Disclaimer This presentation may be recorded. This presentation presents a sampling of best practices and overviews, generalities, and some laws.

Transcription

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2 Disclaimer This presentation may be recorded. This presentation presents a sampling of best practices and overviews, generalities, and some laws. This should not be used as legal advice. Itentive recognizes that there is not a one size fits all solution for the ideas expressed in this presentation; we invite you to follow up directly with us for more personalized information as it pertains to your specific practice and issues. Thank you, and enjoy the presentation.

3 Upcoming Webinars Telemedicine An Industry Prospective Wednesday, October 7 12pm CT

4 Meaningful Use Final Rule As soon as CMS releases the Meaningful Use Final Rule We will send out an invitation to a webinar where we will cover the final changes Keep your eyes peeled for the invite!

5 Making Sense of Your Reason Code Library

6 Introductions Jeannie Logue Director, Consulting Solutions

7 Making Sense of Your Reason Code Library

8 Making Sense of Your Reason Code Library Have you checked the accuracy of your reason code library lately? Most practices have no idea the impact or value of proper setup of the reason code library.

9 Agenda The Importance of the Reason Code Library What is the Reason Code Library What does it do What does it impact Why should you make changes Why does priority matter On the Fly Codes How ERA posting is impacted Denial Management What are Reason Code Categories Denial and Payer Trending How can they help my practice Summary

10 What is the Reason Code Library Payers are required to use HIPAA compliant reason codes in the ERA file to describe how the service was adjudicated. The Reason Code Library gives practices the ability to configure their own business rules. Nextgen out of the box Reason Code Library will follow the rules of the payers.

11 Understanding Reason Codes Group Codes

12 Claim Adjustment Reasons Codes The Claim Adjustment Reason Codes explain full or partial denials of services (CARC).

13 Remittance Advice Remark Codes The Remittance Advice Remark Codes (RARC) are used to provide an additional explanation for an adjustment already described by a CARC code. These are your M and N Codes.

14 Claim Adjustment Reasons LINE ITEM: If you want the reason code to apply to an individual line on a claim, then you would use this code type. LINE ITEM CODES will override transaction and adjudication codes during batch processing. REMARK: This code type is used when you want to identify the reason code as a Remittance Advice Remark for specific lines items. These code types override line item, claim level, and adjudication codes.

15 Claim Reasons and Line Reasons

16 What does it do Based on your set up, your reason code can: Adjust off full or partial charges Skip the payers adjustment Move a balance directly to the patient Set a line item or claim to be appealed Display on a patients statement Be bundled with other similar reason codes for efficient workflow and reporting

17 Getting Started Familiarize yourself with payer specific reason codes. Determine how you want your codes to function. Determine how you desire to subgroup your codes for workflow.

18 Force Item Rebill option is selected when you want to override the charge status and turn on the Rebill indicator during the payment entry process. Write Off Remaining Balance option when you want to adjust off the remaining line item to a zero balance. Display on Patient Statement. Override Line Item Codes option is selected when you select the adjudication code type option. If not selected, the line item code will override the adjudication code.

19 Default to Contract <> Payment Allowed option is selected when you want the payment to default to what is specified in the contract for the line item rather than in the ERA file. Default to ERA Credit Balance Creation so that the EPM automatically adds the reason code to a transaction during the ERA import process when a credit or negative balance for an encounter is created. *A worklog task can be created from this reason code. Transaction Detail Status is selected when you want it to override the line item transaction status.

20 Reason Code Category allows you to link your subgroups. Skip Adjustment Code option determines how to handle the adjustment code: Do not skip adjustments this is the default. Skip ERA adjustments select this option to assign Skip ERA adjustment No Adjustment Generates. Use $0 Adj Amount This option allows the claim level reason code to be carried down to the service line and use a zero dollar adjustment amount.

21 Why Should You Make Changes The Reason Code Library will follow the rules of the code by the payers unless you make changes within your Library. You may be adjusting off full charges without even knowing, when you import your ERA file. Line items that you desire to be written off, are often forced to patient responsibility increasing your patient balances.

22 Why does the priority matter Most line item charges will have more than one reason code attached with the transaction. Each reason code may have a different rule set up and based on if it is a claim or line item code, the priority does matter.

23 How do you set the priority list All new reason codes are added to the bottom of the list. These must be moved up, if you want specific codes to be a higher priority than others. Within File Maintenance, Reason Code Library, right click, Reason Code Priority.

24 How do you set the priority list Determine which codes you want to set as high priority and move them to the top of the list using the blue arrows.

25 On the Fly Codes On the Fly Codes are codes that the payers have put on the 835 file that are not currently in your reason code library. These are often Remark Codes which give you more definition on the denial. If you have your remittance library set to allow on the fly; they will automatically create an On The Fly code for you in your library. These should be updated immediately and the rules set for these new codes.

26 On the Fly Codes You can set up a report to monitor these and assign to a staff member to keep up to date. Don t rely on your payment posters to keep these up to date.

27 Reason Codes and ERA File

28 Reason Code Category and Reports Reports>Daily>By Line Item>Reason Code>

29 Trending How and Why? Trend by charges How are denials affecting your AR? Trend by line items How many denials are your staff working? Trend by Percentages Do you know how to identify denial issues? How do you fix the problem if you don t know where to begin?

30 Trending Denials

31 Graphing your Trends

32 Trending Denials

33 Trending Denials

34 Review by Financial Class

35 In Summary Understand the Reason Code Library. Review the rules you want set to allow payment posting of ERA s to be efficient. Utilize reason code categories for delegating work load. Create denial reports utilizing subgroups for trending and cleaner first claim submission. Your reason code library must always be maintained and kept up to date.

36 Questions Jeannie Logue Director, Managing Consultants

37 Thank you.

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