Revenue Cycle & Compliance
15%of exam
Insurance Eligibility & Payers
20%of exam
Coding & Coding Guidelines
32%of exam
Billing & Reimbursement
33%of exam
Quick Facts
- Exam
- CBCS
- Credential
- Billing & Coding Specialist
- Questions
- 100 scored + 25 pretest
- Time
- 3 hours
- Pass
- Scaled 390 (200-500)
- Format
- Multiple choice
- Manuals
- Coding manuals allowed
- Body
- NHA
Revenue Cycle Order
Register, code, bill, then collect
Front: registerMiddle: code/billBack: collect
Fraud vs Abuse
Fraud
- Intentional
- Knowing deception
- Higher penalties
Abuse
- Unintentional
- Improper practice
- No intent
Intent vs mistake
Revenue Cycle Phases
- Pre-registration
- Collect demographics, insurance
- Registration
- Verify patient at visit
- Charge capture
- Record services rendered
- Coding
- Assign ICD-10-CM, CPT
- Claim submission
- Send claim to payer
- Adjudication
- Payer processes claim
- Remittance
- Payer posts payment
- A/R follow-up
- Work unpaid claims
- Patient collections
- Bill patient balance
HIPAA & PHI
- Privacy Rule
- Protects PHI use, disclosure
- Security Rule
- Safeguards electronic PHI (ePHI)
- Breach Notification
- Notify within 60 days
- PHI
- Health data + identifier
- TPO
- Treatment, payment, operations
- Minimum necessary
- Least PHI needed
- NPP
- Notice of privacy practices
- De-identification
- Remove 18 identifiers
Fraud, Abuse & Audits
- Fraud
- Intentional deception for gain
- Abuse
- Improper practice, no intent
- False Claims Act
- Penalizes false claims
- Stark Law
- Bans physician self-referral
- Anti-Kickback
- Bans pay for referrals
- Upcoding
- Higher code than performed
- Unbundling
- Splitting bundled codes
- OIG
- Inspector General oversight
- RAC
- Recovery Audit Contractor
Medicare Parts
A=hospital B=doctor C=advantage D=drugs
A: inpatient/SNFB: outpatientC: AdvantageD: drugs
HMO vs PPO
HMO
- PCP required
- Referrals needed
- Network only
PPO
- No PCP
- No referral
- Out-of-network allowed
Gatekeeper vs flexibility
Primary Payer Picker
- Patient's own plan→Bills primary
- Covered as dependent→Spouse plan secondary
- Child, both parents→Birthday rule
- Medicare + employer 20+→Employer primary(MSP rule)
- Medicare + retiree plan→Medicare primary
- Job-related injury→Workers' comp
- Auto accident→Auto insurance first
Commercial Plans
- HMO
- PCP gatekeeper, network only
- PPO
- Flexible network, no referral
- EPO
- Network only, no referral
- POS
- HMO/PPO hybrid
- Indemnity
- Fee-for-service, any provider
- Capitation
- Fixed payment per member
- Gatekeeper
- PCP controls referrals
Government Payers
- Medicare Part A
- Hospital, inpatient, SNF
- Medicare Part B
- Physician, outpatient services
- Medicare Part C
- Medicare Advantage plans
- Medicare Part D
- Prescription drug coverage
- Medicaid
- State low-income coverage
- Medigap
- Supplements Medicare gaps
- TRICARE
- Military member coverage
- CHAMPVA
- Veteran family coverage
- Workers' comp
- Job injury coverage
Eligibility & Cost Sharing
- 270/271
- Eligibility inquiry, response
- Prior authorization
- Pre-approval before service
- Referral
- PCP sends to specialist
- Deductible
- Patient pays first
- Copay
- Fixed visit fee
- Coinsurance
- Percentage patient share
- ABN
- Medicare non-coverage notice
- COB
- Which payer first
- Birthday rule
- Earlier birthday pays first
- MSP
- Medicare Secondary Payer
ICD-10-CM Structure
Letter first, 3 to 7 characters
Char 1: letterX: placeholder7th: encounter
ICD-10-CM vs PCS
ICD-10-CM
- Diagnoses
- 3-7 characters
- All settings
ICD-10-PCS
- Inpatient procedures
- 7 characters
- Hospital only
Why vs how
Modifier Picker
- Separate E/M, same day→-25(Distinct service)
- Distinct procedure, same day→-59(Unbundle edit)
- Bilateral procedure→-50
- Multiple procedures→-51
- Repeat, same provider→-76
- Repeat, different provider→-77
- Return to OR, related→-78(Post-op period)
- Unrelated post-op procedure→-79
- Repeat clinical lab→-91
- Telehealth synchronous visit→-95
ICD-10-CM Basics
- Structure
- 3-7 alphanumeric characters
- First character
- Always a letter
- Update cycle
- October 1 annually
- Placeholder X
- Fills empty positions
- 7th character
- Encounter or episode
- Laterality
- Right, left, bilateral
- Z-codes
- Factors, not disease
- Combination code
- One code, two conditions
- Code first
- Sequence underlying cause
Modifier -25 vs -59
-25
- E/M service
- Same-day separate
- With procedure
-59
- Distinct procedure
- Unbundle edit
- Different session
E/M vs procedure
CPT Categories & Codes
- Category I
- Standard 5-digit codes
- Category II
- Performance tracking codes
- Category III
- Emerging technology codes
- Sections
- E/M to Medicine
- Update cycle
- January 1 annually
- Add-on code
- Never billed alone
- Modifier -25
- Separate E/M same day
- Modifier -59
- Distinct procedural service
HCPCS Level II
- Structure
- Letter plus 4 digits
- J-codes
- Injectable drugs
- DME
- Durable medical equipment
- A-codes
- Supplies, transport
- Level I
- CPT codes
- Level II
- Non-physician products, services
- -RT/-LT
- Right, left side
- -GA
- ABN on file
Modifiers & E/M
- -50
- Bilateral procedure
- -51
- Multiple procedures
- -76
- Repeat, same provider
- -78
- Return to OR, related
- -79
- Unrelated post-op procedure
- -91
- Repeat clinical lab
- -95
- Synchronous telehealth
- MDM
- Medical decision making
- Time-based E/M
- Total date-of-service time
- 2021 E/M rules
- MDM or time
Claim Form Split
1500 professional; UB-04 facility
1500: physicianUB-04: hospital837P vs 837I
CMS-1500 vs UB-04
CMS-1500
- Professional
- Physician, supplier
- 837P
UB-04
- Institutional
- Hospital, facility
- 837I
Provider vs facility
Denial Action Picker
- Claim missing data→Correct, resubmit(Not an appeal)
- Front-end rejection→Fix, resend(Never adjudicated)
- Wrong denial→File appeal
- Duplicate denial→Verify original(Do not resubmit)
- No prior auth→Request retro-auth
- Timely filing passed→Submit proof(Or write off)
- Coding edit denial→Check NCCI
Claim Forms
- CMS-1500
- Professional paper claim
- UB-04
- Institutional facility claim
- Box 21
- Diagnosis codes (ICD-10)
- Box 24D
- Procedures, modifiers
- NPI
- 10-digit provider ID
- Form locators
- UB-04 field numbers
- POS code
- Where service performed
- Taxonomy code
- Provider specialty code
Rejection vs Denial
Rejection
- Never processed
- Front-end error
- Resubmit corrected
Denial
- Processed
- Payment refused
- Appeal or correct
Bounced vs refused
EDI Transactions
- 837
- Electronic claim
- 835
- Electronic remittance (ERA)
- 270
- Eligibility inquiry
- 271
- Eligibility response
- 276
- Claim status inquiry
- 277
- Claim status response
- 277CA
- Claim acknowledgment
- 999
- Functional acknowledgment
- 5010
- HIPAA X12 standard
CARC vs RARC
CARC
- Adjustment reason
- Why amount changed
- On remittance
RARC
- Remark code
- Extra explanation
- Supplements CARC
Reason vs remark
Claim Life Cycle
- Clean claim
- No errors, processable
- Dirty claim
- Errors, needs rework
- Rejection
- Front-end, never processed
- Denial
- Processed, then refused
- Adjudication
- Payer decision process
- EOB
- Patient payment explanation
- ERA
- Electronic remittance advice
- Allowed amount
- Payer's contracted rate
- Write-off
- Adjusted, not billed
Denials, Appeals & A/R
- CARC
- Claim adjustment reason code
- RARC
- Remittance advice remark
- Timely filing
- Deadline to submit
- NCCI PTP
- Bundled code edits
- MUE
- Max units per line
- LCD/NCD
- Coverage determinations
- Appeal
- Dispute a denial
- Medicare appeal levels
- Five appeal steps
- 60-day rule
- Refund overpayment promptly
- Aging report
- Unpaid claims by days
Common Traps
Rejection vs denial
Rejection never processed ≠ Denial was adjudicated
Upcoding vs unbundling
Upcoding: higher level ≠ Unbundling: split codes
837 vs 835
837 sends claim ≠ 835 returns payment
ABN scope
ABN is Medicare only ≠ Not commercial payers
Medigap vs Advantage
Medigap supplements Medicare ≠ Advantage replaces Medicare
Modifier -25 vs -57
-25: minor procedure E/M ≠ -57: decision for surgery
Last Minute
- 1.Weights: 15, 20, 32, 33
- 2.100 scored + 25 pretest
- 3.Pass = scaled score 390
- 4.ICD-10-CM updates October 1
- 5.CPT updates January 1
- 6.Fraud = intent; abuse = none
- 7.Rejection resubmit; denial appeal
- 8.CMS-1500 professional; UB-04 facility
- 9.837 out; 835 back
- 10.Birthday rule for children
- 11.ABN is Medicare only
- 12.Modifier -25 with E/M
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