About the Author

Acknowledgments

Introduction

Chapter 1

Revenue Cycle Basics

Overview of the Revenue Cycle

Patient Intake

Clinical Services

Charge Capture

Billing

Collections

The Him Perspective

Considerations within the Him Department

Partnering with Other Departments

Performance Improvement Issues

Establishing Benchmarks

Analysis and Measurement

Quality Assurance

Special Considerations for Practice Settings

Inpatient

Outpatient

Physician Practices

Summary

References

Appendix 1.1

AHIMA Characteristics of Data Quality

Chapter 2

Cost Analysis and Payer Contracts

Cash Flow Issues

Payroll Obligations

The Cost to Provide Service

Reimbursement

Impact of Icd-10

Fraud and Abuse

Patient Safety and Quality Outcomes

Vendor Contracts

Financing

-

Credit

Other Financial Obligations

Determining Coses

Cost Classification

Traceability

Variability

Controllability

Cost Allocation

Activity-Based Costing

HIM Role in Cost Accounting

The Charge Description Master

Medicare Cost Report

Determining Charges

Relative Value Unit

Hourly Rate

Surcharge

Cost-To-Charge Ratio

Contract Negotiation

HIM’s Role in Data Management

Data Quality

Providing Data

Special Considerations for Practice Settings

Inpatient

Outpatient

Physician Practices

Summary

References

Appendix 2.1

HIM Compliance Specialist Sample Position Description

Appendix 2.2

Coding Compliance Program Monitoring Checklist

Appendix 2.3

Hospital and Hospital Health Care Complex Cost Report—Form CMS-2552-96

Chapter 3

Patient Access

Patient Identification

Pre-Existing Identification Numbers

Duplicate Medical Record Numbers

MPI Cleanups

Duplicate Account Numbers

Verification of Demographics

Importance of Verification with Each Visit

Data Integrity

Financial Information

Orders

Completeness

Accuracy

Documentation

Arrangements for Payment

Documentation of Insurance

Verification of Insurance

Prior Approvals

Advance Beneficiary Notices

Financial Needs Assessment

Self-Pay

Government Payers

Other Data Collection Issues

Compliance

Training

Confidentiality

Special Considerations for Practice Settings

Inpacient

Outpatient

Physician Practices

Summary

References

Appendix 3.1

NAHAM’s CHAM and CHAA Exam Content Outlines

Chapter 4

Documentation and Charge Capture

Accounts

Types of Accounts

Impact on Data Collection

Complete Documentation

Impact of Hybrid Records

Clinical Documentation Improvement

Analysis

Education

Tracking

Charges

Chargemaster Maintenance

Bundling Issues

Timeliness

Accuracy

Internal Controls

Preventive Controls

Detective Controls

Corrective Controls

Reconciling Orders

Open Orders

Cancelled Orders

Results

Special Considerations for Practice Settings

Inpatient

Outpatient

Physician Practices

Summary

References

Chapter 5

Record Completion and Coding

Post Discharge Processing

Timely Record Availability

Backlogs

Incomplete Records—Interacting with Physicians

Physician Completion

Physician Query Procedures

Creating a Clean Claim

Charge Review

Modifiers

Data Validation

Patient Status and Disposition Changes

Monitoring Coding Accuracy

Present on Admission

CMI in MS-DRGS

Impact of Internal Guidelines

Establishing Standards

Orientation Process

Regulatory Requirements

Coding Quality and Training

Quality Monitoring—Internal and External Audits (Rac Audits)

Special Considerations for Practice Settings

Inpatient

Outpatient

Physician Practices

Summary

References

Additional Resources

Appendix 5.1

Facility-Based Coding Guidelines

Chapter 6

Claims Management

Clean Claims

Electronic Billing

Payment Cycle

Re-Billing

Contract Management

Payer Identification

Expected Reimbursement

Use of Edits

Facility-Specific Edits

NCCI Edits and Medical Unlikely Edits

Working Failed Edits

Denial Management

Root Causes of Bill Holds and Denials

Performance Improvement Activity

Audits and Denials (Rac Audits)

Appealing Denials

Tracking and Trending Denials

Collections Management

Receipts

Reconciliation

Self-Pay Issues

Bad Debt

Special Considerations for Practice Settings

Inpatient

Outpatient

Physician Practices

Summary

References

Appendix A

How Charges Become Revenue

Sources of Financial Data

Transactions

Clinical Services

Financial Statements

Income Statement

Retained Earnings

Balance Sheet

Accounts Receivable

Impact of Accounts Receivable on Cash Flow

Appendix B

Glossary

Index