Hospital and Office Billing Paper.
Hospital and Office Billing Paper.
Hospital and office billing are similar but there are some differences. Write a 2 page paper describing how the processes differ, including the coding books and processes, and explanations and examples of the terms prospective payment system and diagnostic related group.
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Hospital Billing This course focuses mostly on outpatient or physician billing. This topic will provide a brief overview of the methods of reimbursement employed by hospitals, skilled nursing facilities (SNF), long term care facilities (LTC), and ambulatory surgical centers (ASC). These types of facilities utilize the Prospective Payment System (PPS) based on their services, locations, and other modifiers. The PPS system was developed by CMS to reduce overhead and apply fairness to the Medicare reimbursement system. The PPS is an estimate of the potential services and procedures incurred during hospitalization based on the diagnosis related group (DRG) that caused the patient to become an inpatient. CMS1450 Prospective Payment Systems Most private insurers, such as Blue Cross/Blue Shield, will negotiate contracts with hospitals regarding inpatient payment structures. Many insurances use the DRG system to reimburse the facility for services rendered. Other payment arrangements can include per diems, percentage of allowable charges, and negotiated rates for specific treatments. You must understand the difference between an inpatient and an outpatient in order to apply the correct PPS formula. An inpatient is generally one who is admitted, assigned a bed, and stays at least 24 hours. An outpatient is one that is treated but not admitted and generally is discharged within 24 hours of the initial encounter. For example, most emergency room services are considered outpatient because the patient is usually treated for the illness or injury and sent home. These outpatient services are categorized into the ambulatory payment classification system (APC). The DRG system classifies a patient’s status by the principal diagnosis to include average length of stay, supplies utilized, and associated costs. For example, a Medicare patient hospitalized for an acute asthma condition would receive a principal diagnosis associated with respiratory ailments. The average length of stay for this condition may typically be three days. All costs incurred during this stay are calculated by a nationwide formula on how many services are consumed during a stay of this nature. Medicare would then pay according to the average of this patient population having the same ailment and length of stay to the hospital entity. Should the patient’s hospital admission be significantly longer than the average length of stay, the hospital may receive additional payments to cover costs associated with these atypical patients. This is referred to as cost outliers. Currently, the ICD-9-CM Volume 3 is used to report hospital procedures performed by the facility. As of 1 October 2014, this manual will be replaced by the ICD-10-PCS (Procedural Classification System). Principal diagnoses previously reported from the ICD-9-CM Volumes 1 and 2 will be replaced by the ICD10-CM effective on the same date. The principal diagnosis (the reason for admission) is always used in hospital coding. The CMS-1500 form is used for outpatient, clinical, and physician billing. Hospitals use the UB-04 claim form, also known as the CMS-1450, to bill for professional services and procedures performed by the facility. This form was developed by the National Uniform Billing Committee (NUBC). The patient service representative is primarily responsible for the timely filing of inpatient and outpatient claims to the appropriate third party payers. Generally all hospital billing is performed electronically. An independent physician performing services within the hospital, such as an OB/GYN specialist delivering a baby, would use codes from the CPT manual and bill for the service with the CMS-1500 claim form. To insure proper and fair conduct by hospitals, CMS administers the Quality Improvement Organization (QIO) program. This agency is responsible for conducting reviews regarding admissions, re-admissions, procedures, outliers, DRG validations, and transfers. As with all covered entities, hospitals must conform with HIPAA standards concerning privacy and confidentiality of a patient’s protected health information (PHI). Once payments are received from the insurance contractor, the process is very similar to processing payments in an outpatient setting. The payment is credited to the patient’s account and the patient is sent a net bill detailing deductibles, co-insurance amounts, and non-covered expenses under the insurance contract. Hospital and Office Billing Paper.