The Revenue Cycle

Question 1

What are the basic steps to the Revenue Cycle?

Answer 1

1. Registration & Scheduling
2. Patient Check-in
3. Utilization Management Review
4. Health Care Encounter & Documentation
5. Charge Capture & Coding
6. Patient Check-out
7. Billing
8. Payer Adjudication
9. Receiving & Posting Insurance Payments
10. Appeals & Claims Corrections
11. Patient Responsibility Collection, Payments, & Posting

Question 2

What is Patient Registration & Scheduling?

Answer 2

This is the first step in RCM. It starts with communication between the patient and staff. The patient provides basic demographic details and insurance information.

Question 3

What is Patient Check-in?

Answer 3

1. This informs the organization and patient of coverage details and Out-Of-Pocket expenses are collected(copays, coins, ded..)
2. Patient registration forms are completed and remaining account information is provided(SSN, employer, address…)
3. Assignment of Benefits, Financial Policy, PHI Release forms, and HIPAA Privacy Notifications.
4. Insurance Verification

Question 4

What involves Insurance Verification?

Answer 4

This ensures coverage is valid for the date of service and determines any patient OOP expenses(copay, coins, ded…)

Question 5

What is required to Verify Insurance Eligibility?

Answer 5

You will need the patient’s first & last name, DOB, and Insurance ID number.

Question 6

What is Utilization Management?

Answer 6

This review process determines when referrals and preauthorizations are required. Precertification and screening for medical necessity are also included. This can occur multiple times if needed. Specialty organizations will usually perform this process at check-in.

Question 7

What is Health Care Encounter & Documentation?

Answer 7

The patient is seen by the provider and supporting documentation is entered into the medical record.

Question 8

What is Charge Capture & Coding?

Answer 8

This is the process of selecting codes based on the documentation in the patient’s medical record and entered into the financial portion in your system.

Question 9

Where are the Codes selected from?

Answer 9

The practice’s predetermined electronic Encounter Form or an electronic search within the EHR’s database of codes.

Question 10

What is an Encounter Form?

Answer 10

This is a document that captures diagnoses or procedure codes for the services provided during the patient’s encounter.

Question 11

What does coding involve?

Answer 11

Coding involves confirming appropriate CPT, HCPCS, ICD-10-CM code assignment, and linkage.

Question 12

Why is linkage important?

Answer 12

This is important because ICD-10-CM codes support the medical necessity of the CPT and HCPCS codes selected.

Question 13

What is Patient Check-out?

Answer 13

This step includes determining additional Out-Of-Pocket expenses(noncovered services). Patient follow-up appointments and instructions are discussed, referrals to other providers, and consent forms are reviewed for signatures.

Question 14

What happens in Billing?

Answer 14

Charges are validated and transmitted. Charges are electronically generated based on the codes selected and associated fees. The EHR generates, processes, and submits the claim electronically to the payer.

Question 15

What is the paper claim form for Professional services called?

Answer 15

The CMS-1500

Question 16

What is the paper claim form for Hospital services called?

Answer 16

CMS-1450 or UB04

Question 17

What are the electronic claim forms called?

Answer 17

837P - Professional/CMS-1500

837I - Hospital/CMS-1450

Question 18

What is Payer Adjudication?

Answer 18

This is when the claim has been received and the payer will review the claim and reimburse services or apply charges to patient responsibility(copay, coins, ded…) The provider will typically receive payment 10-30 days from the claim’s submission.

Question 19

What is Receiving & Posting Reimbursement?

Answer 19

The claim has been adjudicated. The payer will transmit payment and an RA or EOB, which details how the claim was processed and paid. Billers will use this information to post any adjustments and update Accounts Receivable(money owed)

Question 20

What are Appeals & Claims Corrections?

Answer 20

Claims that are denied can be corrected or appealed.

Question 21

What is the Appeals Process?

Answer 21

This is a process used to request review of a claim that was denied- to determine if the denial was due to a billing error; if so, correct it; file an appeal at the lowest level; and then move up to higher levels if needed.

Question 22

What is Patient Responsibility Collection, Payments, and Posting?

Answer 22

Any patient responsibility amounts that were specified on the RA/EOB must be collected. Usually remaining balances like deductibles and coinsurances.