Technical Certification: Creating a Program for …...Plan and Schedule Certification Timeline CPAT Test Date Application Deadline Begin Study Sessions Testing Group 11/2012 9/3/2012

Technical Certification: Creating a Program for Success

The Certified Revenue Cycle Specialist

Kenny Koerner MBA, CRCE

President, Illinois AAHAM

On behalf of Illinois AAHAM

AAHAM Certification

Today’s Agenda:

• Overview of CRCS Technical Certification program

• How one hospital structured their training sessions

• Section focus on Patient Access

• Highlights of Billing and Credit and Collections sections

• Changes and additions between the 2011 and 2014

AAHAM Certification Study Guides

• Testing Tips

Today’s Speakers

Today’s Speakers

Today’s Speakers

AAHAM Certification

AAHAM certification options include:

Certified Revenue Cycle Executive (CRCE)

Certified Revenue Cycle Professional (CRCP)

Certified Revenue Cycle Specialist (CRCS)

Certified Compliance Technician (CCT)

The CRCS Certified Revenue Cycle Specialist

What is Specialist (CRCS) Certification?

Specialist certification is an online proctored exam that tests

the proficiency of staff involved in the processing of patient

accounts and to prepare them for the many details needed to

perform their daily job duties. AAHAM offers two types of

Specialist Certification; one focused on the revenue cycle

within an institutional (hospital, health system) environment,

the other focused on the revenue cycle in a professional

(physician, clinic) environment. Dual certification is available

for those interested in obtaining certification in the

institutional and professional specialties.


CRCS-I/CRCS-P Sections

Sections included in the exams include:

CRCS-I Sections CRCS-P Sections

1. Patient Access 1. Front Desk

2. Billing 2. Billing

3. Credit & Collections 3. Credit & Collections

Exam Format

Examinees must initially sit for all three (3) sections, which contain questions in a multiple choice format. Each

section of the CRCS exam is graded separately and all three (3) sections must be passed with a score of 70% or

greater in order to earn the CRCS certification. If only one (1) section is failed, a retake of that section is permitted.

If more than one (1) section is failed, a retake of the full exam is required.


CRCS-I/CRCS-P FEES:

Full Exam — $100

Section Retake —$50

Dual Certification Exam — $80


Re-Certification To retain the CRCS-I or CRCS-P certification designation, two (2)options are available:

• Option One - Retake and pass the entire exam every three years. • Option Two - Join as a national member within the year you become certified and earn continuing education units (CEUs). Members must be in good standing by January 31 of each year and earn and report thirty hours of CEUs within the three calendar years following certification. Fifteen of the CEUs must be obtained from attendance at AAHAM related educational programs. If membership and CEUs are not maintained, the designation will be revoked and can no longer be used.

Creating a Technical Certification Program From Scratch

• Administrative Buy In

• Job Descriptions

• Planning and Scheduling

• Study Guide/Coaching Sessions

• Flash Cards

• Practice Tests

• Jeopardy Game

• Train with a recent test taker

• CEU maintenance

Administrative Buy-in

• Highlight the benefits of certified staff for your organization

• Benefits

• Increase in productivity

• One call, one answer

• Staff more confident

• Better customer service

• Continuing education, staying current

Administrative Buy-in

• Communicate the costs of certified staff for your organization

• Costs to my organization (19 employees went through the program)

• Exam reimbursement

• $100/employee = $1,900 one time fee

• Yearly AAHAM membership

• $200/employee=$3,800 per year

• Webinars for CEU’s

• $139 each webinar through National AAHAM

Job Descriptions

• We included the certification requirement right in to the job description

• Get Human Resources approval

SPECIALIZED KNOW-HOW & REQUIREMENTS

High School Diploma or equivalent required.

CRCS-I or CRCS-P certification required.

Employees must obtain their CRCS certification within 2 years of hire date.

Planning for the year

December 2, 2013

Registration deadline for

February 2014 exams

February 10-21, 2014 exam period

March 3, 2014


May 2014 exams

May 12-23, 2014 exam period

June 2, 2014


August 2014 exams

August 11-22, 2014 exam period

September 2, 2014


November 2014 exams

November 10-21, 2014 exam period

Plan and Schedule

Certification Timeline

CPAT Test Date Application Deadline Begin Study Sessions Testing Group

11/2012 9/3/2012 8/2012 Erika, Gabe, Sue, Beth Cook, Cheryl

2/2013 12/3/2012 11/2012 Jodi, Beth Sage, Leslyn, Shawna, Gabe

5/2013 3/2013 2/2013 Karen, Meaghan, Terry, Pam, Eric

8/2013 6/2013 5/2013

11/2013 9/2013 8/2013

2/2014 12/2013 11/2013

5/2014 3/2014 2/2014

Study Guide/Coaching Sessions

• The office purchased a study guide for the office

• 1 hour each week set aside for coaching

• We did 10am to 11am on Wednesdays

• The group of 4 or 5 given a chapter each week

• Expected to read the chapter at home and come prepared to class

• Class spent going through the chapter, talking about terms and concepts

• 1 chapter each week

Flash Cards Questions

A recorded claim against real or personal property

The average amount of revenue or charges generated each day or

over a period of time

An estimate of the time needed to collect the accounts receivable.

How to calculate average daily revenue

How to calculate average days in revenue in accounts receivable

ADRR (Days in AR)

Flash Cards Answers

Lien

Average Daily Revenue

Average Days of Revenue in Accounts Receivable (ADRR)

Add up the charges for the specified time and divide by the number

of days in the specified time

Take the ending accounts receivable balance at the end of a month

and divide it by the average daily revenue for the previous 3 months.

Practice Tests

CPAT PRACTICE TEST - Patient Access Services

1. Which of the following are primary responsibilities and functions

of the Patient Access division?

a. Insurance verification

b. Observation

c. Scheduling

d. A and C

2. What information is gathered during Pre-registration?

a. Patient demographics

b. Socioeconomic information

c. Financial information

d. All the above

3. This is the diagnostic medical screening of patients in advance of

surgical or invasive procedures to determine hospitalization

and/or surgical suitability:

a. EMTALA

b. HIPAA

c. Pre-Admission Testing (PAT)

d. None of the above

4. What is the key success factor in pre-registration?

a. Inpatient admitting

b. Implementation of an insurance verification and/or pre-

certification program

c. Financial counseling

Acronym Tests

CPAT

1. ABN ____Office of Inspector General

2. ACF ____Resource Utilization Group

3. ADC ____Initial Preventive Physical Examination

4. ADRR ____Centers for Medicare and Medicaid Services

5. AFDC ____Non Physician Practitioner

6. AHA ____Employer Group Health Plan

7. AHRQ ____Quality Improvement Organization

8. ALOS ____Voice Case Information System

9. ANSI ____Military Treatment Facility

10. AOA ____Health Insurance Portability and Accountability Act

11. APC ____Emergency Medical Treatment and Active Labor Act

12. APR ____Medicare Volume Performance Standard

13. AR ____Third Party Administrator

14. ATB ____Civilian Health and Medical Programs of the

Uniformed Services

15. ATSDR ____Health Maintenance Organization

16. CAH ____Evaluation and Management

17. CDC ____Advance Beneficiary Notice of Noncoverage

18. CDM ____Major Diagnostic Category

19. CERT ____Patient Self Determination Act

20. CHAMPUS ____Usual, Customary, and reasonable

21. CLIA ____International Classification of Diseases

22. CMP ____Aged Trail Balance

23. CMS ____Indian Health Service

24. CO ____National Provider Identification

25. COB ____Substance Abuse and Mental Health Services

Administration

26. CPT ____National Uniform Billing Committee

27. CPU ____Initial Enrollment Questionnaire

28. CRA ____Omnibus Budget Reconciliation Act

29. CWF ____American National Standards Institute

30. DHHS ____Health Care Financing Administration

31. DME ____Joint Commission on Accreditation of Healthcare

Organizations

32. DMEPOS ____Clinical Laboratory Improvement Amendment

33. DOJ ____State Children’s Health Insurance Program

34. DSMT ____Veterans Affairs

35. E&M ____Food and Drug Administration

36. EGHP ____Ambulatory Payment Classification

Jeopardy Game

• We created a Jeopardy study game to keep study sessions fun and fresh

• Changed questions and answers and played weekly

100 100 100 100 100

200 200 200 200 200

300 300 300 300 300

400 400 400 400 400

500 500 500 500 500

Patient

Access

Billing Medicare Acronyms Credit and

Collections

Patient Access 100

A deposit collection program

combined with pre-registration

and insurance verification has

what impact on cash collections.

Increases cash collections

Studying with a recent test taker

• Don’t be afraid to allow an employee to run the study sessions

• Found that a recent test taker that enjoyed teaching/coaching

was a better trainer than the supervisor was

• Format stayed the same, but flash card content and study

content changed

• Allow someone from each small group to teach the following

group

CEU Maintenance

• CEU Maintenance required – 30 hours every 3 years, 15 must be

from AAHAM

• If employee loses certification due to not maintaining CEU’s,

must re-certify at next testing and pay for it themselves

• AAHAM webinars

• Local AAHAM educational sessions

• Employees much better informed and educated about changes

It’s Worth The Effort!!!!

• YES it takes time and effort to establish a certification

program in your office

• BUT……..IT’S WORTH IT!!!!!

• Staff will be leary at first, but appreciate when it’s done

• Some staff hadn’t taken a test in 30 years!!!!!

• Tears of joy and happiness when test results came back!!!

Kenny Koerner, MBA, CRCE Director of Patient Accounts CGH Medical Center 100 E. LeFevre Sterling, IL 61081 Tele: 815.564.4407

[email protected]

mailto:[email protected]

Certified Revenue Cycle Specialist

Institutional and Professional

CRCS-I CRCS-P

Presented by Joshua A. Johnson, CRCS-I,P, CRCP-I

IL AAHAM 2nd Vice-President on behalf of Illinois AAHAM

TECHNICAL CERTIFICATION:

CREATING A PROGRAM FOR SUCCESS!

TESTING TIPS:

PREPARATION FOR SUCCESS

REVIEW OF PATIENT ACCESS SERVICES

TESTING TIPS: PREPARATION FOR SUCCESS!!

• The Exam Study Manual is your KEY to success!

• If you study the content of the Exam Study Manual you will pass the exam!

• The study guide has information that applies to both CRCS-I and CRCS-P exams

and is crucial tool to your success!

• The study manual presents all of the information you will need to pass your exam.

• Helpful Tip—There is some crossover of topics on the exam. To be fully prepared

you should review the entire manual.

TESTING TIPS: PREPARATION FOR SUCCESS

• STUDY MANUAL--Coaching Kits

• Coaching Kits are available from the National AAHAM Office!

• Go to www.aaham.org

• Click the “CERTIFICATION” tab

• Select “CRCS”

• Right hand side of the screen—Click “STUDY GUIDE” under Order Study

Materials Online

TESTING TIPS: PREPARATION FOR SUCCESS!

• Knowledge Checks

• Found at the end of each section in the exam study guide.

• Give you a feel for the types of questions that will be asked on the actual exams.

• Remember—Knowledge Checks DO NOT cover every question on the exams…you must

study the entire guide!


• Flash Cards

• VERY useful tool for studying!

• Acronyms

• Glossary Terms

• Federal Regulations

• Metrics

• HICN Suffixes

• Medicare Outline of Deductibles, Coinsurance, Copayments


• “Study-Buddy!”

• Partnering with another person to study with is a very useful method of preparing for

the exams.

• Group Study—If there are multiple people studying for the exam, create a study

group and use that time to help each other study. Quizzing each other, using flash

cards, taking knowledge checks together and making up games like CRCS Jeopardy

are highly effective study methods.

PATIENT ACCESS SERVICES: REVIEW

• Objectives

• Describe the primary functions and responsibilities of the Patient Access department.

• Describe the roles and responsibilities of Case Management/Utilization Review.

• Describe the different levels of patient care, as differentiated by billing and reimbursement requirements.

• Describe the types of consent, and requirements of each.

• Describe guidelines and characteristics of a medical record.

• List individuals who can accept verbal (telephone) orders and the required elements of a verbal order.

• Differentiate between Local Coverage Determinations (LCD’s) and National Coverage Determinations (NCD’s)

• Explain the purpose, triggering events, completion and retention of the Advance Beneficiary Notice (ABN)

• Describe Medicare Secondary Payer provisions, including the use of the Initial Enrollment Questionnaire (IEQ), MSP Questionnaire and Common Working File.

• Define Key Metrics related to Patient Access.


• Primary Functions and Responsibilities of Patient Access

• Scheduling

• Pre-Registration and Pre-Admission Testing

• Pre-Certification and Pre-Authorization

• Registration and Admission

• Insurance Verification

• Financial Counseling

• Point of Service Collections

• Handling the Important Message from Medicare

Note: Recent changes have placed additional demands on the Patient Access department. State and Federal Regulations, EMTALA, HIPAA and the Patient Self Determination Act, plus many other regulations, all have significant effect on Patient Access.


• Scheduling

• Maximizes Office Productivity

• Reduce Physician, Administrative, Clinical Staff, and Patient Dissatisfaction.

• Requires a balance between patient satisfaction; the collection of demographic,

financial and insurance information and clinical services.

• Errors is Scheduling can create havoc, down-time, over-booking and dissatisfied

patients.


• Pre-Registration

• Cornerstone of a successful collections process!

• 70-90% of all scheduled patients be pre-registered within 24 hours of the date of service.

• Gather Patient Demographics, Financial Information, Socioeconomic information.

• Reduces Patient Wait Times!

• Complaints Decrease because:

• Financial planning/counseling can be done in advance of the DOS.

• Patients become familiar with the admission process.

• Special needs can be identified and addressed.

• Patients are more prepared and less anxious.

• Admission time is reduced.


• Insurance Verification

• The purpose of insurance verification is to reduce the financial risk to both the

patient and the provider.

• Obtaining Complete and accurate demographic information

• Obtaining complete insurance information

• Verifying all applicable insurance benefits

• Identifying uninsured individuals


• Financial Counseling

• Integral part of Patient Access. Counselors guide patients through the financial process and ensure the financial viability of the institution.

• Notify the patient of financial responsibility

• Collect patient deductibles and copayments

• Make payment arrangements of patient pay amounts

• Review outstanding patient debts with hospital

• Identify potential 3rd party resources

• Complete applications and/or make referrals for government programs

• Assess patients for ability to pay and/or charity care guidelines

• Collect appropriate signatures

• Participate in the discharge process and work with patients afterwards


• Point of Service Collections

• A good preadmission/preregistration process will include determining the estimated

patient portion for services, and informing patients so they can bring their payment at

the time of service.

• Is the only cost-effective way to collect small-dollar copayments.

• Patients are more likely to pay their estimated portion before or at the time of

service!


• 5 Collection Control Points

• Pre-Admission

• Admission

• In-House

• At Discharge

• After Discharge

• A patient is more likely to pay an estimated portion at the time of service rather than after. Once the urgency is gone, they are less inclined to pay their patient portion.


• Case Management/Utilization Review

• Work very closely with the Patient Access Department.

• Patient Access MUST obtain correct insurance information so Case Management can properly perform its functions.

• Play critical roles during registration and patient stay.

• Prevent unnecessary services or treatment

• Mange approved length of stay (LOS)

• Ensure appropriate level of care

• Serve as Liaison with primary and specialty physicians and insurance companies

• Secure necessary supplies and medical equipment

• Assist in obtaining home care nursing services

• Obtain approvals when clinically necessary

• Advise patient of discharge

• Assist with appeals for denials


• Levels of Patient Care

• Inpatient

• Observation

• Emergency Room (ER) or Emergency Department (ED)

• Outpatient

• Recurring or Series

• Long Term Care

• Skilled Nursing Facility (SNF)

• Hospice Care

• Respite Care

• Custodial Care

• Home Health Care

• Office


• Consents

• General Consents

• Routine Labs

• Diagnostic imaging (radiology, CT, MRI etc.)

• Medical Treatment

• Special Consents

• HIV Positive Testing

• Major/Minor Surgery

• Anesthesia

• Nonsurgical Procedures with more than slight risk

• Cobalt or radiation therapy

• Electroshock procedures

• Experimental procedures

• Treatment for drug/alcohol disorders


• Types of Consents

• Actual or Expressed

• Written or Oral, the patient agrees to the treatment outlined.

• Implied Consent-in fact

• Consent by silence; the patient implies consent by not objecting.

• Implied Consent-by law

• Occurs when the patient is unconscious and is taken to ED; law allows for treating the patient.

• Informed Consent

• Risks and benefits are understood, patient decides whether to receive that treatment. (Special Consents)

• Parental Consent

• Refers to the fact that a parent may give consent on behalf of a child for most services


• Emancipation

• Is the procedure by which a minor is freed from parental control. Minors can

generally become emancipated for one of the following:

• Reaching the age of majority 18

• Military enlistment

• Marriage

• Court decree

• Becoming pregnant or becoming a parent


• Medical Records

• Serve as a legal document and a statistical tracking tool

• Supports charges and coding

• Facilitates appropriate utilization review

• Serves as the communication and continuity of care tool among physicians and other

healthcare professionals involved in the patients care.

• Electronic Health Record (EHR)

• Electronic Medical Record (EMR)


• National Coverage Determinations

• Local Coverage Determinations

• Policies that CMS and fiscal intermediaries use to pay or deny claims based on

medical necessity.

• An NCD sets forth the extent to which Medicare will cover specific

services, procedures, or technologies on a National basis.

• An LCD is a decision by a fiscal intermediary or carrier whether to cover a

particular service on an intermediary-wide or carrier-wide basis.


• Advance Beneficiary Notice of Noncoverage (ABN)

• To Avoid writing off claims that do not meet medical necessity, Providers use the ABN.

• ABN contains a brief description of the service, the estimated cost and the reason the services is not expected to be covered.

• Patients sign and date the ABN after indicating their decision to proceed with the service or to forego the service. (knowing they will have to personally pay if Medicare denies payment)

• Patient’s signature must be witnessed.

• ABN MUST be signed BEFORE the services are provided.

• Triggering Events:

• Initiation—Beginning of the Treatment

• Reduction—When frequency or duration decreases

• Termination—Discontinuation in the services provided.

• Be familiar with Services that DO NOT require an ABN!


• Medicare Secondary Payer (MSP)

• Medicare is the secondary payer for:

• The working aged-

• Individuals aged 65 or older who are currently working and have coverage through an Employer Group Health Plan (EGHP).

• If the Beneficiary has coverage through an employed spouse of any age.

• In order to meet the working aged provision, employers must have at least 20 employees.

• Individuals who are under age 65, disabled, and are covered by a large group health plan (employer has 100 or more employees) due to their own or another family member’s current employment status.

• Individuals with End Stage Renal Disease (ERSD)

• During the 30-month coordination of benefits (COB) period for patients that have their own, a spouse or other family member’s employee sponsored or employee organization group health plan.


• Medicare Secondary Payer Con.’t

• Medicare remains the secondary payer throughout the entire 30 month

period even if the beneficiary becomes entitled to Medicare based on

disability or age before the COB period ends.

• Medicare coverage for ESRD will end 12 months after the individual no

longer requires maintenance dialysis, 36 months after a successful kidney

transplant or if the patient becomes deceased.

• Individuals who receive services covered under:

• Black Lung Benefits

• Worker’s Compensation benefits

• Automobile, no-fault or liability plans


• MSP Questionnaire

• Designed to help determine if Medicare is primary or secondary.

• Information needs to be verified every 90 days for recurring patients.

• Otherwise it is needed at EVERY visit—even if the patient was seen the

previous day…and they must be kept for 10 years!


• Initial Enrollment Questionnaire (IEQ)

• 3 months prior to becoming entitled to Medicare an IEQ is mailed out. The IEQ asks about health coverage that may be primary to Medicare. IEQ responses are processed and entered in the Common Working File.

• Common Working File (CWF)

• CMS file that contains patient eligibility and utilization data.

• Entitlement to Medicare Part A and Part B

• Date of birth

• Date of death

• Part A and Part B deductible information

• Benefit periods and days remaining in current period

• MSP information


• Key Metrics

• Average Length of Stay (ALOS)

• Is calculated by dividing the total number of patient days by the number of discharges.

• Total # Patient Days/Number of Discharges=ALOS

• Midnight Census

• Determined from the census count for the previous midnight, minus and discharges, plus any admissions, plus/minus any status changes.

• Previous Midnight Census- Discharges+ Admissions +/- Status Changes= Midnight Census

• Average Daily Census (ADC)

• The average number of inpatients maintained in the hospital for each day for a specific period of time.

• Total Number of Patient Days/ Number of Days=ADC

• Percentage of Occupancy

• The ratio of actual patient days to the maximum patient days as determined by bed capacity.

• Census/Number of Licensed Beds Available=Percentage of Occupancy

JOSHUA A. JOHNSON, CRCS-I,P, CRCP-I

Certified Revenue Cycle Professional

Director of Patient Financial Services (Patient Access & Central Business Office)

Gibson Area Hospital and Health Services—Gibson City, IL

2nd Vice-President IL AAHAM

[email protected]

AAHAM Technical Examination

Billing Section Study Tips & a couple of “what’s

changed” highlights

A A H A M T E C H N I C A L S T U D Y S E S S I O N ( B I L L I N G

S E C T I O N )

THE NAME! CRCS-I (formerly the CPAT) CRCS-P (formerly the CCAT)

Study TIP: AAHAM will ask you for the full descripton of the abbreviations including

AAHAM!


S E C T I O N )

THE BILLING SECTION IS THE

TOUGH ONE!!

One Strategy if to “condition” the test

by passing TWO of the THREE

Sections. We’ve had several people

focus on the Access and

Collections Section

Tip: Condition Status is good for one

year.


S E C T I O N )

What is Changed: Equal

Credit Opportunity (2-14)

HINT: You can no longer ask if an applicant is widowed or divorced:

only if married, unmarried or separated. This also impacts FL on

the UB—04 and HCFA1500


S E C T I O N )

BILLING SECTION STUDY TIP

The rules of 6. Some areas include lists which require memorization. For Example: HICN suffixes (4-15) UB 04 Type of Bill Codes (4-55) HCFA 1500 Place of Service Codes (4-78), memorize at least SIX of the codes, preferably the FIRST SIX. While there are no guarantees that those six will be asked on each examination, you can use process of elimination to determine the others you didn’t memorize.


S E C T I O N )

CHAPTER 4

Inpatient Hospitalization Part A Deductibles:

Day 1-60 $1216/spell of illness ***If you can only remember ONE number, this is the one!

Days 61-90 $304 per day (hint, it’s always ¼ of the Part A deductible) Days 91-150 $608 per day (hint, it’s always ½ of the Part A deductible)

SNF Care Days 1-20 No deductible or co-insurance Days 21-100: 1/8 of the inpatient deductible, $152

Part B Deductible: $147 and then 20% co-insurance

(4-3)


S E C T I O N )

MEDICARE

Know Definitions:

• Beneficiary

• Referring Physician

• Ordering Physican

(4-2)


S E C T I O N )

Part A

• Inpatient

• SNF (after 3 day stay)

• Home Health

• Hospice

• Blood (4-4)

Part B

• Doctor Services

• Outpatient

hospital

• Some care not

covered by Part

A (therapy,

some home

health care)

PART A AND B DIFFERENCES


S E C T I O N )

Covered Preventative Services: (4-8/10)

There are many in the table but frequently asked include:

PSA >50 annually

Flu Shot: Annually

Pneumonia Shot: Lifetime

IPPE “Welcome to Medicare” : Once

Smoking & Tobacco Cessation: 2 annually for a max of 8 sessions

every 12 months

Behavior Counseling: Annually


S E C T I O N )

Know Examples of Items not covered by Part A or Part B

• Acupuncture

• Dental care

• Cosmetic Surgery

• Custodial Care

• International care

• Hearing aids


S E C T I O N )

Transition to ICD-10 Know:

(4-35)

The limitations of ICD-9 that ICD-10 does not have: lack of specificity, limited code length, outdated terminology

New versions offer: flexibility for updates, greater detail, updated terminology, greater ease in identifying proper reimbursement, greater ease in detecting potential fraud, waste and abuse

While this isn’t new, with the advent of ICD-10, it’s important to know.


S E C T I O N )

PART C

Know Examples and Difference between

HMO, PPO, Fee for Service, Special

Needs Plans and Medicare MSAs

(4-12)


S E C T I O N )

MEDICARE PRIMARY VS SECONDARY

P R I M A R Y

• 65 and no longer

working

• 65 working but

employer doesn’t

offer EGHP

• ESRD after 30

month waiting

period even if

disabled

S E C O N D A R Y

• 65+ covered by EGHP

• Working spouse has coverage (regardless of age)

• First 30 months with ESRD

• <65 disabled and covered by large group plan (100+ employees)

• Receives Work comp coverage, Black Lung, or TPL benefits for services


S E C T I O N )

BILLING CHANGES TO 1500

ITEM 8: Blank. No longer reports patient’s status

ITEM 9B: No longer reports “other insured’s DOB/sex” and is reserved for NUCC

ITEM 9C: No longer has “Employer’s Name” and is reserved for NUCC

ITEM 9D: Enter other insured’s insurance plan or program name (formerly contained 9 digit Medigap number)

ITEM 10D: No longer reports Medicaid # and is no used for NUCC condition codes


S E C T I O N )

MORE 1500 CHANGES

FL 11 was to indicate that a good faith effort had been made to

determine MSP status. It now contains the isnured’s policy,

group or FECA number.

11b: employer name has been replaced and we are to now use the

other claim id

11c insurance plan name

11d: this was blank before this year, now must indicate Y or N to

the question of whether there is another health benefit plan

15: was blank. Now enter any other dates that pertain to the

patient’s medical condition

19: Was to enter a six digit date for the last time patient was seen

and the UPIN, now contains additional claim information (many

listed see page 4-73 for specifics)


S E C T I O N )

MORE 1500 CHANGES

Item 22 was blank now contains an indicator of a resubmitted claim: 7 is replacement , 8 is void/cancel prior claim

Item 24c now can be used for emergency indicator

Item 24h now captures Early Periodic Screening, Diagnosis and Treatment indicators: There are 4: AV, S2, ST and NU

24I NUCC qualifiers

24J individual rendering the service

30 Field eliminated

32B there are now just 3 NPI qualifiers (2 digit) identified by NUUC: 0B State Lincese Number G2 Provider Commercial Number LU Location Number

33B 2 digit qualifies for non-NPI numbers 0B State License Number G2 Provider Commercial Number ZZ Provider Taxonomy


S E C T I O N )

TIMELY FILING

All Medicare providers must

submit claims for services

within 12 months from the date

of service. • For facilities, line items service dates will

be used for determination

• For professional claims the “from” date

will be used


S E C T I O N )

MEDICARE 3 DAY RULE

All diagnostic or outpatient services furnished in connection with the

principle admitting diagnosis within three days prior to the hospital

admission to be bundled with the inpatient services. This is applicable

for Inpatient Prospective Payment System providers paid by DRG.

Know exceptions to the rule:

• Psychiatric Hospitals

• Rehabilitation Hospitals

• Children’s Hospitals

• Long Term Care Hospitals

• Cancer Hospitals

• Any hospital outside the 50 states, DC and Puerto Rico


S E C T I O N )

ELECTRONIC BILLING

PR OS • Faster payment floor

• Less Paper

• Faster submission

• Proof of receipt

• Less clerical intervention

• Greater interest payments received due to delayed payments

• Better reporting

• Easier follow up

C O N S

Challenges with payer acceptance (interface)

Inability to send attachments

Inflexible vendor reporting

Upload and download issues

Challenges with backward integration


S E C T I O N )

MEDICARE EDITS

#1 Medicare Code Editor (MCE) is looking for

correct use of ICD-9-CM codes “code edits”

#2 Coverage Edits—examine the type of patient

and the procedures performed to determine if

the services were covered (Can’t do a

hysterectomy on a male)

#3 Clinical edits examine the clinical consistency

of procedural and diagnostic information to

determine if clinically reasonable. (Can’t do 72

amputations of a toe)


S E C T I O N )

AM I INCOMPLETE OR JUST INVALID


S E C T I O N )

Incomplete has missing information

Invalid has information but it’s

illogical or incorrect

A CLEAN CLAIM IS A HAPPY CLAIM


S E C T I O N )

• Passes all the CWF edits

• It’s Electric (try to get that song out of

your head now)

• If investigated doesn’t require contact

with the provider, beneficiary or SSA

• If medically reviewed, has complete

medical evidence to support it

• Wasn’t developed on a post payment

basis

NATIONAL CORRECT CODING INITIATIVE

Establishes standards of medical

billing

Identify codes that may be a

potential for fraud and abuse

Identify codes that are components

of another code and should not

be unbundled


S E C T I O N )

COMPLIANCE PLANS

7 Steps:

1. Written policies and procedures

2. Designated Compliance Officer (CO) and compliance committee

3. Effective Training and Education

4. Effective lines of communication

5. Enforced standards and well-publicized disciplinary procedures

6. Auditing and monitoring

7. Responding to offenses and developing corrective action plans


S E C T I O N )

POLLED ALL SUCCESSFUL BILLING SECTION EXAMINEES FROM THE

LAST TWO CYCLES

• 100% read the entire section at least twice

• 50% read it three times

• 100% studied on their own time

• 95% participated in study sessions and/or had a study buddy

• 70% used a highlighter to highlight all areas that were challenging for

them

• 100% read the study guide introduction thus they new that all items in

boxes or in bold were fair game for the exam

• 50% used flash cards

• 1 person made a power point of acronyms, abbreviations, organization

names, titles and downloaded it to his phone and quizzed himself while

waiting in line, at appointments, etc.


S E C T I O N )

MY CONTACT INFORMATION

Julie VanPelt

[email protected]

866-633-7291 ext 3010


S E C T I O N )

mailto:[email protected]

Documents

Technical Certification: Creating a Program for …...Plan and Schedule Certification Timeline CPAT Test Date Application Deadline Begin Study Sessions Testing Group 11/2012 9/3/2012