Revenue Cycle Management and HIPAA Overview

Chargemaster Information

• Chargemaster Overview
  • A chargemaster is an electronic database
  • Contains a master list of all services, supplies, devices, and medications charged for inpatient or outpatient services.
• Charge Codes and Prices
  • 2721159: CATHETER, DRAINAGE
  • Charge Code: 0272
  • Price: $79.00
  • 2786337: CATHETER, HEMODIALYSIS LONG TERM
  • Charge Code: C1750
  • Price: $438.00
  • 3008423: DRUG TEST PRESUMPTIVE, ANY NUMBER
  • CPT Code: 80305
  • Price: $41.00
  • 3007215: CBC COMPLETE, WITH DIFFERENTIAL
  • CPT Code: 85025
  • Price: $123.00
  • 3207721: VENOGRAM EXTREMITY BILATERAL
  • CPT Code: 75822
  • Price: $1,320.00
  • 3406973: PARATHYROID SCAN
  • CPT Code: 78070
  • Price: $798.00
  • 3600223: O.R. MINOR SERVICE, 1ST 30 MIN
  • CPT Code: 0360
  • Price: $816.00
  • 3600224: O.R. MINOR SERVICE, EACH ADDL 15 MIN
  • CPT Code: 0360
  • Price: $276.00
  • 3618306: DRAINAGE OF HEMATOMA/SEROMA
  • CPT Code: 10140
  • Price: $1,517.00
  • 3612905: INJECTION OF SACROILIAC JOINT
  • CPT Code: G0259
  • Price: $786.00
  • 4245986: PT EVAL, HIGH COMPLEX 45 MIN
  • CPT Code: 97163
  • Revenue Code: GP
  • Price: $196.00
  • 4302398: OT RE-EVAL EST PLAN CARE
  • CPT Code: 97168
  • Price: $134.00
  • 4802563: ECHO TRANSTHORACIC, CONGENITAL WITH CONTRAST
  • CPT Code: 93303
  • Price: $1,232.00

Revenue Cycle Process

Front-end Process

• Patient access including:
  • Scheduling
  • Preauthorization
  • Insurance verification
  • Point-of-service collection
  • Financial counseling

Middle Process

• Activities involved:
  • Charge capture
  • Chargemaster management
  • Case management
  • Clinical documentation
  • Coding

Back-end Process

• Includes:
  • Claims processing
  • Payment posting
  • Follow-up collections
  • Denial management

Medical Necessity

• Defined as:
  • "Healthcare services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms - and that meet accepted standards of medicine" (Medicare.org, 2020).
• Importance:
  • A physician's order for a diagnostic exam must include a diagnosis that supports its necessity.
• Precertification process:
  • Ensures exams are covered by insurance and meet medical necessity criteria.
• Registration personnel can verify diagnosis-related medical necessity; if uncertain, a coder can assist.
• Immediate Action Required:
  • Contact the provider if the order lacks an adequate diagnosis.

HIPAA Overview

Privacy Rule

• Enacted in 1996 to protect health information.
• Eight Parts:
  1. Uses and disclosures of PHI
  • Identifies how PHI can be used and required authorizations.
  • Includes a minimum necessary standard for information release.
  1. Business Associate Agreements
  • Required when a business associate performs work for a covered entity.
  1. Notice of Privacy Practices (NPP)
  • Informs patients of how their PHI may be used or shared.
  1. Right to Request Privacy Protection
  • Allows patients to limit the use and disclosure of their PHI.
  1. Right of Access to Health Records
  • Patients can inspect and obtain copies of their PHI.
  1. Amendment of PHI
  • Patients can request amendments to their PHI.
  1. Accounting of Disclosures
  • Patients can receive an accounting of PHI disclosures.
  1. Administrative Requirements
  • Necessitates privacy officers, workforce training, privacy safeguards, and complaint procedures.

Security Rule

• Establishes operational standards for PHI protection.
• Four Parts:
  1. Administrative Safeguards
  • Policies to prevent and manage security violations.
  1. Physical Safeguards
  • Identification badges, limited access areas.
  1. Technical Safeguards
  • User IDs, passwords, automatic log-offs.
  1. Organizational Safeguards
  • Include business associate agreements.

Cybersecurity

• Defined as:
  • "The state of being protected against the criminal or unauthorized use of electronic data, or the measures taken to achieve this" (Cybersecurity, 2016).
• Breaches of PHI:
  • Most commonly from hacking, also due to theft, improper disposal, unauthorized access/disclosure, or loss.

Interoperability and Health Information Exchange

• Interoperability:
  • Ability for disparate information systems to share information.
• Health Information Exchange:
  • Defined as: "Allows healthcare professionals and patients to securely share a patient's medical information electronically" (Office of the National Coordinator for Health Information Technology, 2018).
• Benefits include:
  • Reduced duplicate tests
  • Improved patient management
  • Avoidance of readmissions
  • Reduction in medication errors

Health Information Systems (HIS), Radiology Information Systems (RIS), Picture Archiving and Communication Systems (PACS), and Artificial Intelligence (AI)

Health Information Systems (HIS)

• Designed to manage healthcare data and facilitate sharing of PHI across the healthcare enterprise.

Radiology Information System (RIS)

• Responsible for management of imaging orders, scheduling, billing, patient management, and reporting.

Picture Archiving and Communication System (PACS)

• A networked group of computers, servers, and archives that manage digital images, mainly cloud-based for storage needs.

Artificial Intelligence (AI)

• Science of engineering intelligent machines and computer programs.
• Key impacts:
  • Precision
  • Error reduction
  • Automation and augmentation
  • Holistic patient view
• Machine Learning (ML):
  • A method of data science allowing computers to learn independently, involving training, testing, and validation phases.
• AI applications in radiology include:
  • Radiology order scheduling
  • Patient safety screenings
  • Accurate patient positioning
  • Image reconstruction and automated protocols
  • Identifying incidental cases of pulmonary embolism (PE) and classifying kidney cancer.