Revenue Cycle
20%of exam
Patient AccessCharge CapturePostingCollectionsA/R Workflow
Payer Billing Rules
20%of exam
MedicareMedicaidCommercialTRICAREWorkers Comp
Claim Submission
20%of exam
CMS-1500UB-04837PPOS CodesClearinghouse
Denials and Appeals
15%of exam
CARCRARCGroup CodesAppeal LevelsCorrected Claims
Compliance
25%of exam
HIPAAFCAStarkAKSABNModifiers
Quick Facts
- Exam
- CPB
- Credential
- Certified Professional Biller
- Owner
- AAPC
- Questions
- 100 MCQ
- Time
- 4 hours
- Pass
- 70%
- Cost
- $300 member / $400
- Format
- Remote or center
- CEUs
- 36 per two years
RCM Flow
Register, verify, code, submit, post.
AccessEligibilityChargeClaimPayment
Revenue Cycle Stages
- Registration
- Demographics captured
- Eligibility
- Verify coverage
- Authorization
- Prior approval
- Charge capture
- Services billed
- Coding
- Codes assigned
- Submission
- Claim sent
- Adjudication
- Payer review
- Posting
- Payment applied
- Follow-up
- A/R worked
- Collections
- Patient balance
Cost Sharing
- Premium
- Monthly plan cost
- Deductible
- Annual out-of-pocket first
- Copay
- Fixed visit amount
- Coinsurance
- Percent after deductible
- OOP max
- Annual stop-loss
- Allowed amount
- Contracted reimbursement
- Balance bill
- Above allowed amount
- Write-off
- Contractual adjustment
COB Order
Employer, Medicare, birthday, decree.
Active employer firstBirthday rule kidsDecree overrides
Medicare A vs B
Part A
- Inpatient hospital
- SNF and hospice
- Premium-free usually
Part B
- Outpatient services
- Physician visits
- Monthly premium
Facility vs outpatient
Coordination of Benefits
- Patient has employer plan→Employer primary(Other secondary)
- Active employee plus Medicare→Employer primary(20+ employees)
- Retiree plus Medicare→Medicare primary(Retiree secondary)
- Children, both parents covered→Birthday rule(Earlier birthday)
- Custody decree exists→Decree wins(Overrides birthday)
- Workers comp injury→WC primary(Always first)
- Auto accident→Auto/MedPay first(Liability rules)
- TRICARE plus other→Other primary(TRICARE last)
Payer Types
- Medicare A
- Inpatient hospital
- Medicare B
- Outpatient physician
- Medicare C
- Advantage plans
- Medicare D
- Prescription drugs
- Medicaid
- State low-income
- Commercial
- Private insurance
- TRICARE
- Military families
- CHAMPVA
- VA dependents
- Workers comp
- Job injury
- Liability
- Auto/third party
HMO vs PPO
HMO
- PCP referrals
- In-network only
- Lower premium
PPO
- No referral
- Out-of-network allowed
- Higher premium
Gatekeeper vs flexible
PAR vs Non-PAR
PAR
- Accept assignment
- Allowed amount payment
- No balance bill
Non-PAR
- May not accept
- Limiting charge applies
- 115% non-par fee
Contracted vs not
HIPAA Transactions
837 send, 835 paid, 270 ask.
837: claim835: remit270/271: eligibility276/277: status
CMS-1500 vs UB-04
CMS-1500
- Professional services
- Physician/supplier
- 837P electronic
UB-04
- Institutional services
- Hospital/SNF/HHA
- 837I electronic
Provider vs facility
Form Picker
- Physician office service→CMS-1500(837P electronic)
- Hospital inpatient stay→UB-04(837I electronic)
- Hospital outpatient→UB-04(Facility claim)
- Ambulatory surgery center→CMS-1500(Professional claim)
- Home health agency→UB-04(Institutional)
- Independent lab→CMS-1500(Professional)
- DME supplier→CMS-1500(To DME MAC)
- Anesthesia service→CMS-1500(Professional)
Claim Forms
- CMS-1500
- Professional paper claim
- UB-04
- Institutional paper claim
- 837P
- Professional electronic
- 837I
- Institutional electronic
- Box 21
- Diagnosis codes
- Box 24
- Service lines
- Box 27
- Accept assignment
- Box 33
- Billing provider
- Revenue code
- UB-04 department
HIPAA Transactions
- 837P
- Professional claim
- 837I
- Institutional claim
- 835
- Electronic remittance
- 270/271
- Eligibility inquiry/response
- 276/277
- Claim status
- 278
- Authorization request
- 820
- Premium payment
- 834
- Enrollment
Place of Service
- 11
- Office
- 12
- Home
- 21
- Inpatient hospital
- 22
- Outpatient hospital
- 23
- Emergency department
- 24
- Ambulatory surgical center
- 31
- Skilled nursing
- 81
- Independent lab
Denial Group Codes
CO contract, PR patient, OA other.
CO: write-offPR: bill patientOA: adjustmentPI: payer
ERA vs EOB
ERA
- Electronic 835
- Provider remittance
- Auto-posts payments
EOB
- Paper explanation
- Patient or provider
- Human readable
Electronic vs paper
Denial Workflow
- Read ERA/EOB→Identify CARC(Group code first)
- Missing information→Correct and resubmit(CO-16)
- Modifier error→Add correct modifier(CO-4)
- Medical necessity→Send records(Appeal with notes)
- Timely filing→Provide proof(CO-29)
- Patient responsibility→Bill patient(PR group)
- Bundling edit→Verify NCCI(Modifier if distinct)
Common Denial Codes
- CO
- Contractual obligation
- PR
- Patient responsibility
- OA
- Other adjustment
- PI
- Payer initiated
- CO-4
- Modifier missing/invalid
- CO-16
- Missing information
- CO-29
- Timely filing expired
- CO-50
- Not medically necessary
- CO-97
- Service bundled
- PR-1
- Deductible amount
Medicare Appeals
MAC, QIC, ALJ, Council, Court.
1: Redetermination2: Reconsideration3: ALJ4: Council5: Court
Denial vs Rejection
Denial
- Claim adjudicated
- Decision rendered
- Appeal possible
Rejection
- Front-end failed
- Never processed
- Correct and resubmit
Processed vs unprocessed
Medicare Appeal Levels
- Level 1
- Redetermination by MAC
- Level 2
- Reconsideration by QIC
- Level 3
- ALJ hearing
- Level 4
- Appeals Council review
- Level 5
- Federal district court
- Corrected claim
- Rebill with fixes
- Reopening
- Minor error correction
ABN vs NEMB
ABN
- Medicare may deny
- Patient signs first
- Form CMS-R-131
NEMB
- Service never covered
- Voluntary notice
- Statutorily excluded
Maybe denied vs never
HIPAA Rules
- Privacy Rule
- PHI use/disclosure
- Security Rule
- ePHI safeguards
- Breach Rule
- Notification required
- Covered entity
- Provider/plan/clearinghouse
- Business associate
- Vendor with PHI
- TPO
- Treatment payment operations
- Minimum necessary
- Least PHI shared
- NPP
- Privacy practices notice
HIPAA Violation Tiers
- Tier 1
- Did not know
- Tier 2
- Reasonable cause
- Tier 3
- Willful neglect, corrected
- Tier 4
- Willful neglect, uncorrected
- Civil
- OCR enforcement
- Criminal
- DOJ prosecution
Fraud and Abuse Laws
- FCA
- False claims liability
- AKS
- Kickback for referrals
- Stark
- Physician self-referral
- CMPL
- Civil monetary penalties
- Exclusion
- OIG bars participation
- Qui tam
- Whistleblower suit
- Upcoding
- Higher level than documented
- Unbundling
- Separating bundled service
Biller Modifiers
- -25
- Separate same-day E/M
- -26
- Professional component
- -TC
- Technical component
- -50
- Bilateral procedure
- -59
- Distinct service
- -91
- Repeat clinical lab
- GA
- ABN on file
- GY
- Statutorily excluded
- GZ
- Expected denial, no ABN
Common Traps
Denial vs Rejection
Denial processed, appeal ≠ Rejection front-end, resubmit
CMS-1500 vs UB-04
Professional services use 1500 ≠ Facility services use UB-04
ABN vs NEMB
ABN: Medicare may deny ≠ NEMB: never covered statutorily
Upcoding Shortcut
Documented level codes ≠ Higher level than documented
Bundling Override
Modifier with documentation ≠ Modifier just to unbundle
Patient Balance
PR codes bill patient ≠ CO codes write off
Birthday Rule
Earlier birthday primary ≠ Older parent primary
Last Minute
- 1.CMS-1500 = professional; UB-04 = facility
- 2.837P send; 835 receive; 270 eligibility
- 3.CO = write-off; PR = bill patient
- 4.Medicare A = inpatient; B = outpatient
- 5.ABN before Medicare possible denial
- 6.Modifier -25 needs separate E/M
- 7.Stark = self-referral; AKS = kickback
- 8.Verify eligibility before every visit
- 9.Appeal ladder: MAC, QIC, ALJ
- 10.HMO needs referral; PPO does not
- 11.Workers comp always primary payer
- 12.Birthday rule for dependent children
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