# Presentation: 842331

## Protecting the CHS Budget – to pay or not to pay

- April 2006
- Toni Johnson
- I/T/U Partnership Conference

## Objective – Successful CHSPayment Management

**Tightening the purse strings – vendor education**
**Clean claims vs. Dirty**
**Prompt Payment Act**
**Audits - nurse auditor**
**CHS staff development**

## Your Important Role

**CHS payment police**
**Educator**
**Policy analyst**
**Educated on billing, coding and payment requirements for all third party payers**
**Data quality of CHS payment information**

## Vendor Education

- Billing requirements for payment
**Authorizations**
**Payor of Last Resort**
**Billing forms**
**ICD-9 Coding - diagnosis **
**CPT Coding - procedure**
** **
**Timely filing limits**

## Vendor Education – cont.

- Getting the word out
- CHS eligibility and authorization policies
- Letter to vendor announcing new billing requirements and payment policies
- Schedule on-site visit with vendor
- Schedule an informational seminar for all vendors

## Billing Forms

- HCFA -1500 – Health Insurance Claim Form
- Printed in red ink for optical scanning
- Services from physicians and suppliers (except ambulance services)
- Physicians’ professional outpatient claims

## Billing Forms – cont.

- HCFA-1450 (UB-92) Uniform Bill claim form
- Hospital inpatient billing and payment transactions
- Considered a summary statement compiling all charges and is accompanied by a detail statement
- The detailed statement lists dates of service, codes, descriptions, and fees for individual services

## Diagnosis Coding – ICD-9-CM

- International Classification of Diseases, Ninth
- Revision, Clinical Modification
- A system for classifying diseases and
- operations to facilitate collection of uniform and
- comparable health information
- Required for CHS payment processing

## ICD-9-CM – cont.

- Volumes 1 and 2 are used in physicians’ offices and other outpatient settings to complete insurance claims
- Volume 3 is a Tabular List and Alphabetic Index of Procedures used primarily in the hospital setting
- Always coded to the highest degree of specificity

## ICD-9-CM – cont.

- V codes are a supplementary classification of coding.
- V codes are used when a person who is not currently sick encounters health services for some specific purpose
- Donor of an organ or tissue
- To receive a vaccination
- To discuss a problem that is not in itself a disease or injury
- Family planning consultation

## ICD-9-CM – cont.

- E codes are also supplementary classification of coding
- The use of an E code after the primary or other acute secondary diagnosis explains the mechanism for the cause of injury or poisoning
- Looks at **external causes** of injury and poisonings rather than disease

## Procedure Coding

- Current Procedural Terminology (CPT)
- A reference procedural code book using a
- numerical system for procedures, established
- by the American Medical Association
- Required for CHS payment processing

## CPT – cont.

- CPT uses a basic five-digit system for coding services rendered by physicians, plus two-digit add-on modifiers to indicate complications or special circumstances
- Represents diagnostic and therapeutic services on medical billing statements and insurance claim forms

## CPT – cont.

- Healthcare Common Procedure Coding System (HCPCS)
- Pronounced “hick-picks
- Three levels of coding
- Level 1: the AMA CPT codes and modifiers (national codes)
- Level 2: CMS designated codes and alpha modifiers (national codes)
- Level 3: Codes specific to regional fiscal intermediary or individual insurance carrier (local codes) and not found in ether levels one or two

## Clean Claim Definition

- A clean claim means that the claim was
- submitted with the program or policy time limit
- and contains all necessary information so it can
- be processed and paid promptly.

## Dirty Claim Definition 

- A dirty claim is a claim
- submitted with errors
- or is missing required
- information.
- Denied or Delayed Payment

## Slide 17

## Timely Filing Limits

- Notice of claim within a certain number of days
- Limits are determined by payer
- Varies from payer to payer

## Prompt Payment Act

-  **Prompt Payment Final Rule (5 CFR Part 1315) **requires Executive departments and agencies to pay commercial obligations within certain time periods and to pay interest penalties when payments are late
- Applies to Indian Health Service CHS
- No mention of Tribal responsibility

## Slide 20

## Prompt Payment Act

- Example:
- California Payment Timeframes
- Non-HMOs: 30 working days
- HMO’s:   45 working days
- Penalties
- 15% annually; $10 additional non-inclusion of interest with payment

## Audit by Request 

- 	Audits and verifies the doctor’s health record documentation and orders against each charge item on the bill
- Vendor submits photocopies of health record for review
- Nurse auditor or a credentialed coder
- Onsite employee or hired consultant
- Nurse must have clinical and financial expertise

## Audits – cont.

- Quality Assurance
- Random audits – preliminary
- Inpatient
- Outpatient
- Comprehensive Audit
- Triggered by preliminary
- Office of Inspector General
- More in-depth
- Recovery

## Slide 24

## Staff Development

- Where to begin...
- ICD and CPT coding training
- Current code books available
- Medical and dental billing training
- Private insurance, Medicare and Medicaid seminars
- Self-training
- IHS sponsored training
- Medical terminology
- Medical dictionary

## Slide 26

## Questions

## Charlie