RCM Concepts
RCM Concepts
Coding is the function where the Medical Records are interpreted into Diagnosis & Procedure Codes.l The Coded Medical Records is called as Charge Sheet.
Procedure Codes:
CPT: Current Procedural Terminology
Used to Code: All the treatment given by the physician to the patient.
Format: 5 Digit Numeric. Example: 99212, 99281, 99282 etc.
Current Version: CPT-4
Administered by: AMA (American Medical Association)
HCPS: (Healthcare Common Coding System)
Pronounced as Hick-picks
Used to Code: All the Ancillary Medical Supplies. Example: Injection, Ambulance, Emergency Room, Oxygen Cylinder etc.
Format: One Alpha Followed by 4 Digit Numeric. Example: A0123, J0001 etc.
CDT: (Current Dental Terminology)
Used to Code: All the Dental Procedures.
Format: Alpha "D" followed by 4 Digit Numeric. Example: D0120, D4910 etc.
ASA: (American Society of Anesthesiologists)
Used to Code: All the Anesthesia Procedures.
Format: 5 Digit Numeric starting with "Zero". Example: 01642, 01999 etc.
Administered by: ASA themselves.
Diagnosis Codes:
ICD-10-CM/ICD-10-PCS: International Classification of Diseases - 10th Revision - Clinical Modification/ International Classification of Diseases - 10th Revision - Procedure Coding Systems)
Used to Code: The nature of illness.
Format: Minimum of 3 Digit to Maximum of 7 Digits with a decimal after the 3rd Digit. Examples: P09, S32.010A, O9A.211, M1A.0111 etc.
Administered by: DHHS (Department of Health & Human Services)
DEMOGRAPHIC DETAILS
1. Patient Information:
In demographic sheet patient need to enter Name, Address, Date of Birth, Contact information, Social Security Number, Gender, Marital Status etc.
2. Subscriber Information:
The one who pays the premium & holds the policy is termed as the "Subscriber" also termed as "Policy Holder" or "Insured".
Note: Patient cannot always be the Subscriber.
3. Guarantor Information:
Guarantor is the Financial Responsible person to pay the Medical Bills if the patient fails to pay.
Guarantor information is not always mandatory, but compulsory when the patient is:
1. Minor
2. Mentally Challenged
3. Admitted on Medical Emergency
4. Insurance Information:
Insurance Name.
Insurance Claims Address.
Policy number & Group Number.
Wheather Primary, Secondary or Tertiary Insurance.
** If patient does not have any insurance; "Self-Pay/Private-Pay" option is selected.
5. Employer Information:
Name of the Employer.
Address of the Employer.
Contact number etc.
Clearing House
- Clearing House is the International between the Billing Company & the Insurance Company.
- Clearing House is the TPA (Third Party Administrator: Neither a part of the Billing Company nor the Insurance Company).
- The Clearing House clears the dirty/incorrect Claims & sends the clean / correct claims to the Insurance company.
- When the claims get rejected by the Clearing House, the rejection is sent back to the Billing Company with the Scrubber Report.
Clearing House Checks for 2 main things:
- Missing mandatory values.
- Formats of Mandatory values.
EDI: Electronic Data Interchange
The medical billing software on the desktop creates an electronic file (the claim) also known as the ANSI-X12 837 file, which is then uploaded (sent) to your medical billing clearing house account. The clearing house then scrubs the claim checking it for errors (arguably the most important thing a clearing houses does) & then once the claim passes inspection the clearing house securely transmits the electronic claim.
Recoupment and Offset:
Recoupment occurs when the payer has determined that an over payment has occurred and they offset the overpayment or entire remittance.
Offset is a counter balances or compensate for something else.
No comments