death leaving against medical advice or admitted and discharged on the same day hospital outpatient prospective payment system the ops the procedure code is primary access of classification not the diagnostics code reimbursement methodologies based on the median cost of services and the facility cost to determine charge ratios and copayment amounts adjustment for area wage differences are based on the hospital wage index currently used for inpatient services ops may be updated annually the ambulatory payment classification system the procedures that apps are applied to are the ambulatory surgical procedures chemotherapy clinical visits diagnostic services and diagnostic tests emergency department visits implants outpatient services furnished to nursing facility patients not packaged into a nursing facility consolidated billing partial hospitalization services for community mental health centers preventative services example of colon rectal cancer screenings radiology including radiation therapy services for patients who have exhausted medicare part a benefits service to hospice patients for treatment of a non-terminal illness and surgical pathology and this concludes the lecture of chapter 19 hospital outpatient and inpatient billing