Managed Care Readiness Training Series: Revenue Cycle Management - PowerPoint PPT Presentation

Managed Care Readiness Training Series: Revenue Cycle Management 2nd Learning Community Charge Capture and Coding

Charge Capture and Coding Presenter: David Wawrzynek MS, MBA

Managed Care Technical Assistance Center (MCTAC) Overview What is MCTAC? MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC’s Goal Provide training and intensive support on quality improvement strategies including business, organizational and clinical practices, to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care . 3

Revenue Cycle Defined All administrative and clinical functions that contribute to the capture, management, and collection of client service revenue. This describes the life cycle of a client account from creation to payment collection and resolution. The client account cycle is supported by a number of additional activities necessary to assure that all encounters are billable, meet regulatory requirements and revenue collection is maximized. 4

What is the impact? Total Service Revenue 2,000,000 Estimate of % lost 12% Amount of Uncollected Reveue $240,000 5

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Phases of the Revenue Cycle • Prior to Service • Following Services – Pre-registration including – Claims submission eligibility verification and – Payer follow-up authorization – Remittance processing – Scheduling and posting • During Services • Ongoing – New client registration – Analysis – Eligibility verification – Process improvement – Collection of fees – Charge capture and coding 7

Charge Capture and Coding Charge capture and coding – Definition Efficiently documenting the type and duration of the client encounter and transforming that into a data set necessary to support a accurate claim that maximizes allowable revenue. 8

Errors in charge capture and coding, the “silent” revenue loss • Claims that are denied, rejected or voided can be quantified. That is you can tell how much money you have lost. • Errors related to not capturing all the claims or not claiming all that allowable can easily go un-noticed. 9

Coding Data Elements Client Contact Critical Documentation Elements Services Staff Modifying Duration Provided credentials conditions Additional E/M Coding requirements Complexity Client Diagnosis of visit Type 10

Service Provided • Defined by regulation • May be a discrete service or an aggregation of services provided during the month • Modality specific • Each have a rate code and CPT code attached to it 11

Staff Credentials • May determine if a service is billable to a specific payer or not (ex. Medicare eligible provider) • May modify payment amount (i.e. higher payments in clinic for MD/NP) 12

Duration • Time spent providing the service is key to proper coding – Some services have minimum time standards to be billable (ex. Group Psychotherapy in clinic) – Some services have different rate codes based upon duration (ex. Individual Psychotherapy 30 vs 45 minutes) – Some services have different rate codes based upon aggregate time (ex. Billing in 15 min increments for Psychosocial Rehabilitation) 13

Modifying Conditions • Reimbursement rates may be different based upon certain modifying conditions such as: – Location (ex. on-site vs off-site) – Language other than English – Credentials of provider (ex. MD/NP may pay at a higher rate) 14

Evaluation and Management Coding (E/M) – Apply to Physicians, Psychiatrists, and Nurse Practitioners – CPT codes are selected based upon: – Client type (new or established) – Setting of service (outpatient or hospital) – Level of evaluation and management services provided (complexity of the visit) – Diagnosis – Documentation must clearly support the CPT code selected – Secondary review of the documentation and the code selected is recommended. 15

Example of E/M Code Variables 820-831 Psychiatric Assessment – 30 minutes – Select CPT Code from Range: New Established □ 99201 □ 99204 □ 99212 □ 99215 • □ 99202 □ 99205 □ 99213 • □ 99203 □ 99214 • Select Diagnosis: 820 Schizophrenia • 821 Major Depressive Disorders & Other Psychoses • 822 Disorders of Personality & Impulse Control • 823 Bipolar Disorders • 824 Depression Except Major Depressive Disorder • 825 Adjustment Disorders & Neuroses • 826 Acute Anxiety & Delirium States • 827 Organic Mental Health Disturbances • 829 Childhood Behavioral Disorders • 830 Eating Disorders • 831 Other Mental Health Disorders • 16

Results of poor coding – Improper or inaccurate coding may result in billing less than is allowable or in some cases more than is allowable – Improper or inaccurate coding carries a significant risk of disallowance upon subsequent audit • Strong quality assurance programs must be in place to assure codes are correct and supported by the clinical documentation. • It is essential that staff understand the billing rules that guide their practice and documentation 17

Meeting the capture and coding challenge • When ever possible charge capture should be standardized behind the scenes in the EHR with the system selecting the correct rate code, CPT code, modifier combination based upon documentation of service, duration and provider. • EHR setup should make it easy to identify when a modifier should be applied to the basic charge. 18

Meeting the capture and coding challenge (continued) • If charge are not captured through the EHR then: – Staff should be provided with a charge master that they can use to cross walk from the service they provided to the proper billing code. – An efficient process must be in place to record, verify, and accurately report services provided to be entered into the billing program. – Care must be taken to assure that minimum duration standards are met and that the CPT code for the transaction matches the start and end time on the clinical documentation. 19

Meeting the capture and coding challenge (continued) • Modifying conditions must be easily identified and communicated 20

Resources 21

Resources (continued) New York State HARP Mainstream BH Billing and Coding Manual provides billing mechanics for all the Medicaid fee-for-service “government rate” services (including OMH licensed and OASAS certified services). This should be reviewed in conjunction with the coding taxonomy, HCBS Fee Schedule, and the rate table. The second section of the manual gives detailed information on OASAS services. There are numerous links in this document, provided for your convenience. http://www.omh.ny.gov/omhweb/bho/hap-mainstream-billing-manual.pdf 22

Resources (continued) Coding Taxonomy This file provides the required coding construct for billing the OMH government rates services. Government rates must be used for the first 24 months of the behavioral health carve-in. Plans will need to program their payment systems to accept these coding combinations and then look through the Rate Table to ascertain the correct payment amount for the various unique coding combinations (specified using procedure codes, modifier codes, and units of service - all cross-walking to rate code) and the specific provider and BH service (based on MMIS provider ID or NPI and rate code). http://www.omh.ny.gov/omhweb/bho/coding-taxonomy.xlsx 23

Resources (continued) HCBS Fee Schedule This file shows the required coding combinations for providers to bill the Plan for the provision of these services. The rate codes that the Plans will use to receive reimbursement from eMedNY will be provided in the near future and are subject to CMS and NYS DOB approval. http://www.omh.ny.gov/omhweb/bho/fee-schedule.xlsx 24

Resources (continued) Rate Table This will have to be built into the Plan’s payment system. It shows the rate amount for each MMIS provider ID and rate code combination. http://www.omh.ny.gov/omhweb/bho/rate-table.xlsx 25

Update • Managed Care Organizations will be designating a billing contact per Plan to support providers and address questions. • MCTAC will provide Revenue Cycle Management Workshops to address specific program/service needs. State and/or Plan representatives will present during workshops when appropriate. 26

Upcoming Learning Communities The four content areas for the RCM Series are: #1 Scheduling & Pre-registration and Point-of- service registration & collection #2 Charge capture & coding #3 Claim Submission and Payer follow-up #4 Remittance processing and Appeals, collections, and analysis 27

RCM Learning Community-NYC & Rest of the State May Monday Tuesday Wednesday Thursday Friday 4/27-5/1 5/4-5/8 #1 Webinar General Overview 5/11-5/15 (NYC providers) Office Hours #1 #2 Webinar General Overview (NYC providers) 5/18-5/22 Office Hours #2 #3 Webinar General Overview 5/25-5/29 MEMORIAL DAY (NYC providers) Office Hours #3 *All Webinars and Office Hours will be held from 12pm-1pm 28