Introduction to Transaction Editing System (TES) - Editing

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1 Introduction to Transaction Editing System (TES) - Editing Overview Introduction This module focuses on how to enter an additional transaction on an encounter and resolve an edit that appears when entering the transaction and filing the encounter. Edits alert you that required data is missing from a transaction. Edits can appear in real-time when you attempt to file an encounter. These edits can be resolved on the spot or filed to a worklist for someone to resolve. The edit s description informs you why the transaction hit an edit and how the edit should be resolved. In short, missing data must be added to the transaction to make it complete. This usually involves going back to the TES Encounter/Transaction Entry Screen to provide the missing data and resolve the edit. Importance Using edits to catch missing data helps ensure that payers will reimburse the department properly. Without edits, claims with insufficient data might be submitted to payers for reimbursement. These claims would then be denied (rejected) and require additional work and resubmission. This rework is costly and inefficient. Objectives Upon completion of this lesson, you should: Know how to locate an existing encounter that has a transactions Understand how to add an additional transaction and resolve an edit Faculty Practice Plan Education Services 1

2 Prerequisites Prior to beginning this lesson, you should have successfully completed the following courses and/or modules: Introduction to IDX Web Navigation Registration P-Plan Assignment for Clinical Departments TES Transaction Encounter/Transaction Entry Faculty Practice Plan Education Services 2

3 Components of a Patient s Account The diagram below illustrates the components of a patient s account. The diagram further illustrates how the components relate to one another. Registration Information Visit Created: Demographic Information Billing/Insurance Information Schedlink Interface Manual Patient Charge Information Visit Insurance Plan Assigned Registration FSC Registration FSC Special Billing Plan Charge Entry Invoice Created linked to the visit Invoice with Invoice FSC assigned based on Visit Plan Faculty Practice Plan Education Services 3

4 Introduction to TES Edits Edits Edits alert you that a transaction is missing required data. The edit description provides information for resolving the edit. You resolve edits by supplying the missing information. The primary purpose of an edit is to ensure that only clean, claim-worthy charges are considered for billing. Catching missing data up-front helps ensure that payers will reimburse the department correctly. Examples of edits are: Missing Location Missing Patient Address Missing Referring Physician Missing Diagnosis 1 Missing Diagnosis Linkage Edits are set-up in the system using conditions that detect missing or incorrect data in encounters and transactions. Edit Conditions When you file an encounter, TES automatically checks the encounter and each transaction against a set of edit conditions. Edit conditions are set-up by your department to verify that the information for each encounter and transaction is complete and accurate. An example of an edit condition that your department might define would be for a missing Referring Physician. Faculty Practice Plan Education Services 4

5 Options for Resolving Edits Real-Time Edits Edit conditions can be set-up so that edits appear during transaction entry when you attempt to file the encounter. These edit conditions can be considered realtime edits. These types of edits can usually be resolved fairly quickly. If for some reason, however, the edit requires thorough investigation, the edit can be filed without resolving the edit. The edit is sent to a workfile for someone to resolve the edit. Nightly Edits TES evaluates transactions as they are entered into the system. If you file an encounter without resolving all of the edits for that encounter, the system files the edits in a workfile. The system checks the workfile during the nightly evaluation process. Edit conditions can also be set-up so they do not appear during transaction entry when you file an encounter. These types of edits require more effort to investigate and resolve. Example: Missing provider number Edits can also be set-up so they are resolved automatically. Autofix Edits Edits can be set-up so they can be resolved without user intervention. These types of edits are referred to as auto-fix edits. Whenever possible, edits should be set-up to systematically auto-fixed. Auto-fix edits are not conditional. Example: An auto-fix edit can be set-up so every time a certain procedure code is present, the system always defaults a specific modifier. Faculty Practice Plan Education Services 5

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7 TES Overview Transaction Editing Systems The Transaction Editing System (TES) is a charge suspense system designed to capture, evaluate and correct charge transactions before filing in the IDX Billing and Accounts Receivable (BAR) application. TES Benefits Charges with edits do not extract to the Billing and Accounts Receivable (BAR) system inflating accounts receivable o Encounters with edits are placed in a workfile Encounters do not age until the encounter is clean and extracted from TES to the Billing and Accounts Receivable (BAR) application Ability to correct an encounter at time of charge entry or before extraction to BAR No required fields in TES o No need to remove fee tickets from batches for referrals or missing information to be researched later Improves work flow monitoring for Clinical Departments Lower risk of rejections from insurance carriers Reduces days in accounts receivable Reduces charge corrections Claims Manager Claims Manager is a tool that enables the departments to ensure invoices meet the correct coding initiative. Claims Manager identifies incorrect coding and returns an instruction message on how to properly code the invoice. Claims Manager reviews patient age, sex, date of service, diagnosis and the procedure code/modifiers to determine coding errors. Faculty Practice Plan Education Services 7

8 Evaluation and Extraction Enter encounter in TES (Function 1000) o Manually o Charge Interface o Anesthesia Interface Encounter reviewed for edits o Nightly evaluation o The TES evaluation and extraction process occurs every day Encounter with TES edits moves to workfile Encounter without TES edits are reviewed in Claims Manager and then extracted to BAR TES edits are corrected and reprocessed during nightly evaluation Clean encounters are extracted to BAR which creates an invoice for billing which displays in Invoice Inquiry TES Nightly Process Both the BAR and TES batch display in Invoice Inquiry: o Select o Select Faculty Practice Plan Education Services 8

9 Example: Invoice Inquiry To view the detail of the selected invoice select Faculty Practice Plan Education Services 9

10 Example: View Invoice Detail Screen To display the BAR batch number information select Example: View Invoice Detail Screen Faculty Practice Plan Education Services 10

11 TES Batch and Encounter Number Display TES Terms and Definitions Encounter: equivalent to a BAR invoice Transaction: procedure code Batches: manage entry of transactions TES Batch: created at Transaction Entry BAR Batch: created by the system when charges are extracted to BAR Note: Both the TES and BAR Batch display in Invoice Inquiry TES Screens There are four pages in TES: 1. TES Encounter/Transaction Entry (Page 1 - A) 2. TES Encounter/Transaction Entry Encounter Details (Page 2 - B) 3. TES Encounter/Transaction Entry - Transaction Details (Page 3 - C) 4. TES Encounter/Transaction Entry - Comments (Page 4 - D) Faculty Practice Plan Education Services 11

12 Example: 1. TES Encounter/Transaction Entry Screen (Page 1 - A) Allows you to create an encounter Example: 2. TES Encounter/Transaction Entry Encounter Details Screen (Page 2 - B) Allows you to add or edit a Diagnosis(s) for a specific encounter Note: All diagnosis changes must be entered on this screen after the system creates an encounter number. After making any changes on this screen, you must re-link the diagnosis code(s) to each transaction within the encounter. Faculty Practice Plan Education Services 12

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14 Example: 3. TES Encounter/Transaction Entry - Transaction Details Screen (Page 3 - C) Allows you to correct edits on an encounter at the transaction level Note: There will be a Transaction Detail Screen for each transaction within the encounter. 3 transactions = 3 Transaction Detail Screens Faculty Practice Plan Education Services 14

15 Example: 4. TES Encounter/Transaction Entry Comments Screen (Page 4 - D) Allows you to enter up to 100 lines of free text regarding the encounter. Encounter comments can only be viewed in TES. Example: 6/22/06 OY, Contacted primary care physician for authorization number.tmj* Faculty Practice Plan Education Services 15

16 Lesson Summary In this lesson, you learned: High level workflow Review the components of a patient account structure Benefit of using TES Evaluation and Extraction process Viewing BAR and TES batch information in Invoice Inquiry TES terms and definitions Four screens used with TES: 1. Transaction Entry 2. Header Editing 3. Transaction Detail Editing 4. Comment Faculty Practice Plan Education Services 16