1, Revenue Cycle Denial Dashboard The denial management coordinator at Pine Vall
ID: 362465 • Letter: 1
Question
1, Revenue Cycle Denial Dashboard
The denial management coordinator at Pine Valley Community Hospital provides administration with the following dashboard information monthly. As the revenue cycle manager for the facility, you also receive a copy of this dashboard.
2, Chargemaster (CDM)
Billing has indicated that they are receiving rejections (OCE edit 28) on Medicare vaccination claims. As the new physician practice manager, you have decided to review the chargemaster for influenza, pneumonia, and hepatitis B vaccination charges to identify the issue, since these claims would be hard-coded. The practice sees only adult patients, with a significant portion of them having Medicare as their payer, so it is important to resolve the error quickly.
Review the relevant portion of the chargemaster below and revise as necessary.
3, Claim Reconciliation
Based on the scenario below:
1. Determine what the remittance advice remark code (RARC) N122 signifies.
2. Determine the steps needed to correct the claim.
Mrs. Jones had an arthroscopic shoulder procedure on 7/8/15. Her physician performed a subacromial decompression. The coder assigned CPT 29826 to the encounter. The bill dropped on 7/12/15. On 7/22/15, the patient accounting department was processing the latest remittance advice and remark code N122 was attributed to the CPT code for this claim.
4,OCE Audit
Review the scenario below,
Determine what your next steps should be to resolve the issue below and reduce the accounts receivable.
Two months ago, your organization initiated pain management services. In recent weeks, you have watched the accounts receivable for Medicare slowly climbing. You begin to audit the accounts that are outstanding, and realize the reason for the increase is pain management operative procedures, specifically sacroiliac joint injections. These were all billed with CPT code 27096 at approximately $410.00 per case with an average of 5 cases per day over the past two months. They all have an Outpatient Code Editor (OCE) edit of 28.
5, Fraud and abuse focus
Based on the scenario below:
Recommend to the coding supervisor a minimum of four best practices for determining focus areas for auditing and monitoring of coding compliance
New to your role as revenue cycle manager, you are nonetheless surprised to learn that there is no formal process in place for isolating potential areas of compliance concern. You recognize that this would generate a focused approach for internal or external auditing, leading to identification of coding compliance concerns and opportunities for coder education.
Explanation / Answer
1. Remittance Advice Remak Codes (RARCs) are used to provide additional explaination for an adjustment already described by a Claim Adjustment Reason Code(CARC) or to convey information about remittance processing. Each RARC identifies a specific messageas shown in the Remittance Advice Remark Code List. (RARC) N122 is a add-on code that cannot be billed by itself without a related or qualifying service being previously paid or present on then claim.
2. Following are the steps needed to coreect the claim:
(a) Correct and refile or resubmit a corrected claim, by either correcting a code or adding a code.
(b) Make an adjustment by adjusting off or declaring that the charge is not valid or transfer the charge to patient's responsibility.
(c) Send an appeal.
(d) Correct the insurance company and have the reprocess the claim.
Steps to resolve the given issue and reduce the account receivable are:
(a) Understand the rules of engagement: You can expect medical reimbursement within two days of claim receipts provided you file a clean claim.
(b) Engage provider relation representative: Establish relationship with each payer on your roster.
(c) Shorten review cycles: Complete a comprehensive AR review atleast bi-anually. More frequently if you see a high volume of accounts.
(d) Tighten your patient account policies: Strict correction policies for patient accounts are necessary for financial survival.
(e) Equip staff to manage collections with every patient encounter: Payers provide online tools to estimate coverage for specific servicesand verify deductible balances.
Four best practices for determining focus areas for auditing and monitoring of coding compliance are:
(a) Establish your coding compliance goal: Facilities should adopt a standardized method to measure coding quality performance.
(b) Determine the frequency of reviews: Frequency is determined by different variables. Volume of cases may require more frequent audits.
(c) Define the scope of your audit: Will your audit be prospective or retrospective In prospective audit, accounts are claimed before submission and in retrospective audit, accounts are claimed after submission.
(d) Prepare a summary of findings: A spreadsheet reflecting the comparison of the coders code selection and the auditors code selectionis preferable for documenting code over code reporting.
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