Claims and Billing Specialist Roles
Overview of Claims Review and Billing Specialist Roles
The claims review process is a critical stage in the revenue cycle that occurs after the patient encounter, the completion of documentation, and the capture of charges.
Billing and coding specialists are responsible for reviewing claims once they have been created to ensure accuracy and compliance.
The primary purpose of this review prior to submission is to identify and correct claim errors and edits.
Correcting errors before billing third-party payers is significantly easier than addressing denials later and results in both faster and more accurate reimbursement.
An effective method for reviewing claims is to process them in batches according to payer types. This method accounts for specific payer variables that can affect processing speed.
Payer Variable Example: Workers’ Compensation claims must include a date of injury. However, if a date of injury is included on a commercial insurance claim, it will cause a delay in processing.
Essential Elements of Claim Verification
Claims review involves verifying several specific details to ensure a clean claim is submitted:
Patient Demographics: Ensuring all personal information for the patient is accurate.
Third-Party Payer Information: Verifying the correct insurance provider is attached to the claim.
Billing Particulars: Adhering to specific requirements for different payers, such as the aforementioned date of injury for Workers' Compensation.
Date of Service: This serves as the focal point of the claim. It is used to:
Determine if the patient had active insurance coverage at the time of the encounter.
Determine global periods for specific procedures.
Fee Schedules: Specialists must be mindful of payment policies for different payers and ensure the fee schedule matches the payer or payer type.
Definition: Fee schedules are lists of allowed or billed amounts for each service within the billing software, organized by payer (e.g., Medicare, commercial payers, or Workers’ Compensation).
Provider Information:
Verify the appropriate place of service code is used.
Ensure the correct rendering provider is listed.
Verify the inclusion of the provider's National Provider Identifier (NPI).
Claim Charges: Reviewing billed amounts is necessary because certain modifiers can increase or decrease the financial value of a code.
Code Duplication: Checking for duplicate codes or services on a single encounter form.
Abstraction Errors: These occur when a patient is referred for a service or an order is placed during an encounter.
Definition: An abstraction error happens when codes for the referred or ordered services are incorrectly included as part of the codes for the current encounter.
Telehealth Specifics: For telehealth visits, specialists must verify the specific place of service code and ensure the appropriate modifiers are appended.
Preauthorization and Attachments:
Certain services require preauthorization. The reference number must be included on the claim; some payers will deny reimbursement without it, even if authorization was properly obtained.
Payer-specific requirements may mandate attachments for certain codes, such as assessment reports, progress evaluations, or procedure notes.
Service Code Verification and Sequencing
When verifying service codes on claims, specialized focus is placed on the following:
Detail and Accuracy: Ensuring code assignment reflects clinical concepts such as acuity, manifestations, and the specific nature of the encounter.
Contradiction Identification: Identifying codes that create potential contradictions, such as labeling a condition as both acquired and congenital simultaneously.
Correct Sequencing:
ICD-10-CM: Following etiology/manifestation sequencing rules.
CPT Manual: Ensuring correct use of add-on codes.
Units Control: Verifying the correct number of units billed for a service.
Payer-Specific Guidelines: Choosing between HCPCS codes and CPT codes based on what the specific payer requires.
Modifier Application: Ensuring the correct application of modifiers, such as and .
Medical Necessity: Confirmed by correctly linking diagnosis codes with service, supply, and procedure codes.
Value-Based Sequencing: When a claim contains multiple CPT codes on the same date of service, they are sequenced in order from the highest value to the lowest value to ensure optimal reimbursement. This is often automated by billing applications.
Claims Editing and National Initiatives
Claims Editing Definition: A step in the claims process where appropriate codes and rules are verified before the claim is submitted for payment.
Tools and Resources: Practice management and billing systems often have built-in software programs to identify conflicting entries, inconsistencies, or edits before submission.
National Correct Coding Initiative (NCCI):
This initiative provides a code editing system designed to prevent the inappropriate reporting of CPT codes.
Bundling: The NCCI edits identify codes that are considered "bundled" into another service.
Medically Unlikely Edits (MUE): A sub-feature of NCCI used to prevent overpayments for codes with unit values that are considered unlikely for a single patient on a single day.
Mutually Exclusive Edits: These identify code combinations restricted by CPT guidelines or procedures that could not reasonably be performed during the same encounter.
Medicare Coverage Guidelines and Scrubbing
National Coverage Determination (NCD): Describes Medicare coverage policies for specific services, procedures, or devices on a national level.
Local Coverage Determination (LCD): Describes coverage decisions made by a Medicare Administrative Contractor (MAC) regarding a particular service.
Clinical Guidance: LCD and NCD articles explain coverage circumstances, indications, limitations, and specific coding guidance for services.
Scrubbing Applications:
These are often add-on services used to further edit and clean claims.
Small or provider-owned organizations may not have access to these and must rely solely on the manual review of billing and coding specialists.
Clearinghouses: Once claims are reviewed and edited, they are typically sent to a clearinghouse for a final validation as part of the submission process.
Questions & Discussion
Challenge 1: Match information with the correct SOAP format in a patient’s chart.
1. S (Subjective): B. Patient reports of SOB, cough, and extreme fatigue.
2. O (Objective): A. Temp: , HR: , RR: .
3. A (Assessment): D. Productive cough, rattling. Suspected COVID-19 infection.
4. P (Plan): C. COVID screen conducted and tolerated well. Patient advised to quarantine, rest, and intake plenty of fluids until results are received. Benzonatate prescribed.
Key: 1, B; 2, A; 3, D; 4, C.
Challenge 2: Match the coding convention with the correct definition of use.
1. Meaning "other specified": C. NEC (Not Elsewhere Classifiable).
2. Meaning "unspecified": D. NOS (Not Otherwise Specified).
3. Placeholder: A. X.
4. Eponym: B. Lou Gehrig’s disease.
Key: 1, C; 2, D; 3, A; 4, B.
Challenge 3: CPT codes are used to describe which of the following types of information?
Options:
A. The reason why the patient is being treated.
B. The medical services that have been provided to the patient.
C. The dates of when the services were provided.
D. The type of provider and the location.
Correct Answer: B. CPT codes are 5-digit codes used to indicate what medical services were provided to the patient during an encounter.