Medical Billing process - Charge Entry

How to enter charges - Charge entry process

Charge-entry is one of the key departments in Medical Billing. Key department?? Yeah, that’s true. It is the keying-in department in Medical Billing. After receiving the super bills from the Doctor’s office, it gets passed through the coding, pre-coding department, and then comes to the charge-entry department. It is only here in this department, the claim/bill is actually created. The charge-entry person creates an individual account for every patient demographics that comes for the first time, and also assigns individual account #for the same.

A patient account # is a unique number (For example) 9 digit # created for our own internal reference, and for our record purpose. These 9 digits are segmented as per their relevance. The first two digits represents the company #, next three digits are for the Julian date (it is the number of days counted from January 1st till the current day), next one digit for the year, last three digits for patient serial #. It is one of the important aspects of charge-entry, which helps us to access any patient’s account easily in the software. Then, as a non-stop person, he looks into the patient demographics, and enters the patient’s information, Insurance information and Doctor’s information (tax id #, Upin #, Facility address etc) in the software, and thus makes a particular patient’s account accessible with complete information as and when needed.

A Charge-entry person also has one other vital role to perform. That is, to look-up the codes entered in the claim, and to assign the relevant charges for those codes. This is also one of the key functions in Medical Billing as there should not be any up billing done by assigning an incorrect charge for the codes. Likewise, he does a commendable job by entering all the relevant information needed, and creates a claim ready for auditing, and then for transmission to the insurance company

The basic document for charge entry is either the charge sheet or the super-bill or the medical record giving basic information of codes required for charge entry.

Charge Entry is described here with software (I am using) in mind. However the principles are the same in whichever software you use for charge entry. During charge entry the following fields are required.

BATCH DETAILS

[This is a number again fixed according to the requirement of the project. This is four-digit number and is generally the Julian date followed by the serial number. For e.g. If we are processing patients for dates of service 03/25/2000, then the batch # would be 0851, 0852 and so on. Julian date is the serial number of the date in that year i.e. Jan 31st would be 031, Feb 1st would be 032, March 1st would be 061 and so on.]

Patient Account #,

[This is the number, which you have allotted to the patient during registration. If you type this number the other particulars such as the patient name, insurance coverage and the patient type would default.]

Facility ID,

[Facility is a synonym for hospital. We need to capture the name of the hospital where the services were rendered. The names of the hospital would be stored in the facility master. You need to give the id # from that master for the hospital for which you are doing charge entry.]

Doctor ID,

[The Doctor who performed the service i.e. the attending doctor should be stated here. The doctor’s particulars are stored in the doctor master. We need to mention the id # of the relevant doctor here.]

Ref Dr ID,

[Referring Doctor is a doctor who has referred the patient to the doctor who performed the service. These doctors’ particulars are stored in the referring doctor master. You need to mention the id # of the referring doctor here.]

PCP ID (optional),

[PCP is Primary Care Physician. A PCP is one who has diagnosed the patient first before the attending doctor treats him. In some specialties/ states, PCP is a vital link in obtaining information for insurance processing. We need to get the PCP name and phone # in such cases.]

Place of Service,

[Give the correct place of service code for inpatient, outpatient, office consultation, emergency room, ambulatory surgical center etc.]

Admit Date, Discharge Date, Injury Date,

[Though these are not compulsory fields it is desirable to provide this information. Injury date is a must for Workermen’s compensation claims.]

Referral #, Prior authorization #

[As explained above, for cases which require prior authorization the authorization or the referral # should be stated. If there is an authorization or referral on file but no number has been allotted, we should just state “referral on file” in the above field.]

LINE ITEM DETAILS

From Date of Service, To Date of Service,
[Date of service is the date on which the treatment is rendered to the patient. This may be just one date or a range of dates. We need to fill in this information as given in the charge sheet/ super-bill.]

Procedure,

[Here you will have to give the key-in code for the CPT/ ASA/ HCPCS code for the procedure performed. The complete procedure details are stored in the procedure master. We need to specify the key-in code here.]

Modifier,

[Enter the appropriate modifier code. All modifiers are stored in the modifier master. Most common modifiers used are 26 for Professional Component, TC for Technical Component, 50 for Bilateral, 59 for Distinct Procedural Service etc.]

Diagnosis,

[Enter the ICD-9 code here. You cannot enter more than 4 different ICD-9 codes in a ticket since HCFA has the capacity to accept only 4.]

Units,

[This is stored in the procedure master in most cases and will default once you enter the procedure. Otherwise you will have to enter the number of units here. In Anesthesia Billing, the number of units will be time units + base units.]

Amount.

[This is also stored in the procedure master. If will default once you enter the procedure.]

Once you complete all items in charge entry you need to update the charge. You will have to take a charge summary and check your work.



Sample Super bill



Sample Super bill


How to Enter charges

In the software go to charge entry screen, select the correct patient and servicing provider and Date of Service

In the above super billing provider marked one CPT code 99215 and two ICD code. Enter all the above information in the software . The fee amount would populate automatically and dont change it otherwise if required. Select the POS. If patient paid any copay capture that amount. Finally the charge entry would be like the.



Charge posting Entry



Claims submission
 
The next step after demographics and charge entry is claims generation. Claims may be paper claims or electronic claims.

A claim is a comprehensive pooling of all data relating to a patient for a particular treatment. All registration, charges and provider information is contained in this form which is sent to the insurance carrier for processing. The data presented in this form should be 100% accurate since payment or otherwise to the doctor for the patient’s treatment is based on the information provided in this form. Hence this should be thoroughly audited before sending to the carriers.

 Electronic Transmission


Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company’s computer system or to the clearing house.

The major advantages of this method are less administrative costs, no concerns of claims being lost in transit, no concerns regarding data entry errors being made by insurance staff while processing claims, less rejections, less turnaround time between the process of data and process of claim by the carrier and above all we can receive reports of the number of claims sent and received by the carriers.

Medicare pays electronic claims within 14 days while paper claims take 27 days in processing. In some cases there is a facility for Electronic Fund Transfer (EFT) wherein the carriers deposits the check directly into the bank account of the provider or the group. Here again the number of days it takes to send the check through post and then manually depositing them into the bank is avoided.

For Federal Carriers, in order to transmit claims electronically, we need to enroll the providers through EDI of that carrier. These carriers have facility of transmission directly and not through any clearing house. Certain other carriers also have the facility of accepting electronic claims, but they have to send through a clearing house.

For this purpose we need to establish vendors (Clearing House) who has the facility of receiving claims from the billing office, performs edit checks which are more or less equal to the carrier requirements and has numerous carriers registered under it for forwarding claims electronically.


These vendors accepts data in a single format and edits, sorts and distributes the data into formats that are acceptable by various plans. They charge a fee that is generally a fixed amount per claim.
ENCOUNTERS DEFINITION

An allowable FQHC encounter means a face-to-face medical visit between a patient and the provider of health care services who exercises independent judgment in the provision of health care services.  An encounter occurs between a medical provider and a patient when medical services are provided for the prevention, diagnosis, treatment, or rehabilitation of an illness or injury. Included in this category are physician visits and mid-level practitioner visits. Family planning medical visits are a subset of medical visits.

An encounter occurs between a dentist or dental hygienist and a patient when services are for the purpose of prevention, assessment, or treatment of a dental problem, including restoration. A dental hygienist is credited with an encounter only when the professional provides a service independently, not jointly with a dentist. However, two encounters may not be billed for the dental clinic in one day. An encounter occurs between a speech or physical therapist, audiologist, occupational therapist, clinical psychologist, or clinical social worker and a patient when allied health or mental health services are
provided. Allied health services are those provided by specially trained health workers, other than medical and dental personnel. Mental health services are those of a psychological or crisis intervention nature or related to alcohol or drug abuse treatment. For the purpose of these reports, visits with a psychiatrist are included under medical visits.

The following examples help to define an encounter:

* To meet the encounter criteria for independent judgment, the provider must be acting independently and not assisting another provider. For example, a nurse assisting a physician during a physical examination by taking vital signs, taking a history or drawing a blood sample is not credited with a separate encounter.

* Such services as drawing blood, collecting urine specimens, performing laboratory tests, takingX-rays, filling/dispensing prescriptions, or optician services, in and of themselves, do not  constitute encounters. However, these procedures may accompany services performed by medical, dental, or other health providers that do constitute encounters.

* Encounters must be documented in the medical record. When a provider renders services to several patients simultaneously, the provider can be credited with a visit for each person if the provision of services is noted in each person’s health record. This also applies to family therapy or counseling sessions in which several members of the family receive services relating to mutual family problems and the services are noted in each family member’s health record.

* The same billing limitations identified in the General Information for Providers Chapter of this manual apply to claims submitted for FQHC encounters.

The encounter criteria are not met in the following circumstances: 

* When a provider participates in a community meeting or group session that is not designed to provide health services.

* When the only service provided is part of a larger scale effort, such as a mass immunization program, screening program, or community-wide service program.


* When the following services are provided as stand-alone services: taking vital signs, taking a history, drawing a blood sample, collecting urine specimens, performing laboratory tests, taking x-rays, and/or filling/dispensing prescriptions. Refilling prescriptions, filling out insurance forms, etc. are not visits. Allergy injections are not visits.


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