Practice Management Alert

A few questions can go a long way in helping you determine a biller's competence and experience

 Your practice's financial success depends on skilled and dependable new hires to help your billing office run smoothly - and asking the right questions up front can save you a lot of time and money down the line.
 
 Integrate this billing knowledge assessment into your interview process to help illuminate excellent candidates and better understand the strengths of your potential new employees.

Billing Specialist Knowledge Assessment Questions

Please answer all of the following questions to the best of your ability. Your answers will assist us in determining where we can best use your skills in our practice.

1. Explain the difference between a CPT code and an ICD-9-CM code.

2. A CPT code has ____ digits, and an ICD-9-CM code has ____ digits.

3. What are evaluation and management (E/M) codes?

4. List all the outpatient consultation codes.

5. Which two types of hospital E/M codes can you not bill for the same physician on the same day?

6. What is the difference between a consultation and a transfer of care?

7. How do payers define the "global package"?

8. What is "unbundling"?

9. How is the posting of a commercial insurance payment different from the posting of a PPO payment?

10. What is a "withhold"? Explain exactly how to post it in the computer system.

11. What is the difference between pre-certification and pre-authorization?

12. What is the difference between Regular Medicare and a Senior HMO in terms of reimbursement?

13. What does it mean to post payments by line item? Why is it so important to do so?

14. You should follow up on an unpaid Medicare claim at ____ days if the practice is participating and files electronically.

15. You should follow up on an unpaid non-Medicare claim at ____ days.

16. How would you handle the following EOB rejections or "$0.00 pays"?
 a) "Procedure not a covered benefit"
 b) "Patient not eligible on date of service"
 c) "Contract number does not match information on file"
 d) "Applied to deductible"

17. What is the minimum balance you think appropriate for a patient to pay under a monthly budget plan?

18. How would you set up a budget plan for a working 35-year-old mother who has not yet met her deductible? The account is 60 days old.

 - Billing Specialist Knowledge Assessment provided at the America Medical Billing Association's annual conference by Mike Edmonds, owner and executive director of Physicians Financial & Management Services LLC in Cordova, Tenn. Questions and answers edited by Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.


Billing Specialist Knowledge Assessment - Answer Key

Note: There is some room for individual interpretation with the answers to these questions. A potential hire may provide a correct answer that is not stated exactly as in this answer key.
 
1. A CPT code describes a service or procedure (what the provider did for the patient), and an ICD-9-CM code describes the diagnosis (why the provider performed the service or procedure).
 
2. A CPT code has five digits and an ICD-9-CM code has between three and five digits (depending on the level of specificity required).
 
3. E/M codes describe office visits, hospital and outpatient services, and consultation services rendered by providers. The "evaluation" is the history and physical exam. The "management" is the medical decision-making process.
 
4. The outpatient consultation codes are 99241, 99242, 99243, 99244 and 99245.
 
5. You cannot bill an inpatient service (99221-99223, 99231-99233, 99251-99255, 99261-99263) and a discharge (99238, 99239) for the same physician on the same day.
 
6. A consultation is when a patient's physician asks another physician (usually a specialist) to give his opinion about the patient's medical problem. A consultation visit must include a documented request for opinion from the requesting physician, documentation of the consulting physician's E/M service and opinion, and documentation of a report from the consulting physician explaining his opinion and findings to the requesting physician.
 
A transfer of care is when a physician thinks the patient needs another physician (sometimes a specialist) to assume responsibility for all or a portion of the patient's care because he can better manage the patient's medical problem. Therefore, the treating physician "transfers" the care of his patient to another physician.
 
7. The "global package" is a concept payers use to require that you report one procedure code as all-inclusive to bill for a procedure that has pre- and postoperative care "built-in." For example, in obstetrics, there is one code for delivery that includes all the antepartum care.
 
8. "Unbundling" is when you bill several CPT procedure codes that are more accurately billable under a single CPT code. The National Correct Coding Initiative outlines bundling edits for codes. Billers often use modifiers, such as modifier -59 (Distinct procedural service), to override NCCI bundling edits and get paid for services that deserve payment.
 
9. When you post a payment from a commercial insurer, you can transfer the difference between what the plan pays and the practice's fee to the patient's responsibility and send a statement to the patient. For a PPO, you must write off the difference between the PPO's contracted payment and the practice's fee.
 
10. A "withhold" is a percentage of reimbursement (typically 10 to 25 percent) that is "withheld" from the contracted payment amount for each service, then returned to the practice at the end of the year based on utilization or other performance targets of the managed-care company. Because withholds are potential receivables, you should post them separately from contractual adjustments.
 
11. Pre-certification means the plan said, "Yes, you can do that procedure for that diagnosis." Pre-authorization means the plan said, "You will be paid for the procedure." Pre-authorization is like a guarantee for payment, whereas pre-certification may not be.
 
12. Regular Medicare has an allowable charge that CMS sets annually. Medicare pays 80 percent of this allowable, and the patient is responsible for the remaining 20 percent. Senior HMOs, on the other hand, have any number of reimbursement schedules that are typically less than Regular Medicare. And, Senior HMOs send claims to different third-party administrators for reimbursement.
 
13. Posting by line item means you post payments and adjustments to the actual CPT code that your practice billed, as opposed to the oldest outstanding balance on the account, or the entire "claim." If payments are not posted in this manner, you have no way of retrieving historical payment information by CPT code or by payer.
 
14. You should follow up on an unpaid Medicare claim at 14 days if the practice is participating and files electronically.
 
15. You should follow up an unpaid non-Medicare claim at 30-45 days, depending on contractual arrangement.
 
16. a) Check the plan guidelines. If this rejection is accurate, transfer the balance to the patient and send a statement.
 b) Verify the patient's effective insurance coverage dates with the payer. If the patient was not covered at the time of service, then call the patient and explain what happened and that the bill is now the patient's responsibility.
 c) Call the patient to obtain correct information and rebill. Be sure the front desk is notified that they erred by not updating the patient's account information, or made a typo.
 d) Transfer balance to patient's account and send statement.
 
17. Typically, $50 should be the minimum monthly balance, but this amount may vary by region or specialty. Keep in mind that all told, sending a statement costs about $6 to $8 when you add up labor, postage, supplies and other overhead expenses.
 
18. Depending on the amount outstanding, try to get her to agree to $100 per month, and work backward if she cannot afford the $100. Explain that there will be fewer payments if she agrees to the higher amount.