charge entry process, important fields

• What are Patient Charges and what does it contain?

Patient charge is nothing but the fees claimed by the physician who rendered the services to the patient. Charges can be either based upon demographic evaluation or a flat fee rate as prescribed by the physician’s office. Each piece of information is important because correct and quality entry of such information will directly impact physician’s monthly revenue. This sheet is also called as face sheet of a charge or claim.

• How Charge Sheets originate and reach us?

Once patient /spouse completes Pd sheet, patient is then referred to physician in the appointed time. After preliminary investigation physician provides the services required by the patient. In the super-bill, kind of treatment is denoted by procedure code and diagnosis code denotes the nature of illness for which services were administered.

Super bills or charge sheets contain information like Date of Service, Kind of Service, Diagnosis Code, Attending Doctor, Modifier details. Super bills are usually completed by physician or their assistant. Sometimes Coding of diagnosis & procedures are done by coding specialists.
Once Charge sheets are completed, they are batched with PD at physician’s office and are forwarded to our office for charge entry. Mode of transfer of data may vary from client to client. But most preferred mode is thru FTP. Here patient demographics are scanned & captured as image file. These image files are placed in FTP site. These image scan files are retrieved at our office & charge entry begins.

• For our easy understanding now let us see each of the information found in patient charge sheet. Information found in patient charge sheet is 1. Attending Physician 2. Referring Physician 3. Admit Date 4. Date of Service 5. Type of Service 6. Place of Service 7. Prior Authorization Number 8. Modifiers 9. Procedure code 10. Diagnosis Code 11. # Of days/ units, 12. Location Details 13. Physician Name, Address, Provider id

1. Attending Physician: Attending physician is also referred as rendering physician. A physician who renders the service to patients is called attending or rendering physician. Each Rendering/Attending Physician of a particular facility is assigned a unique code with the Name of the Physician, Address of the Clinic/Facility, PIN (Provider Identification Number), License number, Federal TaxID#.

The Rendering Physician Name, Address, and PIN are printed in the 33rd field and if the Address of the Facility where the service was rendered differs from the Physicians location then that address is printed in the 32nd field and the corresponding Federal Tax ID of the Provider is printed in the 25th field of CMS-1500 form.

2. Referring Physician: Physician who refers patient to specialists is called referring Physician or Primary Care Physician (PCP) information is integral to continuity of care, reimbursement and community relations. In simple words, the physician who has sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is known as a Referring Physician. Each Referring Physician is allotted a unique code in the Medical Billing software which stores the Name of the Physician, Address of the Clinic/Facility, UPIN (Unique Physician Identification Number).
The Referring Physician Name is printed in the 17th field of the CMS-1500 claim form. The UPIN which is stored along with the code is printed in the 17a field of the CMS-1500 claim form.

3. Admit Date: Admit date refers to the date in which patient was admitted into the Hospital. For workers compensation Date of Injury (DOI) is very important for processing the claim. For the purpose of determining the date of injury for an occupational disease, the date of injury shall be taken to be the last date of injurious exposure to the hazards of such disease or the date on which the employee first knew or reasonably should have known of the condition and its relationship to the employee's employment, whichever is the later.

4. Date of Service: DOS is the date in which services were rendered to patient by attending physician. In certain cases we have thru date of service and also it will be in the single date format. Standard format for entering DOS is mm/dd/yyyy. DOS must be greater than or equal to admit date.

5. Type of Service: We need to input the type of service which was administered to patient. Broadly we have two digit TOS codes which needs to be entered in block 24C of CMS-1500 form. The type of service defines what type of service it is like radiology, cardiology and etc.

6. Place of Service: Two digit place of service needs to be entered in block 24b of CMS-1500 form while submitting claims to insurance carriers. POS can be for inpatient, Outpatient & ER. Health care that you get when you are admitted to a hospital is an inpatient. Medical or surgical care that does not include an overnight hospital stay is an outpatient. Care given for a medical emergency when you believe that your health is in serious danger when every second counts is an Emergency care. This field consists of the place or the location where services were provided to the patient. Location details are printed in block 32 of CMS-1500 form. Details like location name, address are printed. Where services are rendered in patient’s home & physician’s office location details in CMS-1500 form can be blank.

7. Preauthorization: An insurance plan requirement in which you or your primary care physician must notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense. Preauthorization are of two types. 1) Requesting authorization of date of services that have not been previously requested or the request was previously rejected. 2) Requesting authorization for increase or decrease units for previously approved dates of service. In other words, Preauthorization means Insurance is notified in advance about specific procedures. This allows for a review of medical necessity, efficiency, and quality of proposed care. It is also an opportunity to inform patient/physician about benefits, including length-of-stay guidelines and plan limitations. This will help to understand the costs if patient receive the proposed care.

8. Procedure Code: Procedure codes are used to indicate the kind of treatment or service was administered in patient. Utmost care should be given while entering the procedure code. We need to first know what kind of procedure code each insurance accepts to process claims. Healthcare Common Procedure Coding System (HCPCS) is a coding system that is composed of Level I codes (Current Procedural Terminology (CPT) codes), Level II codes (national codes), and Level III codes (local codes). Level I (CPT) codes are five digit numeric codes that describe procedures and tests. CPT codes are developed and maintained by the AMA with annual updates. Level II (national) codes are five digit alpha numeric codes that describe pharmaceuticals, supplies, procedures, tests and services. Level II codes are developed and maintained by CMS with quarterly updates. Level III (local) codes are five digit alpha numeric codes that are being phased out by the fiscal intermediaries.

Examples of CPT codes:
• 85025 – CBC with automated differential
• 71020 – Chest x-ray 2 views
• 45378 – Colonoscopy
• 93501 – Right heart catheterization

In other words, this field contains the Code of the procedure done (CPT/HCPCS Code). The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties. All the Procedure codes are stored in a Master database of the Medical Billing software with the description of the code and the dollar amount. This helps the charge entry person to cross verify the procedure before saving the claim.

This field is printed in the 24d field and the corresponding dollar amount of the procedure stored in the Medical Billing Software is printed in the 24f field of the CMS-1500 claim form

No comments:

Medical Billing Popular Articles