1. Using the Electronic Health Record for Reimbursement
Chapter 6
Using the Electronic Health Record for Reimbursement
Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

2. Chapter Objectives
Discuss the role of the patient, the provider, and the third-party payer in the medical reimbursement process.
Define medical coding.
Discuss ICD-9-CM coding classifications, and outline the CPT-4 coding system.
Learn how to enter maintenance codes in Practice Partner.
Evaluate the advantages and disadvantages of the pay-for-performance (P4P) incentive model.

3. Chapter Objectives (cont’d.)
List the information contained in a typical encounter form, and explain how the form is used in an outpatient facility
Discuss the concept of medical necessity and indicate how it affects third-party reimbursement.
Create a new insurance account for EHR patients.
Define fraud and abuse, explain the difference between the two, and give examples of each.

4. Coding Systems Medical coding
Process of assigning standard numeric or alphanumeric codes to diagnoses, procedures, and treatments for reimbursement purposes
Diagnosis codes: International Classification of Diseases, Ninth Edition, with Clinical Modification (ICD-9-CM)
Procedure codes: Current Procedural Terminology, Fourth Edition (CPT-4)

5. Coding and Claims Processing Errors
Coding variances
Mistakes
Caused by computer error or by human error of various sorts, ranging from simple carelessness to incorrect application of coding guidelines and procedures
Coding requires complete and accurate documentation
According to the American Health Information Management Association (AHIMA), which tracks trends in coding error rates, causes can be categorized as coder, provider, or computer errors, lack of leadership (such as failure to implement an EHR effectively), and miscellaneous.

6. ICD-9-CM Coding
Translates complex medical diagnoses and procedures into a universal language used by healthcare providers to request reimbursement for inpatient hospital services and hospital-based outpatient services and doctor office visits
CMS and the National Center for Health Statistics

7. ICD-9-CM Coding (cont’d.)
Volume 1: Tabular List of Diseases
Volume 2: Alphabetic Index of Diseases
Volume 3: Tabular List and Alphabetic Index of Procedures
Volume 1: section lists diseases in numeric order by code. Contains both V and E codes.
Volume 2: contains diagnostic terms that do not appear in Volume 1. Helps to locate the complete code.
Volume 3: used by hospitals, report inpatient care

8. CPT Coding
Uniform language for describing procedures and treatments performed by healthcare providers
Category I
Evaluation and Management
Anesthesia
Surgery
Radiology
Pathology and Laboratory
Medicine
The purpose of the system was to standardize the way in which claims are submitted to the Centers for Medicare and Medicaid (CMS).

9. CPT Coding (cont’d.) Category II Category III
Supplemental codes used to help researchers collect data, track illness and disease, and measure quality of care
Category III
Temporary codes applied to emerging technology
To stay current with emerging technology, CMS publishes updated CPT codes every November.

10. Maintenance of Codes in the EHR
Updating CPT Codes in Practice Partner
1. Click Maintenance > Tables > Procedure Codes from the menu bar.
2. Using the buttons at the bottom of the box to select either “New,” “Edit,” “Delete,” or “Print.”

11. Pay for Performance
An outcomes-based payment model that rewards providers for delivering evidence-based care according to specific standards and for electronically documenting compliance with those standards
In 2008, about one fourth of all doctors were working under a P4P contract.
The Institute of Medicine (IOM) predicts that within 5 years, all medical practices will have converted to a P4P reimbursement model.

12. Incentives and Penalties
In 2009, providers who used a computerized physician order entry (CPOE) system to submit claims for Part D Medicare recipients were rewarded with performance pay amounting to 2% of their annual Medicare billing.
Providers who chose not to use CPOE were dinged with a penalty equal to 1% of their annual Medicare billing, increasing incrementally to 2% in 2014 and thereafter.
The American Medical Association has spoken out against this and other policies that reduce reimbursement based on substandard results.

13. Use of the EHR in P4P Compliance
EHR offers a way to record improvement by noting laboratory results, findings of imaging studies, and clinical progress notes.
P4P model works best when applied to patients with chronic illnesses such as diabetes, hypertension, and arthritis.
Medical assistants need to understand how the system works, because it affects not just reimbursement but also how patient care is delivered to achieve the outcomes specified by the program.

14. Encounter Form
Also known as a superbill, walkout form, route slip, fee slip, or checkout form
Is attached to the patient’s chart for use during an office visit
Patient’s copy of the encounter form serves as a bill
Typically printed in threes: one copy for insurance, one for the patient, and one for the office.
Used by the medical biller to create a claim for reimbursement of services.

15. Encounter Form (cont’d.)
Figure 6-11 is a sample encounter form.

16. Electronic Encounter Form
The form includes the following information:
Demographic data (patient’s name, address, phone number, and date of birth)
Date of appointment
Guarantor (the person responsible for the account)
Insurance policy number and group ID
Problem and diagnosis codes
Account balance
Guarantor (the person responsible for the account)

17. Medical Necessity
A legal doctrine which holds that medical services rendered must be reasonable and necessary according to generally accepted clinical standards
Preauthorization
EHR’s reporting capabilities can be used to identify codes that are being consistently rejected.
Claims that fail to meet such standards will be denied.

18. Billing Using practice management software integrated with an EHR
Information entered on the demographic screens can be accessed and modified while doing scheduling and billing tasks.

19. Fraud and Abuse
Fraud is misrepresentation of the medical services provided to deceive or mislead another person or entity, such as Medicare.
Abuse is an unintentional deception in which a provider inappropriately bills for services that are not medically necessary, do not meet current standards of care, or are not medically sound.
See Box 6-1 for examples of fraud and abuse.