CRCS Exam Study Manual Update for 2017

Transcription

1 CRCS Exam Study Manual Update for 2017 This document reflects updates made to the instructional content from the Certified Revenue Cycle Specialist (CRCS-I, CRCS-P) Exam Study Manual to the 2017 version of the manual. This does not include updates to Knowledge Checks and Answers or the Glossary. Table of Contents Edit to page 2 8: Implementation for Tax Exempt Hospitals... 2 Edit to page 2 10: Anti Fraud and Abuse... 2 Edit to page 3 4: Inpatient Admitting and Outpatient Registration... 2 Edit to page 3 8: Case Management/Utilization Review... 2 Edit to page 3 17: Levels of Patient Care... 2 New topic on page 3 23: Billing with an ABN... 3 Edit to page 4 2: Medicare... 3 Edit to pages 4 3 and 4 4: Part A Deductibles, Coinsurance, and Copayments... 4 Edit to page 4 5: Part B Deductibles, Coinsurance, and Copayments... 4 Edit to page 4 13: Part C Overview... 5 Edit to page 4 15: Health Insurance Claim Number... 5 New topic on page 4 20: Insurance Payer Contracts... 5 Edit to page 4 37: Evaluation & Management (E&M) Levels... 6 Edit to page 4 42: Resource Based Relative Value Scale (RBRVS)... 7 Edit to pages 4 42 and 4 43: Chargemaster... 7 Edit to page 4 53: UB 04 (and 837I)... 8 Edit to page 4 66: New Sample CMS 1500 Form... 9 New topic on page 4 92: Explanation of Benefits (EOB) or Remittance Advice (RA) Edit to page 4 94: Medicare 3 Day Rule

2 Note: Unless otherwise stated, information in yellow below has been inserted and information struck through has been deleted. Edit to page 2-8: Implementation for Tax-Exempt Hospitals Recently, the IRS proposed regulation # Section 501 (r) 4 6 for tax exempt hospitals as part of the implementation of the PPACA. This regulation has three sections that will impact healthcare: financial assistance, charging limitations, and collection actions. In regulation 501(r), the PPACA imposes additional requirements on charitable hospital organizations in the following areas: Financial assistance Section of the PPACA deals with the notification requirements for financial assistance programs (FAPs) that are available, eligibility requirements, the financial assistance application process, and the calculation of amounts charged to patients who are eligible for financial assistance. This section requires a hospital facility s FAP to include a list of providers, other than the hospital facility itself, delivering emergency or other medically necessary care in the hospital facility and to specify which providers are covered by the hospital facility s FAP and which are not (the provider list ). This section also discusses information about emergency medical care requirements as they relate to a patient s eligibility for financial assistance programs. Edit to page 2-10: Anti-Fraud and Abuse TIP: Know the differences between fraud and abuse. Edit to page 3-4: Inpatient Admitting and Outpatient Registration Verifying insurance Completing the Medicare Outpatient Observation Notice (MOON), when applicable (The MOON is completed by Case Management staff in some hospital facilities.) Edit to page 3-8: Case Management/Utilization Review Assisting with appeals for denials, when applicable Completing the MOON, when applicable (The MOON is completed by Patient Access staff in some hospital facilities.) Edit to page 3-17: Levels of Patient Care Observation Though these patients occupy a bed, they are outpatients. Observation time is intended for monitoring of the patient's acute condition, which may resolve or worsen. Because of this, observation is not the kind of service that can be scheduled in advance. It is also not intended for routine use such as surgical recovery. Many commercial insurance payers require most one day stays to be classified as observation. Some limit these stays to 23 hours. The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act), enacted in 2015, states that hospitals must inform patients who are hospitalized for more than 24 hours that they are in observation status. No later than 36 hours after a patient begins to receive observation services, the patient must be informed, both orally and in writing, of his or her observation status. 2

3 The MOON is a standardized notice developed to inform beneficiaries (including Medicare health plan enrollees) when they are an outpatient receiving observation services and are not an inpatient of the hospital or critical access hospital (CAH). The MOON is mandated by the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act), passed on August 6, The NOTICE Act requires all hospitals and CAHs to provide written and oral notification within 36 hours to patients who are in observation status for more than 24 hours. NOTE: See Federal Register IPPS NOTICE Act Final Rule to view the final NOTICE Act regulation (Section L and 42 CFR ). Also see CMS dated for additional details. New topic on page 3-23: Billing with an ABN Billing with an ABN Certain modifiers are required on the claim form when billing with an ABN. Modifiers for Billing with an ABN Modifier Description When Used GA Waiver of liability statement issued as required by payer Report when you issue a mandatory ABN for a service as required. Do not submit a copy of the ABN, but it must be kept on file. GX Notice of liability issued Report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. This modifier may be used in combination with the GY modifier. GY GZ Item or service statutorily excluded, does not meet the definition of any Medicare benefit Item or service expected to be denied as not reasonable and necessary This modifier may be used in combination with the GX modifier. Report when you expect Medicare to deny payment of the item or service due to lack of medical necessity and no ABN was issued. Edit to page 4-2: Medicare TIP: Medicare and You is an annual booklet CMS makes available for beneficiaries. It is helpful not only to beneficiaries but to those working in Patients Accounts, as well. It will also help Billing and Collection staff learn basics about Medicare and will assist staff in explaining coverage to the patient. The booklet can be found at: and you/different formats/m and y different formats.html 3

4 Edit to pages 4-3 and 4-4: Part A Deductibles, Coinsurance, and Copayments Medicare Part A Service Beneficiary Obligation 2017 Amount Hospital stay Semi-private room, meals, general nursing, other hospital services, and supplies. This includes care in critical access hospitals. This does not include private duty nursing or a television or telephone in the room. It also does not include a private room, unless medically necessary. Inpatient mental healthcare in an independent psychiatric facility is limited to 190 days in a lifetime. SNF care Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a three-day hospital stay). Days 1 through 60*: Part A current year inpatient deductible *Renewable during the next benefit period Days 61 through 90*: Part A coinsurance (1/4 or 25% of current year inpatient deductible) *Renewable during the next benefit period Days 91 through 150*: Part A lifetime reserve (LTR, 1/2 or 50% of current year inpatient deductible) *Nonrenewable; hospitals alert patients when they have 5 days of coinsurance left so they can choose whether to use LTR Days 1 through 20: No deductible or coinsurance Days 21 through 100: 1/8 of current year inpatient deductible $1,316 per spell of illness $329 per day $658 per day $0 per benefit period $ per day Edit to page 4-5: Part B Deductibles, Coinsurance, and Copayments Medicare Part B Service Beneficiary Obligation 2017 Amount Medical and other services Doctors services (except for routine physical exams); outpatient medical and surgical services; supplies; diagnostic tests; ambulatory surgery center facility fees for approved procedures; and DME. Also covers second surgical opinions; outpatient physical, occupational, and speech therapy; and outpatient mental healthcare. Medical and other services: Current year deductible, then coinsurance (20% of Medicare-approved amount, except in the outpatient setting) Outpatient physical, occupational, and speech-language therapy services: Coinsurance Outpatient mental healthcare: Coinsurance $183 per year, then 20% of Medicareapproved amount 20% of Medicareapproved amount 20% of Medicareapproved amount 4

5 Edit to page 4-13: Part C Overview Medicare Part C, or Medicare Advantage Plans, is managed care coverage provided by private insurance companies approved by Medicare. Medicare Part C, also known as Medicare Advantage or Replacement Plans, is a replacement for traditional Medicare. This is managed care coverage provided by private insurance companies approved by Medicare. The private insurance companies are paid a fixed amount each month. These plans must follow the minimal rules set by Medicare. Depending on if the provider is contracted with the payor, the payment received may be the same, more or less than traditional Medicare. Edit to page 4-15: Health Insurance Claim Number TIP: Patient Access and Billing staff need to be able to distinguish between a Part C plan beneficiary card and traditional Medicare cards. Most often the back of the card will indicate "Do not bill Medicare." The address to mail or electronically send claims will be different from the Medicare Administrative Contractor (MAC). New topic on page 4-20: Insurance Payer Contracts Insurance Payer Contracts Many insurance payers will contract with providers to receive discounts off normally billed charges. Payer contracts may have several different elements and payment restrictions. Contracts can be with individual payers, individual group employer plans, health maintenance organizations (HMOs), or networks of various insurance payers. It is important that all departments involved in the provider revenue cycle are aware of the contracts in place, their effective dates, and terms of the contracts specifically as they relate to discounting. Staff should be aware of and understand the following elements of a payer contract: Contract effective and renewal dates This is the date payers become entitled to the discount and the date to renegotiate a payer contract. Fee schedule revision The payer could be allowed to unilaterally revise their fee schedule prior to the contract renewal date. Termination provisions These provisions indicate: Is there auto renewal of the contract unless one party gives advance notice to the other? What is the advance notice period? Is elective termination allowed and, if so, what is the notice period? Is termination for a material breach allowed and, if so, what are the key conditions and requirements. Timely filing requirement This is the payer's requirement for timely claims submission. Refund request time allowance This is the time limit of how far back the payer is allowed to go to request a refund for a previously paid claim. Denials rate This identifies the overall payer denials percentage. Medical policies In order to keep the payer contract matrix from getting too large and complex, this box can simply be a rating and refer by abbreviation to key medical policies, local coverage determinations, and national coverage determinations that are important. Prior authorizations See medical policies above. 5

6 Fee schedule rating This is an overall rating of each payer's fee schedule. Reimbursement rate This is the percent of billed charges paid, amount allowed by case or level of care, excluded services, if any, and out of network penalty coverage. Staff should know the difference between preventive care coverage and diagnostic care coverage as it relates to deductibles and copays. Charge percentage of payer mix This identifies the percentage of charges that the payer comprises in the overall payer mix. The charge percentage gives a readily available means to judge the relative amount of services rendered for the payer. Payment percentage of payer mix This identifies the percentage of payments that the payer comprises in the overall payer mix. Reimbursement Performance This payer reimbursement information is useful on issues such as days in Accounts Receivable (A/R), A/R greater than 90 days, coding/bundling issues, expected payments performance, and hassle factor to generate a rating for the payer's reimbursement performance. Credentialing It is important to understand the key requirements, difficulty, and likely timeline required for credentialing new providers. Also note if the payer will be required for credentialing new providers for the practice and if the payer will backdate the effective date to when the provider started at the practice if the payer provider number has not been issued at the time the provider starts working at the practice. Other This can include any additional elements. Edit to page 4-37: Evaluation & Management (E&M) Levels *History, examination, and medical decision making are considered the three key components in selecting a level of E&M service. An exception is the case of visits that consist predominantly (more than 50% of the visit time) of counseling or coordination of care. For these services, time spent is the key or controlling factor to qualify for a particular level of E&M service. Providers must ensure that medical record documentation supports the level of service being billed to a payer. Physician practices should pay close attention to E&M codes indicating new versus established patients (except the emergency department, where there is no distinction). TIP: For payment of E&M consultation services, the NPI of the referring physician is a key element to include in the CMS 1500 claim form. TIP: The Current Procedure Terminology (CPT) coding book will assist in determining the correct level of E&M service. Also the Medicare Learning Network document Evaluation & Management Services ICN August 2015 is a good reference document to assist in E&M level assignments and to review established versus new patient codes. 6

7 Edit to page 4-42: Resource Based Relative Value Scale (RBRVS) The RVU is the heart of the fee schedule, whereby every medical procedure recognized by Medicare has been assigned units of value for various resources used to provide the service. The RVU is comprised of: Three separate RVUs are associated with the calculation of a payment under the Medicare Prospective Payment System (MPPS): Work required (Work RVU) Practice expense (PE) Malpractice insurance expense (MP) NOTE: Further information about RVUs is available in the annual Medicare Physician Fee Schedule Final Rule or the file can be accessed at Fee for Service Payment/PhysicianFee Sched/index.html on the CMS website. Edit to pages 4-42 and 4-43: Chargemaster Chargemaster The chargemaster is an electronic file that resides in the provider's information system and that contains all of the charges that might be posted to a patient account. It is also called the Charge Description Master (CDM), fee schedule, item master, and other similar names. Each item has a system entry that includes the description and price of the item, its CPT or HCPCS codes, what general ledger account it impacts, and, in the case of supplies and medications, inventory control information such as supplier and cost. Individual departments generate charges for a patient account by using an automated charge or order entry system or manually by paper encounter forms. The cost, charge description, and all codes attached to a line item in the CDM file flow through to the bill. Depending on the patient accounting system, some chargemasters allow default UB 04 revenue code or CPT/HCPCS code assignment and an override by insurance, financial class, or standard class. Additionally, some chargemasters store pricing and cost data and accommodate multi tier pricing. In most hospitals or clinics, the line item chargemaster is hard coded with the CPT or HCPCS code as often as possible. This saves the coding staff time in abstracting and finalizing the visit for final billing. (Only the charge that can be clearly defined in the chargemaster should be hard coded. If interpretation is needed to define the codes, assigning CPT or HCPCS codes should be performed by the coding staff.) The chargemaster may also include professional fee (pro fee) amounts (or calculations) and other physician billing information (such as modifiers, CPT/HCPCS codes, ICD 10, diagnosis flags, physician group numbers, and so on). Elements of a chargemaster (see UB 04 field locators 42 through 49) include: Department numbers Revenue codes Chargemaster numbers Charge description 7

8 Charge amounts CPT/HCPCS codes Modifiers General ledger numbers As a best practice, a facility chargemaster should be reviewed at least annually. This review should check for items that should be deleted or added. Many electronic health record (EHR) systems perform an interface routine to ensure all assigned codes are still in effect. Assigning an incorrect code to a charge could be construed by Medicare as fraudulent billing. Department directors and/or managers should be included in these annual reviews. Edit to page 4-53: UB-04 (and 837I) A sample UB 04 appears below, with information about field locators and codes after that. For some of the most important UB 04 codes, there are descriptions and examples of the codes in shaded text. These codes are used by several payers, but most particularly by Medicare to obtain from the provider detailed information regarding the need for medical services on an inpatient or outpatient basis. The codes are used to define significant events, insurance coverage conditions, and clinical or monetary data that may affect payer processing and payment of the claim. TIP: Pay special attention to the most important UB 04 codes, where descriptions and examples are included in the following tables. You should know various Bill Types to print in field locator 4 and various Condition Codes and Value Codes. 8

9 Edit to page 4-66: New Sample CMS 1500 Form 9

10 New topic on page 4-92: Explanation of Benefits (EOB) or Remittance Advice (RA) Medicare Summary Notice The MSN is a statement to the payee and/or beneficiary reflecting services received, charges submitted, charges allowed, amount for which the beneficiary is responsible, and the amount that was paid to the provider or beneficiary. MSNs may specify deductible and coinsurance amounts. The MSN is also known as a remittance advice and was formerly known as the Medicare Explanation of Benefits (EOB). Explanation of Benefits (EOB) or Remittance Advice (RA) An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. A remittance advice (RA) reports the same information. The terms EOB and RA are often used interchangeably; the only distinct difference in the two terms is: An EOB may or may not have a check attached for payment of services. An RA should have a check attached or a voucher for an electronic payment which was made directly to the provider s bank. Other names for these documents include: Electronic EOBs are called EDI files. When Medicare is the payer, these documents are called the MSN (Medicare Summary Notice). EOB documents contain protected health information. Payment posting staff must understand how to read an EOB to ensure accurate payment posting, know how to recognize contract discounts and identify exact portion due by the beneficiary or secondary insurance. An EOB typically indicates: The payee, the payer and the patient The service performed, the date of the service, the description and/or insurer's code for the service, the name of the person or place that provided the service, and the name of the patient The doctor's fee and what the insurer allows (the amount initially claimed by the doctor or hospital minus any reductions applied by the insurer) The amount the patient is responsible for Adjustment reasons and adjustment codes At least a brief explanation of any claims that were denied along with information on how to start an appeal 10

11 A member with secondary insurance gives such information to the provider for the next bill to go out to that insurance company. Generally secondary insurance pays only the amount the EOB says the member is responsible for. Secondary EOBs show if the patient still has any responsibility to the provider. After the member's insurances have processed the claim, the provider bills the member for the remaining balance, if any. The Role of EOBs in Identifying Healthcare Fraud and Abuse Third party payers try to keep their beneficiaries informed of what healthcare claims were submitted on their behalf by healthcare providers. They inform their patients of expected financial obligations for healthcare received, such as copays, coinsurance, and deductibles. They also inform patients that they may have received services that a payer considers medically unnecessary, experimental, or cosmetic in nature. EOBs are an important factor in identifying healthcare fraud and abuse. The federal Medicare program also has recognized that EOBs are a powerful fraud and abuse detection tool by actively enlisting beneficiaries to report suspected fraud and abuse. Medicare beneficiaries receive quarterly Medicare Summary Notices (MSNs) that detail all healthcare claims that have been submitted on their behalf in a three month period. Recent changes in the format of MSNs are designed to make them more easily understood by people who are not fluent in the language of medical coding or HIPAA standard adjudication codes. New MSNs contain plain language, and the CMS has undertaken an extensive public information campaign directing patients to compare their MSN to services actually received by healthcare providers. Edit to page 4-94: Medicare 3-Day Rule Medicare 3-Day Rule The Medicare 3 Day Rule was established by the Omnibus Budget Reconciliation Act (OBRA) and requires 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 for Medicare billing. Through public notice and comment period rulemaking, CMS defined services related to the admission as those nondiagnostic services that are furnished in connection with the principal diagnosis assigned to the inpatient admission. Medicare s 3 Day Rule is applicable to Inpatient Prospective Payment System (IPPS) providers paid by DRG. This provision applies to diagnostic services (including clinical diagnostic laboratory tests) or other services related to the admission furnished by a subsection (d) hospital subject to the IPPS (or by an entity wholly owned or wholly operated by the hospital). This provision does not apply to ambulance services, and non diagnostic outpatient services not related to the primary diagnosis ambulance and chronic maintenance renal dialysis services provided within three days of the admission. For these, the services are not bundled. This rule does not apply to Non PPS Hospitals or units that are on a reasonable cost reimbursement system. a non subsection (d) hospital (that is, a hospital not paid under the IPPS). Instead, these hospitals are subject to a 1 Day Rule rather than the 3 Day Rule. Hospitals exempt from the 3 Day Rule, but subject to the 1 Day Rule, include: Psychiatric hospitals and units 11

12 Inpatient rehabilitation hospitals and units Children s hospitals Long term care hospitals Cancer hospitals Any hospital outside the 50 states, District of Columbia, and Puerto Rico Critical Access Hospitals (CAHs) Billing for Services Unrelated to the Inpatient Admission Sometimes outpatient nondiagnostic services provided during the three days (or one day, for a nonsubsection (d) hospital) before an inpatient admission truly are unrelated to the admission. When a hospital believes this is the case, the hospital may separately bill for the service to Part B (provided that the hospital documents its claim and maintains that documentation). These separately billed outpatient preadmission services may be subject to subsequent review by CMS or its representative. The 3 Day Rule for bundled payments is an area of focus with the OIG and Medicare auditors. Hospitals should pay special attention to these rules to ensure proper billing practices. 12