1. Using the Electronic Health Record for Reimbursement
Chapter 7
Using the Electronic Health Record for Reimbursement

2. Using the Electronic Health Record for Reimbursement
Lesson 7.1
Using the Electronic Health Record for Reimbursement
Discuss the role of the patient, the provider, and the third-party payer in the medical reimbursement process.
Define medical coding.
Discuss diagnostic coding classifications, and outline the CPT-4 coding system.
Evaluate the advantages and disadvantages of the pay-for-performance (P4P) incentive model.
List the information contained in a typical Superbill, and explain how the form is used in an outpatient facility.

3. Using the Electronic Health Record for Reimbursement
Lesson 7.1
Using the Electronic Health Record for Reimbursement
Post charges, payments, and adjustments to a patient ledger.
Discuss the concept of medical necessity, and indicate how it affects third-party reimbursement.
Complete HIPAA 5010 compliant claims.
Complete a Day Sheet.
Define fraud and abuse, explain the difference between the two, and give examples of each.

4. Overview of Reimbursement
Submitting insurance claims to a third-party payer
HIPAA 5010 claim format
Patient payments
Out-of-pocket expenses
Copayment/coinsurance
Deductibles
EHRs have integrated practice management systems to provide billing functions
What role will you play in medical insurance and billing? (Answers will vary.)
How will the EHR help you perform those duties? (Answers will vary.)

5. 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)
ICD-10-CM and ICD-10-PCS (tentative implementation Oct. 2015)
Procedure codes: Current Procedural Terminology, Fourth Edition (CPT-4)
What challenges has healthcare faced with the numerous delays in ICD-10 implementation?

6. Role of the EHR in Medical Coding
Stores complete sets of codes
Links codes to appropriates findings in patient progress note
Posts payments
Submits insurance claims
Quick follow-up on unpaid patient accounts
Part of the medical assistant’s job is to ensure that patients are billed and credited properly, to see that insurance claims are submitted correctly, and to follow up on unpaid claims and delinquent patient accounts.

7. 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
A key factor, says the American Health Information Management Association (AHIMA), is that too few medical office staff hold providers responsible for providing clear, complete documentation.
Errors often occur after the claim leaves the office.

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 CPT system, introduced in 1992, is now in its fourth edition.
It was devised by the American Medical Association (AMA) at the request of the federal government’s Centers for Medicare & Medicaid Services (CMS). The purpose of the system was to standardize the way in which claims are submitted to the CMS, which is responsible for issuing periodic rules and guidelines for how the codes may be applied and for conducting audits when fraud is suspected.
To stay current with emerging technology, CMS publishes updated CPT codes every November.

9. CPT Coding (Cont.) 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
The use of Category II codes is not required, and there is no reimbursement value attached to using them.

10. 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, hospital-based outpatient services, and doctor office visits
Overseen by the CMS and the National Center for Health Statistics
It’s important to remember that the code must directly reflect the doctor documentation, without making assumptions. If there is any question, the healthcare provider should be consulted.

11. ICD-9-CM Coding (Cont.) Volume 1: Tabular List of Diseases
Volume 2: Alphabetic Index of Diseases
Volume 3: Tabular List and Alphabetic Index of Procedures
Volume 1 contains 17 chapters for classifying diseases by etiology (cause) or anatomic site. In addition, it includes a list of V codes and E codes.
Volume 2 contains diagnostic terms that do not appear in Volume 1. It’s used as a guide to help locate the complete code in Volume 1.
The third volume of the ICD-9-CM code is used by hospitals. These codes are used to report inpatient care and are not intended for use by ambulatory care practices.

12. ICD-10 Coding Implementation tentatively set for October 2015
Allow greater specificity of codes
Alignment with worldwide coding practice
What are some of the reasons for the transition from ICD-9-CM to ICD-10-CM?
(ICD-9-CM codes do not accurately reflect the current procedures and technology being performed.
The healthcare industry cannot accurately measure quality of care using ICD-9-CM codes due to the lack of specificity. ICD-10-CM codes will allow for a more detailed classification of the patient’s condition or injury.
Improved efficiencies and lower costs.
Reduced coding errors.
Alignment of the United States with coding systems worldwide.)

13. ICD-9 vs. ICD-10
This table outlines the basic differences between ICD-10-CM and ICD-9-CM coding systems.

14. Pay for Performance An outcomes-based payment model
Rewards providers for:
Delivering evidence-based care according to specific standards
Electronically documenting compliance with those standards
This model is quickly becoming the gold standard by which most health plans (such as health maintenance organizations [HMOs] and preferred provider organizations [PPOs]) operate.

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

16. 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
Providers who haven’t adopted an EHR are at a distinct disadvantage in adhering to the program’s requirements.

17. Superbill
Also known as an encounter form, 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
Using an EHR vastly simplifies the process of completing a Superbill.

18. Superbill (Cont.)
Pictured here is a screen shot of a Superbill.

19. Superbill (Cont.) 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
The purpose of the Superbill is twofold: to collect data about the patient and to record details of the patient’s visit.

20. HIPAA 5010 Claim Processing
Once the Superbill is submitted, it’s time to request reimbursement of services from the third-party payers
The electronic format of the claim form is HIPAA 5010
Once the claim is submitted, it is paid, pending, or denied
It is important for the medical assistant to accurately complete and review the claims prior to submission to decrease the incidence of denials due to data entry errors.
Refer students to EHR Exercise 7-4 (p. 180) for practice preparing a claim.

21. Medical Necessity
Is a legal doctrine that 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
The provider’s establishment of medical necessity ensures that a patient’s treatment is consistent with the diagnosis and is provided in the appropriate setting under adequate supervision.

22. Patient Ledger
Search by patient name; ledger is organized by responsible payer
Documentation of all charges, payments, adjustments, and balances to an account
Access is not limited by patient encounter
The Ledger, located in the left Info Panel of the Coding and Billing module, is not linked to a patient encounter, which allows the user to document payments and charges at any time.

23. Day Sheet
At the end of the day, the medical assistant documents all payments and charges processed during the day on the Day Sheet, which acts as a summary of accounting for a specific date
The information documented within the Day Sheet is then used to complete a Bank Deposit Slip, located in the Office Forms section of the Form Repository
Refer students to EHR Exercise 7-7 (pp ) for practice completing a Day Sheet.

24. Fraud and Abuse
Fraud: Misrepresentation of the medical services provided to deceive or mislead another person or entity, such as Medicare
Abuse: 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
Fraudulent schemes are carried out primarily for financial gain.
Regardless of the motive, fraud is unacceptable and is not tolerated by the government, by private insurers, or by patients.
The best way to ensure that your office is not engaging in abusive practices is to create and enforce a compliance plan.
Refer students to Box 7-1 on p. 187 for examples of fraud and abuse.

25. Questions?