C811
HIP TASK ONE
Financial Resource Management – C811
Western Governors University
A. There are six steps in the revenue cycle: provider services, document services,
establish charges, prepare claim/bill, submit the claim, and receive payment. The first step is
providing services; this is when the services for the patient are provided. The medical record is
formed as information is being collected from different departments and areas throughout the
facility.
The second step is document services. In document services, all information that has been
collected throughout the facility becomes vital. In 1996, HIPAA proposed the requirement of two
coding methods to be used for all payors. These coding methods are referred to as ICD-10-CM
and CPT/HCPCS codes. ICD-10-CM is diagnosis coding, where CPT/HCPCS is procedure
coding. Both are required for the professional and facility side. This varies based on whether it is
an inpatient or outpatient event or whether diagnosis or procedure affects the final
reimbursement.
The third step is establishing charges. In establishing charges, the chargemaster
(CDM) comes into play. For every service, there is a unique cost. The CDM takes critical
information required for the claim and the patient medical record and determines charges
that will be placed on the claim. Vital data needed in the CDM includes a number unique
to a specific amount, revenue cost, dollar value for the service, designated department
number, and HCPCS/CPT code, if applicable (Casto & Forrestal, 2015).
The fourth step is preparing the claim or bill. This step is where all charges found during
a patient's encounter generate a claim. There are usually two types of claims, CMS-1500 and
CMS-1450 (UB04). CMS-1500 is the typical use for physician practices and suppliers. CMS-
, 1450 is used for various institution types. Previously claims traveled to the insurance carriers
manually, but since October 2003, HIPAA now requires them to be sent electronically.
Although there is an exception to this, and it is for institutions with less than 25
employees/physician offices with less than ten employees.
The fifth step is submitting the claim. Here the prepared claim is ready to be submitted to
the payor for reimbursement. Before it moves, a scrubber/form of software that can capture
discrepancies/various edits are needed. CMS sets edits from two different sources, National
Correct Coding Initiative (NCCI) and Outpatient Code Edits (OCE). After the claim is scrubbed,
if it hits no OCE/NCCI edit, it is ready to be sent for reimbursement. An example of when an
account can stop during this set for various edits is a particular drug administration, but no
charge has been associated. Once the correction is made, the claim can be re-submitted, back
through the scrubber, and off to the payor (Oachs & Watters, 2020).
The sixth and final step is to get payment. This is when the organization receives
compensation for the services rendered. Although the amount will not be what the bill initially
stated, several factors play into how much an organization will be reimbursed. All insurance
carriers have a unique contract set up for what they will reimburse for services.
A1. How the coding/billing cycle processes impact healthcare organization revenue
cycles are outlined below:
First, the provider step, and although HIM does not provide any medical treatment to the
patient, the information produced by different departments is overseen/housed by HIM. Say a
patient goes to a facility for a chest x-ray. The HIM position does not perform the procedure.
Still, they are responsible for preserving the x-ray report for the patient and responsible for the
appropriate and available documentation.
HIP TASK ONE
Financial Resource Management – C811
Western Governors University
A. There are six steps in the revenue cycle: provider services, document services,
establish charges, prepare claim/bill, submit the claim, and receive payment. The first step is
providing services; this is when the services for the patient are provided. The medical record is
formed as information is being collected from different departments and areas throughout the
facility.
The second step is document services. In document services, all information that has been
collected throughout the facility becomes vital. In 1996, HIPAA proposed the requirement of two
coding methods to be used for all payors. These coding methods are referred to as ICD-10-CM
and CPT/HCPCS codes. ICD-10-CM is diagnosis coding, where CPT/HCPCS is procedure
coding. Both are required for the professional and facility side. This varies based on whether it is
an inpatient or outpatient event or whether diagnosis or procedure affects the final
reimbursement.
The third step is establishing charges. In establishing charges, the chargemaster
(CDM) comes into play. For every service, there is a unique cost. The CDM takes critical
information required for the claim and the patient medical record and determines charges
that will be placed on the claim. Vital data needed in the CDM includes a number unique
to a specific amount, revenue cost, dollar value for the service, designated department
number, and HCPCS/CPT code, if applicable (Casto & Forrestal, 2015).
The fourth step is preparing the claim or bill. This step is where all charges found during
a patient's encounter generate a claim. There are usually two types of claims, CMS-1500 and
CMS-1450 (UB04). CMS-1500 is the typical use for physician practices and suppliers. CMS-
, 1450 is used for various institution types. Previously claims traveled to the insurance carriers
manually, but since October 2003, HIPAA now requires them to be sent electronically.
Although there is an exception to this, and it is for institutions with less than 25
employees/physician offices with less than ten employees.
The fifth step is submitting the claim. Here the prepared claim is ready to be submitted to
the payor for reimbursement. Before it moves, a scrubber/form of software that can capture
discrepancies/various edits are needed. CMS sets edits from two different sources, National
Correct Coding Initiative (NCCI) and Outpatient Code Edits (OCE). After the claim is scrubbed,
if it hits no OCE/NCCI edit, it is ready to be sent for reimbursement. An example of when an
account can stop during this set for various edits is a particular drug administration, but no
charge has been associated. Once the correction is made, the claim can be re-submitted, back
through the scrubber, and off to the payor (Oachs & Watters, 2020).
The sixth and final step is to get payment. This is when the organization receives
compensation for the services rendered. Although the amount will not be what the bill initially
stated, several factors play into how much an organization will be reimbursed. All insurance
carriers have a unique contract set up for what they will reimburse for services.
A1. How the coding/billing cycle processes impact healthcare organization revenue
cycles are outlined below:
First, the provider step, and although HIM does not provide any medical treatment to the
patient, the information produced by different departments is overseen/housed by HIM. Say a
patient goes to a facility for a chest x-ray. The HIM position does not perform the procedure.
Still, they are responsible for preserving the x-ray report for the patient and responsible for the
appropriate and available documentation.
