computers in the medical office Copyright ©2016 McGraw-Hill Education SUSAN M SANDERSON, CPEHR Ninth Edition COMPUTERS IN THE MEDICAL OFFICE, NINTH EDITION Published by McGraw-Hill Education, Penn Plaza, New York, NY 10121 Copyright © 2016 by McGraw-Hill Education All rights reserved Previous editions © 2013, 2011, and 2009 No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning Some ancillaries, including electronic and print components, may not be available to customers outside the United States RMN/RMN ISBN 978-0-07-783638-2 MHID 0-07-783638-3 Senior Vice President, Products & Markets: Kurt L Strand Vice President, General Manager, Products & Markets: Marty Lange Vice President, Content Design & Delivery: Kimberly M ­ eriwether David Managing Director: Chad Grall Executive Brand Manager: William R Lawrensen Director, Product Development: Rose Koos Senior Product Developer: Michelle L Flomenhoft Executive Marketing Manager: Roxan Kinsey Market Development Manager: Kimberly Bauer Digital Product Analyst: Katherine Ward Director, Content Design & Delivery: Linda Avenarius Program Manager: Angela R FitzPatrick Content Project Managers: Vicki Krug / Brent dela Cruz Buyer: Laura M Fuller Senior Design: Srdjan Savanovic Content Licensing Specialists: Lori Hancock / Lorraine Buczek Cover Image: ©Magnilion / Getty images Compositor: Lumina Datamatics, Inc Printer: R R Donnelley All credits appearing on page or at the end of the book are considered to be an extension of the copyright page Design Element Puppet on Monitor: © frentusha/Getty RF CiMO logo: ©Magnilion / Getty images CO1: © Tetra Images/INMAGINE.COM; CO2: © Getty RF; CO3: © McGraw-Hill Education Rick Brady, photographer; CO4: © Ingram Publishing RF; CO5: © Reza Estakhrian/Getty; CO6: © McGraw-Hill Education Rick Brady, photographer; CO7: © Reza Estakhrian/Getty; CO8: © Tom Grill/Getty; CO9: © Getty RF; CO10: © Jupiterimages/Getty RF; CO11, CO12: © Getty RF; CO13: © Tetra Images/Getty RF; CO14: © Getty RF Medisoft® is a registered trademark of McKesson Corporation and/or one of its subsidiaries Screenshots and material pertaining to Medisoftđ Software used with permission of McKesson Corporation â 2013 McKesson Corporation and/or one of its ­subsidiaries All Rights Reserved The Medidata (student data file), illustrations, instructions, and exercises in Computers in the Medical Office are compatible with the Medisoft Advanced Version 19 Patient Accounting software available at the time of publication Note that Medisoft Advanced Version 19 Patient Accounting software must be available to access the Medidata It can be obtained by contacting your McGraw-Hill sales representative All brand or product names are trademarks or registered trademarks of their respective companies CPT five-digit codes, nomenclature, and other data are © 2015 American Medical Association All Rights Reserved No fee s­ chedules, basic units relative values, or related listings are included in CPT The AMA assumes no liability for the data contained herein All names, situations, and anecdotes are fictitious They not represent any person, event, or medical record Library of Congress Cataloging-in-Publication Data Sanderson, Susan M      Computers in the medical office / Susan M Sanderson, CPEHR.—Ninth edition       pages cm     Includes index     ISBN 978-0-07-783638-2 (alk paper) Medical offices—Automation. 2 MediSoft. I Title     R864.S26 2016   610.285—dc23 2015010737 The Internet addresses listed in the text were accurate at the time of publication The inclusion of a website does not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not guarantee the accuracy of the information presented at these sites mheducation.com/highered Copyright ©2016 McGraw-Hill Education CPT codes are based on CPT 2015 ICD-10-CM codes are based on ICD-10-CM 2015 brief contents part CHAPTER part Introduction to Health Information Technology and Medical Billing MEDISOFT ADVANCED TRAINING 47 CHAPTER Introduction to Medisoft 48 CHAPTER Scheduling 85 CHAPTER Entering Patient Information 128 CHAPTER Working with Cases 156 CHAPTER Entering Charge Transactions and Patient Payments 196 CHAPTER Creating Claims 237 CHAPTER Posting Payments and Creating Patient Statements 273 CHAPTER Creating Reports 326 CHAPTER 10 Collections in the Medical Office 371 APPLYING YOUR SKILLS 409 part Copyright ©2016 McGraw-Hill Education INTRODUCTION TO COMPUTERS IN THE MEDICAL OFFICE CHAPTER 11 Appointments and Registration 410 CHAPTER 12 Cases, Transactions, and Claims 416 CHAPTER 13 Reports and Collections 423 CHAPTER 14 Putting It All Together 427 SOURCE DOCUMENTS 435 part GLOSSARY 472 INDEX 476 iii contents part INTRODUCTION TO COMPUTERS IN THE MEDICAL OFFICE Chapter 1.1 THE CHANGING HEALTHCARE LANDSCAPE HITECH Act Affordable Care Act Implications for Physician Practices 1.2 FUNCTIONS OF PRACTICE MANAGEMENT PROGRAMS Creating and Transmitting Claims Monitoring Claim Status Receiving and Processing Payments 1.3 FUNCTIONS OF ELECTRONIC HEALTH RECORD PROGRAMS 10 Health Information and Data Elements 10 Results Management 11 Order Management 12 Decision Support 13 Electronic Communication and Connectivity 13 Patient Support 13 Administrative Processes 13 Reporting and Population Management 14 1.4 THE MEDICAL DOCUMENTATION AND BILLING CYCLE: PRE-ENCOUNTER 14 Step 1: Preregister Patients 16 1.5 THE MEDICAL DOCUMENTATION AND BILLING CYCLE: ENCOUNTER 16 Step 2: Establish Financial Responsibility 16 Step 3: Check In Patients 17 Step 4: Review Coding Compliance 17 Step 5: Review Billing Compliance 23 STEP 6: Check Out Patients 23 1.6 THE MEDICAL DOCUMENTATION AND BILLING CYCLE: POST-ENCOUNTER 23 Step 7: Prepare and Transmit Claims 23 iv Step 8: Monitor Payer Adjudication 25 Step 9: Generate Patient Statements 27 Step 10: Follow Up Payments and Collections 27 1.7 HIPAA, THEN AND NOW 27 HIPAA Electronic Transaction and Code Sets 28 HIPAA Privacy Requirements 30 HIPAA Security Requirements 35 part MEDISOFT ADVANCED TRAINING 47 Chapter Introduction to Medisoft 2.1 THE MEDISOFT DATABASES 2.2 THE MEDISOFT MENUS File Menu Edit Menu Activities Menu Lists Menu Reports Menu Tools Menu Window Menu Help Menu Exercise 2-1 Medisoft Menus 2.3 THE MEDISOFT TOOLBAR Exercise 2-2 Toolbar Buttons 48 49 50 50 51 51 52 53 53 53 54 55 55 55 Copyright ©2016 McGraw-Hill Education Introduction to Health Information Technology and Medical Billing 2.4 ENTERING, EDITING, SAVING, AND DELETING DATA IN MEDISOFT 57 Entering Data 58 Editing Data 58 Exercise 2-3 Editing Data 58 Saving Data 61 Deleting Data 61 2.5 CHANGING THE MEDISOFT PROGRAM DATE 62 2.6 USING MEDISOFT HELP 64 Hints 64 Built-in 64 Exercise 2-4 Using Built-in Help 66 2.7 CREATING AND RESTORING BACKUP FILES 66 Creating a Backup File While Exiting Medisoft 66 Exercise 2-5 Backing Up 68 Restoring the Backup File 69 Exercise 2-6 Restoring a Backup File 69 2.8 MEDISOFT’S FILE MAINTENANCE UTILITIES 71 Rebuilding Indexes 72 Packing Data 72 Purging Data 74 Recalculating Patient Balances 75 2.9 USING MEDISOFT SECURITY FEATURES TO ENSURE HIPAA AND HITECH COMPLIANCE 76 User Logins and Audit Controls 78 Auto Log Off and Unapproved Codes 78 Chapter 3.4 SEARCHING FOR AVAILABLE TIME SLOTS 99 Exercise 3-5 Searching for Open Time, Ramos 100 Exercise 3-6 Searching for Open Time, Klein 101 3.5 ENTERING APPOINTMENTS FOR NEW PATIENTS 101 Exercise 3-7 Entering an Appointment for a New Patient 102 3.6 BOOKING REPEAT APPPOINTMENTS 102 Exercise 3-8 Booking Repeat Appointments 103 3.7 RESCHEDULING AND CANCELING APPPOINTMENTS 104 Exercise 3-9 Rescheduling Appointments 105 3.8 VERIFYING INSURANCE ELIGIBILITY AND BENEFITS 105 Eligibility Verification Icons 108 Exercise 3-10 Verifying a Patient’s Eligibility 109 3.9 CHECKING PATIENTS IN AND OUT 109 Exercise 3-11 Checking In a Patient 110 3.10 CREATING AN OVERDUE BALANCE REPORT FOR PATIENTS WITH APPOINTMENTS 111 Exercise 3-12 Creating an Overdue Balance Report 111 3.11 CREATING A PATIENT RECALL LIST 111 Adding a Patient to the Recall List 113 Exercise 3-13 Adding a Patient to the Recall List 115 3.12 CREATING PROVIDER BREAKS 115 Exercise 3-14 Entering a Provider Break 117 3.13 VIEWING AND PRINTING SCHEDULES 117 Copyright ©2016 McGraw-Hill Education Scheduling 85 3.1 THE OFFICE HOURS WINDOW Program Options Entering and Exiting Office Hours 3.2 ENTERING APPOINTMENTS Exercise 3-1 Entering an Appointment, Leila Patterson Exercise 3-2 Entering an Appointment, Elizabeth Jones Exercise 3-3 Looking Up a Provider and Entering an Appointment 3.3 BOOKING FOLLOW-UP APPOINTMENTS Exercise 3-4 Booking an Appointment with a Follow-up 86 89 89 89 95 96 97 98 99 CONTENTS     v Exercise 3-15 Viewing a Provider Schedule 118 Applying Your Skills 1: Enter an Appointment for a New Patient 119 Applying Your Skills 2: Search for an Open Time 119 Applying Your Skills 3: Preview a Physician’s Schedule 119 Chapter 128 4.1 HOW PATIENT INFORMATION IS ORGANIZED IN MEDISOFT® 129 4.2 ENTERING NEW PATIENT INFORMATION 130 Name, Address Tab 131 Exercise 4-1 Chart Numbers 132 Other Information Tab 134 Payment Plan Tab 137 Exercise 4-2 Adding a New Patient 138 Adding an Employer to the Address List 141 Exercise 4-3 Adding an Employer 143 4.3 SEARCHING FOR PATIENT INFORMATION 144 Search for and Field Option 145 Exercise 4-4 Search Using Field Box 147 Locate Buttons Option 147 Exercise 4-5 Search Using Locate Button 149 4.4 EDITING PATIENT INFORMATION 149 Exercise 4-6 Editing Patient Information 150 Applying Your Skills 4: Entering a New Patient 150 Chapter Working with Cases   CONTENTS 5.6 5.7 171 171 172 173 176 176 178 178 181 182 182 183 185 185 188 188 189 189 Chapter Entering Charge Transactions and Patient Payments 196 6.1 UNDERSTANDING CHARGES, PAYMENTS, AND ADJUSTMENTS 197 6.2 SELECTING A PATIENT AND CASE 197 156 5.1 UNDERSTANDING CASES 157 When to Set Up a New Case 157 Case Examples 158 5.2 NAVIGATING CASES IN MEDISOFT 159 Case Command Buttons 159 The Case Dialog Box 160 5.3 ENTERING PATIENT AND ACCOUNT INFORMATION 162 Personal Tab 162 Exercise 5-1 Entering Data in the Personal Tab 164 Account Tab 166 vi   5.5 168 168 168 Copyright ©2016 McGraw-Hill Education Entering Patient Information 5.4 Exercise 5-2 Entering Data in the Account Tab ENTERING INSURANCE INFORMATION Policy Tab Exercise 5-3 Entering Data in the Policy Tab Policy Tab Policy Tab Medicaid and Tricare Tab ENTERING HEALTH INFORMATION Diagnosis Tab Exercise 5-4 Entering Data in the Diagnosis Tab Condition Tab Exercise 5-5 Entering Data in the Condition Tab ENTERING OTHER INFORMATION Miscellaneous Tab Comment Tab Exercise 5-6 Entering Data in the Comment Tab EDI TAB EDITING CASE INFORMATION Exercise 5-7 Editing a Case Exercise 5-8 Copying a Case Applying Your Skills 5: Creating a Case for a New Patient 6.3 6.4 6.5 6.6 6.7 Chart 198 Case 199 Additional Information 199 ENTERING CHARGE TRANSACTIONS 200 Buttons in the Charges Area of the Transaction Entry Dialog Box 204 Color Coding in Transaction Entry 206 Saving Charges 207 Editing Transactions 208 Exercise 6-1 Entering a Charge for Hiro Tanaka 208 Exercise 6-2 Entering a Charge for Elizabeth Jones 210 ENTERING PAYMENTS MADE AT THE TIME OF AN OFFICE VISIT 211 Applying Payments to Charges 213 Saving Payment Information 216 Exercise 6-3 Entering a Copayment 216 Exercise 6-4 Entering Charges and Copayment 219 PRINTING WALKOUT RECEIPTS 220 Exercise 6-5 Creating a Walkout Receipt 223 PROCESSING A PATIENT REFUND 223 Exercise 6-6 Processing a Refund 225 PROCESSING A NONSUFFICIENT FUNDS (NSF) CHECK 227 Exercise 6-7 Processing an NSF Check 228 Applying Your Skills 6: Add a Diagnosis and Enter Procedure Charges 229 Chapter Copyright ©2016 McGraw-Hill Education Creating Claims 237 7.1 THE BASICS OF MEDICAL INSURANCE 238 Types of Health Plans 239 7.2 THE ROLE OF CLAIMS IN THE BILLING CYCLE 241 Medical Necessity 241 Clean Claims 242 CMS-1500 and X12 837 Health Care Claim 242 Exercise 7-1 Exploring the CMS-1500 in Medisoft Help 246 7.3 CLAIM MANAGEMENT IN MEDISOFT 248 7.4 CREATING CLAIMS 249 Exercise 7-2 Creating Claims 251 7.5 LOCATING CLAIMS 252 Exercise 7-3 Using the List Only Feature 255 7.6 EDITING CLAIMS 256 Carrier Tab 256 Carrier and Carrier Tabs 257 Transactions Tab 257 Comment Tab 258 EDI Note Tab 259 Exercise 7-4 Reviewing a Claim 260 7.7 CHANGING THE STATUS OF A CLAIM 260 Exercise 7-5 Changing Claim Status 261 7.8 ELECTRONIC CLAIMS WORKFLOW 262 Exercise 7-6 Perform an Electronic Claim Edit Check 263 7.9 SENDING ELECTRONIC CLAIM ATTACHMENTS 265 Applying Your Skills 7: Reviewing Claims 267 Chapter Posting Payments and Creating Patient Statements 273 8.1 THIRD-PARTY REIMBURSEMENT OVERVIEW 274 Indemnity Plan Example 274 Managed Care Example 274 Medicare Participating Example 275 8.2 REMITTANCE ADVICE (RA) PROCESSING 276 Claim Adjustments and Denials 278 Processing Payments 278 8.3 ENTERING INSURANCE PAYMENTS IN MEDISOFT 279 The Deposit List Dialog Box 279 The Deposit Dialog Box 282 Exercise 8-1 Entering a Deposit: ChampVA 285 CONTENTS     vii Chapter Creating Reports 9.1 CREATING REPORTS IN MEDISOFT Selecting Print Options Selecting Data for a Report 9.2 THE IMPORTANCE OF ACCOUNTS RECEIVABLE REPORTS Daily Reports Monthly Reports 9.3 CREATING DAY SHEETS viii     CONTENTS 326 327 327 329 334 334 335 336 9.4 9.5 9.6 9.7 9.8 Patient Day Sheet 336 Exercise 9-1 Printing a Patient Day Sheet 338 Procedure Day Sheet 340 Payment Day Sheet 341 CREATING ANALYSIS REPORTS 342 Billing/Payment Status Report 342 Practice Analysis Report 344 Exercise 9-2 Saving a Practice Analysis Report as a PDF File 344 Insurance Analysis Report 346 Referring Provider Report 346 Referral Source Report 347 Unapplied Payment/Adjustment Report 347 Unapplied Deposit Report 347 Co-Payment Report 347 Outstanding Co-Payment Report 347 Appointment Eligibility Analysis— Detail and Summary 347 Electronic Claims Analysis—Detail and Summary 347 CREATING PATIENT LEDGER REPORTS 348 Exercise 9-3 Printing a Patient Account Ledger 349 CREATING STANDARD PATIENT LIST REPORTS 351 Exercise 9-4 Printing a Patient by Insurance Carrier List 352 NAVIGATING IN MEDISOFT REPORTS 352 The Medisoft Reports Menus 353 The Medisoft Reports Toolbar 355 The Medisoft Reports Find Report Box 355 The Medisoft Reports Help Feature 355 CREATING AGING REPORTS 356 Exercise 9-5 Printing a Patient Aging Report 356 Copyright ©2016 McGraw-Hill Education 8.4 APPLYING INSURANCE PAYMENTS TO CHARGES 287 Exercise 8-2 Applying Payments to Charges: ChampVA 291 Exercise 8-3 Entering a Deposit and Applying Payments: East Ohio PPO 293 Exercise 8-4 Entering a Deposit and Applying Payments: Blue Cross and Blue Shield 295 8.5 PROCESSING A PATIENT PAYMENT RECEIVED BY MAIL 297 Exercise 8-5 Entering a Patient Payment Received by Mail 297 8.6 ENTERING CAPITATION PAYMENTS 299 Exercise 8-6 Entering a Capitation Payment 303 Exercise 8-7 Entering a Zero Amount Payment 304 Exercise 8-8 Adjusting a Capitated Account 304 8.7 CREATING STATEMENTS 307 Statement Management Dialog Box 307 Create Statements Dialog Box 308 Exercise 8-9 Creating Statements 310 8.8 EDITING STATEMENTS 311 General Tab 311 Transactions Tab 312 Comment Tab 312 Exercise 8-10 Reviewing a Statement 313 8.9 PRINTING STATEMENTS 313 Selecting a Format 314 Selecting the Filters and Printing the Statements 315 Exercise 8-11 Printing Statements 316 Applying Your Skills 8: Enter Insurance Payments 318 Applying Your Skills 9: Create Statements 318 Copyright ©2016 McGraw-Hill Education 9.9 CREATING CUSTOM REPORTS Exercise 9-6 Printing a List of Patients Exercise 9-7 Printing a List of Procedure Codes 9.10 USING REPORT DESIGNER Exercise 9-8 Modifying a Report Applying Your Skills 10: Print a Patient Day Sheet Applying Your Skills 11: Print an Insurance Payment by Type Report 356 358 358 359 360 363 363 10.10 CREATING A COLLECTION TRACER REPORT 399 Exercise 10-8 Creating a Collection Tracer Report 400 Applying Your Skills 12: Print a Patient Aging Report 401 Applying Your Skills 13: Add a Patient to the Collection List 401 Applying Your Skills 14: Create a Collection Letter 401 Chapter 10 part Collections in the Medical Office 371 APPLYING YOUR SKILLS 10.1 FOLLOWING UP ON INSURANCE CLAIMS 372 Prompt Payment Laws 372 Working Claim Denials 373 Aging Insurance Claims 374 Resubmitting Claims 374 10.2 THE IMPORTANCE OF A FINANCIAL POLICY 374 10.3 LAWS GOVERNING PATIENT COLLECTIONS 377 10.4 CREATING AND ASSIGNING PAYMENT PLANS 378 Exercise 10-1 Creating a Patient Payment Plan 379 Assigning a Patient Account to a Payment Plan 380 Exercise 10-2 Assigning a Patient Account to a Payment Plan 381 10.5 WORKING WITH COLLECTION AGENCIES 381 Exercise 10-3 Posting a Payment from a Collection Agency 382 10.6 WRITING OFF UNCOLLECTIBLE ACCOUNTS 384 Exercise 10-4 Writing Off a Patient Balance 384 10.7 USING A PATIENT AGING REPORT FOR COLLECTIONS 385 Exercise 10-5 Identifying Overdue Accounts 386 10.8 ADDING AN ACCOUNT TO THE COLLECTION LIST 387 Using the Collection List Window 387 Entering a Tickler Item 391 Exercise 10-6 Creating a Tickler 393 10.9 CREATING COLLECTION LETTERS 395 Exercise 10-7 Creating a Collection Letter 398 409 Chapter 11 Appointments and Registration 410 Exercise 11-1 Scheduling an Appointment: Lawana Brooks 411 Exercise 11-2 Scheduling an Appointment: Edwin Hsu 411 Exercise 11-3 Scheduling an Appointment: Anthony Battistuta 412 Exercise 11-4 Scheduling an Appointment: Stewart Robertson 412 Exercise 11-5 Scheduling an Appointment: Hannah Syzmanski 413 Exercise 11-6 Making an Appointment Change 413 Exercise 11-7 Juggling Schedules 414 Exercise 11-8 Scheduling an Appointment: Michael Syzmanski 414 Exercise 11-9 Printing a Provider Schedule 415 CONTENTS     ix source document 33 CHAMPVA PROVIDER REMITTANCE THIS IS NOT A BILL 240 CENTER ST COLUMBUS, OH 60220 A PAYMENT SUMMARY AND AN EXPLANATION OF CODES ARE AT THE END OF THIS STATEMENT PAGE: DATE: ID NUMBER: FAMILY CARE CENTER 285 STEPHENSON BLVD STEPHENSON, OH 60089-4000 OF 12/30/2018 76374021 PROVIDER: JOHN RUDNER, M.D PATIENT: FITZWILLIAMS JOHN CLAIM: 123456789 FROM DATE THRU DATE PROC CODE UNITS AMOUNT BILLED AMOUNT ALLOWED 10/01/18 10/01/18 10/01/18 10/01/18 99212 82270 1 54.00 19.00 73.00 CLAIM TOTALS DEDUCT COPAY/ COINS PROV PAID 37.36 4.54 00 00 15.00 00 22.36 4.54 41.90 00 15.00 26.90 REASON CODE Copyright ©2016 McGraw-Hill Education ******************* CHECK #76374021 IN THE AMOUNT OF $26.90 IS ATTACHED ******************* PAYMENT SUMMARY TOTAL ALL CLAIMS TOTAL AMOUNT PAID 26.90 PRIOR CREDIT BALANCE 00 CURRENT CREDIT DEFERRED 00 PRIOR CREDIT APPLIED 00 NEW CREDIT BALANCE 00 NET DISBURSED 26.90 AMOUNT CHARGED AMOUNT ALLOWED DEDUCTIBLE COPAY OTHER REDUCTION STATUS CODES: AJ - ADJUSTMENT IP - IN PROCESS R - REJECTED 73.00 41.90 00 15.00 00 V - VOID SOURCE DOCUMENTS     469 34 source document EAST OHIO PPO PROVIDER REMITTANCE THIS IS NOT A BILL 10 CENTRAL AVENUE HALEVILLE, OH 60890 A PAYMENT SUMMARY AND AN EXPLANATION OF CODES ARE AT THE END OF THIS STATEMENT PAGE: DATE: ID NUMBER: FAMILY CARE CENTER 285 STEPHENSON BLVD STEPHENSON, OH 60089-4000 OF 12/30/2018 376490713 PROVIDER: DANA BANU, M.D PATIENT: SYZMANSKI HANNAH CLAIM: 78901234 FROM DATE THRU DATE PROC CODE UNITS 11/09/18 11/09/18 99383 CLAIM TOTALS DEDUCT COPAY/ COINS PROV PAID 224.00 201.60 00 20.00 181.60 224.00 201.60 00 20.00 181.60 THRU DATE PROC CODE UNITS AMOUNT BILLED AMOUNT ALLOWED 11/12/18 11/12/18 11/12/18 11/12/18 99215 82270 1 163.00 19.00 182.00 DEDUCT COPAY/ COINS PROV PAID 146.70 17.10 00 00 20.00 00 126.70 17.10 163.80 00 20.00 143.80 PAYMENT SUMMARY TOTAL ALL CLAIMS TOTAL AMOUNT PAID 325.40 PRIOR CREDIT BALANCE 00 CURRENT CREDIT DEFERRED 00 PRIOR CREDIT APPLIED 00 NEW CREDIT BALANCE 00 NET DISBURSED 325.40 AMOUNT CHARGED AMOUNT ALLOWED DEDUCTIBLE COPAY COINSURANCE REASON CODES: AJ - ADJUSTMENT REASON CODE CLAIM: 89012345 FROM DATE CLAIM TOTALS 470   AMOUNT ALLOWED IP - IN PROCESS   PART   SOURCE DOCUMENTS R - REJECTED REASON CODE EFT INFORMATION 406.00 365.40 00 40.00 0.00 NUMBER DATE AMOUNT V - VOID 376490713 12/30/18 325.40 Copyright ©2016 McGraw-Hill Education PATIENT: SYZMANSKI MICHAEL AMOUNT BILLED source document 35 OHIOCARE HMO 147 CENTRAL AVENUE HALEVILLE, OH 60890 PAGE: DATE: ID NUMBER: FAMILY CARE CENTER 285 STEPHENSON BLVD STEPHENSON, OH 60089-4000 OHIOCARE HMO CAPITATION STATEMENT MONTH OF NOVEMBER 2018 PROVIDERS BANU DANA BEACH ROBERT MCGRATH PATRICIA RUDNER JESSICA RUDNER JOHN YAN KATHERINE MEMBER NUMBER 0003602149 OF 12/30/2018 767729 MEMBER NAME FAMILY CARE CENTER CONTRACT NUMBER YG34906 CONTRACT STATUS APPROVED Copyright ©2016 McGraw-Hill Education AMOUNT OF PAYMENT $2,500.00 EFT STATUS: SENT 12/30/18 2:46PM TRANSACTION #767729 SOURCE DOCUMENTS     471 glossary a in an episode of care, creating a sense of shared accountability among providers access rights  Security option that determines the areas of the program a user can access and whether the user has rights to enter or edit data business associate  An individual or entity that ­creates, receives, maintains, or transmits PHI on behalf of a covered entity; may also include ­subcontractors of an entity accounts receivable (AR)  Monies that are coming into the practice adjudication  Series of steps that determine whether a claim should be paid adjustments  Changes to patients’ accounts that alter the amounts charged or paid c capitated plan  An insurance plan in which prepayments made to a physician cover the physician’s services to a plan member for a specified period of time capitation  Payment to a provider that covers each plan member’s healthcare services for a certain period of time Affordable Care Act  Federal legislation passed in 2010 that includes a number of provisions designed to increase access to healthcare, improve the quality of healthcare, and explore new models of delivering and paying for healthcare capitation payments  Payments made to physicians on a regular basis for providing services to patients in a managed care plan after-visit summary (AVS)  A communication tool that provides the patient with relevant and actionable information and instructions charges  Amounts a provider bills for the services performed aging report  A report that lists the amount of money owed to the practice, organized by the amount of time the money has been owed audit  A formal examination or review undertaken to determine whether a healthcare organization’s staff members comply with regulations audit trail  A report that traces who has accessed electronic information, when information was accessed, and whether any information was changed Auto Log Off  Feature of Medisoft that automatically logs a user out of the program after a period of ­i nactivity autoposting  The automatic posting of data in the remittance advice to a practice management program b backup data  A copy of data files made at a specific point in time that can be used to restore data breach  The acquisition, access, use, or disclosure of unsecured PHI in a manner not permitted under the HIPAA Privacy Rule bundled payments  A model of reimbursement in which single payments to multiple providers involved 472  case  A grouping of transactions that share a common element chart number  A unique number that identifies a patient clean claims  Claims with all the correct information necessary for payer processing clearinghouse  A company that receives claims from a provider, prepares them for processing, and t­ransmits them to the payers in HIPAA-compliant format CMS-1500  The mandated paper insurance claim form coding  The process of translating a description of a diagnosis or procedure into a standardized code coinsurance  Percentage of charges that an insured person must pay for healthcare services after payment of the deductible amount collection agency  An outside firm hired to collect on delinquent accounts collection list  A tool for tracking activities that need to be completed as part of the collection process collection tracer report  A tool for keeping track of collection letters that were sent copayment  A fixed fee paid by the patient at the time of an office visit covered entity  A person or entity that furnishes, bills, or receives payment for healthcare in the normal course of business and conducts certain transactions in electronic form Copyright ©2016 McGraw-Hill Education accountable care organization (ACO)  A network of doctors and hospitals that share responsibility for managing the quality and cost of care provided to a group of patients crossover claims  Claims that are processed by Medicare and then transferred to Medicaid, or to a payer that provides supplemental insurance benefits to Medicare beneficiaries ® Current Procedural Terminology (CPT )  The standardized classification system for reporting medical procedures and services cycle billing  A type of billing in which statement printing and mailing are staggered throughout the month d database  A collection of related bits of information day sheet  A report that provides information on practice activities for a twenty-four-hour period deductible  Amount due before benefits begin diagnosis  Physician’s opinion of the nature of the patient’s illness or injury diagnosis code  A standardized value that represents a patient’s illness, signs, and symptoms documentation  A record of healthcare encounters between the provider and the patient e electronic data interchange (EDI)  The exchange of routine business transactions from one computer to another using publicly available communications ­protocols electronic funds transfer (EFT)  The electronic ­movement of money from one bank account to another electronic health record (EHR)  A computerized ­lifelong healthcare record for an individual that ­incorporates data from all providers who treat the individual Copyright ©2016 McGraw-Hill Education electronic prescribing  The use of computers and handheld devices to transmit prescriptions in digital format electronic protected health information (ePHI)  ­Protected health information (PHI) that is created, stored, transmitted, or received electronically electronic remittance advice (ERA)  An electronic ­document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier encounter form  A list of the procedures and ­diagnoses for a patient’s visit established patient  A patient who has been seen by a provider in the practice in the same specialty or subspecialty within three years explanation of benefits (EOB)  Paper document from a payer that shows how the amount of a benefit was determined f fee-for-service  A model of physician reimbursement in which payment is provided for specific, individual services provided to a patient fee schedule  A document that specifies the amount the provider bills for provided services filter  A condition that data must meet to be selected g guarantor  An individual who may not be a patient of the practice but who is financially responsible for a patient account h HCPCS  Codes used for supplies, equipment, and services not included in the CPT codes health information technology (HIT)  Technology that is used to record, store, and manage patient healthcare information Health Information Technology for Economic and Clinical Health (HITECH) Act  Part of the American Recovery and Reinvestment Act of 2009 that provides financial incentives to physicians and hospitals to adopt EHRs and strengthens HIPAA privacy and security regulations Health Insurance Portability and Accountability Act of 1996 (HIPAA)  Federal act that sets forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information health maintenance organization (HMO)  A managed healthcare system in which providers agree to offer healthcare to the organization’s members for fixed payments high-deductible health plan with savings option (HDHP/SO)  A type of managed care insurance in which a high-deductible plan is combined with a pretax savings account to cover out-of-pocket medical expenses HIPAA Omnibus Rule  Legislation passed in 2013 that made significant changes to the privacy, security, and enforcement provisions of the original HIPAA legislation HIPAA Privacy Rule  Regulations for protecting individually identifiable information about a patient’s health and payment for healthcare that is created or received by a healthcare provider HIPAA Security Rule  Regulations outlining the minimum administrative, technical, and physical ­safeguards required to prevent unauthorized access to protected healthcare information GLOSSARY     473 ICD-9-CM  Abbreviated title of International Classification of Diseases, Ninth Revision, Clinical Modification, the source of the codes used for reporting diagnoses until October 1, 2015 NSF check  A check that is not honored by a bank because the account it was written on does not have sufficient funds to cover it o ICD-10-CM  Abbreviated title of International Classification of Diseases, Tenth Revision, Clinical Modification, the source of the codes used for reporting diagnoses Office Hours break  A block of time when a ­physician is unavailable for appointments with patients indemnity plan  Also known as a fee-for-service plan; a health plan that repays the policyholder for covered medical expenses Office Hours calendar  An interactive calendar that is used to select or change dates in Office Hours insurance aging report  A report that lists how long a payer has taken to respond to insurance claims m managed care  A type of insurance in which the ­carrier is responsible for both the financing and the delivery of healthcare meaningful use  The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system medical documentation and billing cycle  A ten-step process that results in timely payment for medical ­services medical necessity  Treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and is provided in accordance with generally accepted standards of medical practice Medisoft Program Date  Date the program uses to record when a transaction occurred MMDDCCYY format  The way dates must be keyed in Medisoft, in which MM stands for the month, DD stands for the day, CC represents the century, and YY stands for the year MultiLink codes  Groups of procedure code entries that relate to a single activity n Office Hours patient information  The area of the Office Hours window that displays information about the patient who is selected in the provider’s daily schedule once-a-month billing  A type of billing in which statements are mailed to all patients at the same time each month p packing data  The deletion of vacant slots from the database patient aging report  A report that lists a patient’s ­balance by age, date, and amount of the last payment patient-centered medical home (PCMH)  A model of primary care that provides comprehensive and timely care to patients, while emphasizing teamwork and patient involvement patient day sheet  A summary of patient activity on a given day patient information form  A form that includes a patient’s personal, employment, and insurance data needed to complete an insurance claim patient ledger  A report that lists the financial activity in each patient’s account patient portal  A secure online website which provides patients with the ability to communicate with their provider and access their health information at any time patient statement  A list of the amount of money a patient owes, the procedures performed, and the dates the procedures were performed National Health Information Network (NHIN)  A common platform for health information exchange across the country payer  Private or government organization that insures or pays for healthcare on behalf of beneficiaries National Provider Identifier (NPI)  A standard identifier for healthcare providers consisting of ten numbers payment day sheet  A report that lists all payments received on a particular day, organized by provider navigator buttons  Buttons that simplify the task of moving from one entry to another payment plan  An agreement between a patient and a practice in which the patient agrees to make ­regular monthly payments over a specified period of time new patient  A patient who has not received services from the same provider or a provider of the same ­specialty or subspecialty within the same practice for a period of three years 474     GLOSSARY payments  Monies received from patients and insurance carriers Copyright ©2016 McGraw-Hill Education i payment schedule  A document that specifies the amount the payer agrees to reimburse the provider for a service point-of-service (POS) plan  A plan, combining ­features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network policyholder  A person or entity who buys an ­insurance plan; the insured practice analysis report  A report that analyzes the revenue of a practice for a specified period of time practice management programs (PMPs)  Software programs that automate many of the administrative and financial tasks in a medical practice preferred provider organization (PPO)  Managed care network of healthcare providers who agree to perform services for plan members at discounted fees premium  The periodic amount of money the insured pays to a health plan for insurance coverage primary insurance carrier  The first carrier to whom claims are submitted procedure  Medical treatment provided by a ­physician or other healthcare provider procedure code  A code that identifies a medical ­service procedure day sheet  A report that lists all the ­procedures performed on a particular day, in numerical order progress notes  A physician’s notes about a patient’s condition and diagnosis prompt payment laws  State laws that mandate a time period within which clean claims must be paid; if they are not, financial penalties are levied against the payer protected health information (PHI)  Information about a patient’s health or payment for healthcare that can be used to identify the person provider’s daily schedule  A listing of time slots for a particular day for a specific provider that ­corresponds to the date selected in the calendar Copyright ©2016 McGraw-Hill Education provider selection box  A selection box that ­determines which provider’s schedule is displayed in the provider’s daily schedule purging data  The process of deleting files of patients who are no longer seen by a provider in a practice r rebuilding indexes  A process that checks and ­verifies data and corrects any internal problems with the data recalculating balances  The process of updating ­balances to reflect the most recent changes made to the data recall list  A list of patients who need to be contacted for future appointments referring provider  A physician who recommends that a patient see a specific other physician remainder statements  Statements that list only those charges that are not paid in full after all insurance carrier payments have been received remittance advice (RA)  A document that lists the amount that has been paid on each claim as well as the reasons for nonpayment or partial payment restoring data  The process of retrieving data from backup storage devices revenue cycle management  Managing the activities associated with a patient encounter to ensure that the provider receives full payment for services s sponsor  In TRICARE, the active-duty service ­member standard statements  Statements that show all charges regardless of whether the insurance has paid on the transactions t tickler  A reminder to follow up on an account timely filing  The requirement that claims must be submitted to payers within a specific number of days from the date of service u uncollectible account  An account that does not respond to collection efforts and is written off the practice’s expected accounts receivable w walkout receipt  A receipt given to the patient after a payment is made that lists the procedures, diagnosis, charges, and payment write-off  A balance that has been removed from a patient’s account x X12 837 Health Care Claim or Equivalent Encounter Information (837P)  HIPAA standard format for ­electronic transmission of a professional claim from a provider to a health plan GLOSSARY     475 index ACA See Affordable Care Act (ACA) Access rights, 76 Accountable care organization (ACO), 7–8 Accounts receivable (AR), 334 Accounts receivable (AR) reports daily, 334–335 function of, 334 monthly, 335–336 Account tab, 166–168 Accredited Standards Committee, 29 Activities menu, 51–52, 89, 106, 387 Add Collection List Item button, 56 Address List button, 57 Address List dialog box, 141–143 Adjudication, 25, 27 Adjustments defined, 197 for nonsufficient funds checks, 227–228 patient refunds as, 223–227 Administrative functions, 13–14 Administrative safeguards, 35–36 Affordable Care Act (ACA) defined, 4–5 HIPAA and, 27–29 patient information requirements in, 133 provisions of, After-visit summary (AVS), 13 Aging buckets, 335 Aging claims, 374 Aging reports defined, 335 insurance, 336 patient, 335–336, 385–386 as tool in collections process, 385–386 American Hospital Association (AHA), 241 American Medical Association (AMA), 241–242 Analysis reports appointment eligibility, 347 billing/payment status, 342–344 copayment, 347 electronic claims analysis, 347 function of, 342 insurance, 346 outstanding copayment, 347 practice, 344–345 referral source, 347 476 referring provider, 346 unapplied deposit, 347 unapplied payment/adjustment, 347 Analysis Reports submenu, 342 Apply Payment/Adjustments to Charges dialog box, 287, 288, 290, 298, 302, 306 Apply to Co-pay button, 214 Appointment Book button, 56 Appointment eligibility analysis— detail and summary, 347 Appointment Entry button, 87 Appointment List button, 87 Appointment scheduling See also Office Hours program allowing for provider breaks in, 115–117 creating patient recall list and, 111–115 finding available time slots for, 99–101 for follow-up appointments, 98–99 general procedure for, 89–98 importance of, 86 for new patients, 101–102 printing provider schedules and, 117–118 for repeat appointments, 102–104 rescheduling and canceling ­previous appointments and, 104–105 transferring information to ­electronic health records and, 120 verifying insurance eligibility and benefits and, 105–109 Assigned Provider drop-down list, 135 Attachments, sent with electronic claims, 265–267 Attending provider, 250 Audit controls, 78 Audits, 38 Audit trail, 37 Auto Log Off, 78, 79 b Backup data, 66 Backup files created when exiting Medisoft, 66–68 function of, 66–67 restoring, 69–70 steps to create, 67–69 Backup Reminder dialog box, 67 Backup Warning dialog box, 67 Billing Codes box, 250 Billing cycle, 241–248 See also ­Medical documentation and billing cycle Billing/payment status reports, 342–344 Blue Cross/Blue Shield, 295–297 Breach, 37, 38 Break Entry button, 87 Break List button, 87 Breaks, provider, 115–117 Bundled payments, Business associate (BA), 31 c Calendar, 63, 64 Canceling appointments, 104–105 Capitated accounts, 304–306 Capitated plan, 170 Capitation payments defined, 281 entering, 299–304 Carrier tab, 256–257 Carrier tab, 257 Carrier tab, 257 Case dialog box, 160–162 Case drop-down list, 199, 200 Case Indicator box, 250 Cases Account tab for, 166–168 command buttons for, 159–160 Comment tab for, 183–185 Condition tab in, 178–181 created for imported transactions, 190 defined, 157 Diagnosis tab in, 176–178 EDI tab for, 185–188 editing information for, 188–189 entering health information for, 176–182 entering insurance information for, 168–175 entering miscellaneous information for, 182–188 entering patient and account information for, 162–168 examples of, 158 Medicaid and Tricare tab in, 173–175 Copyright ©2016 McGraw-Hill Education a Copyright ©2016 McGraw-Hill Education Miscellaneous tab in, 182–183 navigating in Medisoft, 159–162 Personal tab for, 162–165 Policy tab for, 168–170 Policy tab in, 171–172 Policy tab for, 172, 173 when to set up new, 157, 158 Cash flow, 14 Centers for Medicare and Medicaid Services (CMS), 238 See also Medicaid; Medicare CHAMPUS See TRICARE CHAMPVA (Civilian Health and Medical Program) applying payments to charges, 291–293 defined, 238 entering a deposit from, 285–286 Charges applying payments to, 213–215, 287–293 buttons for, 204–206 defined, 197 entering, 200–204, 208–211, 219–220 imported from electronic health record, 229–230 saving, 207 Chart drop-down list, 199 Chart Number boxes, 250, 331 Chart numbers assignment of, 132 for cases, 198–199 defined, 91 function of, 131–132 Checking in/checking out patients, 17, 18, 23, 109–110 Checks, 227–228 CIGNA, 238 Civilian Health and Medical ­Program (CHAMPVA) See CHAMPVA (Civilian Health and Medical Program) Claim dialog box, 156 Claim Management button, 56 Claim Management dialog box, 248, 249, 252, 254, 300, 301, 305 Claims (insurance) See also ­Collection issues; Health insurance; Payments adjustments to, 278 aging, 374 changing status of, 260–261 clean, 242, 372 clearinghouses for, 24–25, 262–263, 372, 373 CMS-1500 form for, 242–248 creating, 249–252 denial of, 278, 279, 373–374 editing process for, 256–260 electronic, 242, 262–267 (See also Electronic claims) following up on, 372–374 locating, 252–256 management in Medisoft, 248–249 medical necessity of, 241–242 monitoring status of, preparing and transmitting, 8–9, 23–25 prompt payment laws and, 372–373 resubmitted, 374 review of, 260 sending attachments with, 265–267 timely filing of, 373 workflow for, 262–265 X12 837 Health Care Claim or Equivalent Encounter ­Information (837P), 242 Clean claims, 242, 372 Clearinghouse for claims, 262–263, 372, 373 defined, 24–25 CMS-1500 defined, 242 example of, 243 for exempt practices, 29 field names, 244–245 in Medisoft help feature, 246–248 Codes/coding color, 206–207, 213, 215 compliance review and, 17, 19–20 CPT, 20–21, 275 defined, 19 HCPCS, 21 ICD-9-CM, 20, 21, 50 ICD-10-CM, 20, 21, 49–50 patient payment plan, 378 Coinsurance, 105, 239 Collection agencies, 381–383 Collection issues See also Patient balances adding accounts to collection list and, 387–395 clearing houses and, 372, 373 collection agencies and, 381–383 collection letters to address, 395–399 collection tracer reports and, 399–400 following up on insurance claims and, 372–374 laws governing patient, 377–378 medical practice financial policy and, 374–377 patient aging reports and, 385–386 patient collection timetable and, 377 payment plans to deal with, 378–381 writing off uncollectible accounts and, 384–385 Collection letters creating, 395–396, 398–399 example of, 397 Collection list adding accounts to, 387–391 defined, 387 entering tickler item for, 391–395 Collection List button, 56 Collection List dialog box, 387, 388 Collection tracer reports, 399–400 Color coding for payment status, 213, 215 for transaction entry, 206–207 Comment tab for cases, 183–185 to edit claims, 258, 259 for patient statements, 312, 313 Commonwealth Fund, 3, 375 Completed Find Open Time dialog box, 100 Completing New Appointment Entry dialog box, 96 Computerized medical records (CMRs) See Electronic health records (EHRs) Computerized patient records (CPRs) See Electronic health records (EHRs) Computers See Health information technology (HIT) Condition tab, 178–181 Confidentiality See Privacy Consumer Credit Protection Act, 378 Consumer-driven health plans (CDHP), 241 Copayment reports, 347 Copayments See also Payments defined, 239 entering, 214, 216–220 in Office Hours, 94 verification of, 105 Copy Case button, 160 Covered entity, 31 CPT codes, 20–21, 275 See also ­Current Procedural ­Terminology (CPT); Procedure codes Create Claims dialog box, 249, 251 Create Statements dialog box, 308–310 Current Procedural Terminology (CPT), 20–21, 50 See also CPT codes Custom reports creating, 356–358 function of, 327 Custom Reports List button, 57 Cycle billing, 315 INDEX     477 Daily reports, 334–335 Data backup, 66 deleting, 61–62 editing, 58–61 entering, 58 packing, 72–73 purging, 74–75 for reports, 329–334 restoring, 69–70 saving, 61, 66 Databases defined, 8, 49 Medisoft, 49–50 restoration of, 69–70 Dates, in Medisoft, 62–64, 249–251, 331–333 Day sheets defined, 334–335 patient, 336–340 payment, 341–342 procedure, 340–341 Debt collections See Collection issues Deductible, 105, 170, 239 Delete button, 204 Delete Case button, 159–160 Deposit dialog box, 282–286, 299 Deposit List dialog box, 211, 279–282, 285, 286 Detail button, 205, 280 Diagnosis, 19 Diagnosis Code List button, 56 Diagnosis codes, 19–20 Diagnosis tab, 176–178, 265, 266 Diagnostic code database, 49–50 Diagnostic codes, HCPCS, 21 Documentation, 10 See also Medical documentation and billing cycle e EDI See Electronic data interchange (EDI) EDI Notes button, 205, 266, 267 EDI Note tab, 259 EDI Report, 177, 265, 266 EDI Tab, 185–188 Edit Case button, 159 Edit feature for case information, 188–189 for claims, 256–259 for data in Medisoft, 58–61 for insurance claims, 256–260 for patient information, 149–150 for patient statements, 311–313 for transactions, 208 478     INDEX Edit menu, 51, 52 Edit Patient Notes in Final Draft button, 57, 87 Edits, 25 Edit Templates button, 87 EFT (electronic funds transfer) See Electronic funds transfer (EFT) EHRs See Electronic health records (EHRs) Electronic claims See also Claims (insurance) clearinghouse for, 262–263 creating, 262 performing edit check for, 263–265 sending attachments with, 265–267 transmission of, 242 Electronic claims analysis—detail and summary, 347 Electronic data interchange (EDI), 28–29 Electronic funds transfer (EFT), 25, 29, 278–279 Electronic health records (EHRs) administrative processes and, 13–14 charge transactions imported from, 229–230 creating cases for imported ­transactions, 190 decision support and, 13 defined, 4, 10 electronic communication and connectivity and, 13 health information and data ­elements of, 10–11 McKesson Practice Interface ­Center program and, 363 order management and, 12 patient support and, 13 reporting and population ­management and, 14 results management and, 11–12 transferring appointment ­information to, 120 transferring patient information to, 120, 151–152 Electronic patient records (EPRs) See Electronic health records (EHRs) Electronic prescribing, 12 Electronic protected health ­information (ePHI), 31 Electronic remittance advice (ERA), 25, 276 Eligibility verification, 106–109 Employer identification number (EIN), 30 Employer information, 141–144 Encounter forms, 21–23, 161 Enter Deposits and Apply Payments button, 57 Entering data in Medisoft, 58 EPSDT (Early and Periodic Screening, Diagnosis, and Treatment), 173, 175 Established patients, 130 See also Patients Exit button, 87 Exiting Medisoft, creating backup file while, 66–68 Exit Program button, 57 Explanation of benefits (EOB), 25 f Fair Debt Collection Practices Act of 1977, 377–378 Fee for service, Fee-for-service plans See Indemnity plans Fee schedule, 274 Field options, 146 Fields box, 145–148 File Maintenance dialog box, 71, 75 File maintenance utilities creating backup files in, 66–69 packing data in, 72–73 purging data in, 74–75 rebuilding indexes in, 72 recalculating patient balances in, 75, 76 restoring backup files in, 69–70 File menu, 50–51 Filters, 249 Financial policy importance of, 374–377 of medical practice, 17 Find Open Time dialog box, 100 First Claim button, 248 Flash drives, saving data on, 66 Follow-up appointments, 98–99 See also Appointment scheduling Forms See also Reports CMS-1500, 243 encounter, 21–23, 161 g General tab, 311–312 Go to a Date button, 87 Go to Today button, 87 Guarantor, 134–135 h HCPCS codes, 21 Healthcare spending, Healthcare system Affordable Care Act and, 4–5 electronic health record programs and, 10–14 Copyright ©2016 McGraw-Hill Education d Copyright ©2016 McGraw-Hill Education www.downloadslide.net HIPAA and, 27–38 (See also Health Insurance Portability and Accountability Act of 1996 (HIPAA)) HITECH Act and, 10, 14, 27–28, 38, 76–79 medical documentation and billing cycle and, 14–27 (See also Medical documentation and billing cycle) physical practice challenges and, 5–8 practice management programs and, 8–9 trends in, 3–4 Health Information Technology for Economic and Clinical Health (HITECH) Act HIPAA and, 27–28, 38 meaningful use incentives in, 10, 14 security requirements of, 76–79 Health information technology (HIT) See also Electronic claims; Practice management programs (PMP) defined, HITECH Act and, 76–79 practice management programs and, 10 Health insurance See also Thirdparty payers basic information about, 238 patient eligibility verification and benefits of, 105–109 plan types for, 239–241 Health insurance claims See Claims (insurance) Health Insurance Portability and Accountability Act of 1996 (HIPAA) Affordable Care Act and, 27–29 electronic transaction and code sets and, 28–30 function of, 27 HITECH Act and, 27, 28, 38 privacy requirements of, 30–35, 377 sections of, 28 security requirements of, 35–38, 76–79 Health management organizations (HMOs), 239–240 Health Plan Identifier (HPID), 30 Health savings account (HSA), 241 Help button, 87 Help feature built-in, 64–66, 242, 246–248 hints, 64 Medisoft Help button, 57 Help menu, 54, 64–66 High-deductible health plan with savings option (HDHP/SO), 240–241 HIPAA Breach Notification Rule, 37, 38 HIPAA Omnibus Rule, 28, 37 HIPAA Privacy Rule, 30–31, 37 HIPAA Security Rule, 35–37 HIPAA See Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA/ICD-10 tab, 78, 79 HIT See Health information ­technology (HIT) HITECH Act See Health Information Technology for ­Economic and Clinical Health (HITECH) Act Home health claims, 187–188 l i Managed care defined, 239 reimbursement for, 274–276 McKesson Practice Interface Center (MPIC) program, 363 Meaningful use, Medicaid ACA and, in cases, 169, 173–175 explanation of, 238 Medical coder, 241 Medical documentation and billing cycle billing compliance review and, 23 claim preparation and transmittal and, 23–25 coding compliance review and, 17, 19–20 defined, 14–15 establishment of financial responsibility and, 16–17 ICD-10 implementation and, 20–23 patient check in and, 17, 18 patient check out and, 23 patient statement generation and, 27 payer adjudication and, 25–27 payment and collection followup and, 27 preregistering patients and, 16 role of claims in, 241–248 steps in, 14–16 Medical Group Management Association (MGMA), 374–375 Medical insurance See Health insurance Medical necessity, 241–242 Medical practices See also Providers collection agency use by, 381–383 financial policies of, 374–377 writing off uncollectible accounts by, 384–385 ICD-9-CM codes defined, 20, 50 ICD-10-CM codes vs., 20, 21 ICD-10-CM codes defined, 20, 49–50 ICD-9-CM vs., 20, 21 implementation of, 20–21, 23 Medisoft and, 78, 79 Indemnity plans defined, 239 reimbursement for, 274 Indexes, rebuilding, 72 Information See Patient information Institute of Medicine, 10 Insurance See Health insurance Insurance aging reports, 336 Insurance analysis reports, 346 Insurance carrier database, 49 Insurance carriers primary, 168–170 secondary, 171–172 Insurance Carriers List button, 56 Insurance Carriers List dialog box, 61 Insurance claims See Claims ­(insurance) Insurance identification cards, 17, 19 International Classification of Disease 9th Revision, Clinical Modification (ICD-9-CM), 20, 50 10th Revision, Clinical Modification (ICD-10-CM), 20, 49–50 k Karnofsky Performance Status Scale, 180 Last Claim button, 249 Launch Medisoft Reports button, 57 Launch Work Administrator button, 57 List Only Claims That Match dialog box, 252–255, 305 Lists menu, 52–53, 378 List window, 145, 146 Locate buttons, 147–149, 280 Locate window, 148 Location box, 250 Logins, 78 Logoffs, 78–79 Lookup dialog box, 330, 331 m INDEX     479 480     INDEX Edit menu, 51, 52 File menu, 50–51 Help menu, 54, 64–66 Lists menu, 52–53, 378 Reports menu, 53, 327, 336, 337, 352, 353, 395 Window menu, 53–54 Medisoft payment entry applying insurance payments to charges, 213–215, 287–293 for capitation payments, 299–304 for patient payments received in mail, 297–299 Medisoft printing See Printing ­procedures Medisoft Program Date, 62–64 Medisoft Report Designer, 327 Medisoft reports See also Reports aging, 356 custom, 356–358 navigating in, 352–355 Report Designer to create, 327, 359–362 standard, 351–352, 363 types of, 327 Medisoft Reports menu, 352–354 Medisoft Reports toolbar, 355 Medisoft Security Permissions ­dialog box, 77 Medisoft utilities creating backup files and, 66–69 file maintenance, 71–76 packing data and, 72–73 purging data and, 74–75 rebuilding indexes and, 72 recalculating patient balances and, 75, 76 restoring backup files in, 69–70 Miscellaneous tab, 182–183 MMDDCCYY format, 64 Monthly reports, 335–336 MultiLink button, 204–205 MultiLink codes, 204–205 n Name, Address tab, 131–133 National Council for Prescription Drug Programs (NCPDP), 29 National Provider Identifier (NPI), 30 National Uniform Claim Committee (NUCC) (American Medical Association), 242 Navigator buttons, 248–249 Need Referral, 94 New Appointment Entry dialog box, 91, 92, 94, 96, 97, 102, 103 New Break Entry dialog box, 116 New Case button, 159 New patients See also Patients defined, 130 entering information for, 130–144 scheduling appointments for, 101–102 New York Prompt Payment Law, 372 Next Claim button, 249 Nonsufficient funds (NSF) checks, 227–228 Note button, 205 Notice of Privacy Practices, 31–35 o Office Office Office Office Office Office for Civil Rights (OCR), 37, 38 Hours break, 115–117 Hours calendar, 88 Hours menu bar, 86, 87 Hours patient information, 88 Hours program See also Appointment scheduling booking follow-up appointments in, 98–99 checking patients in and out in, 109–110 creating overdue balance report for patients in, 111 creating patient recall list in, 111–115 creating provider breaks in, 115–117 entering and exiting, 89 functions of, 86–89 looking up provider in, 97–98 procedure to enter appointments in, 89–98 program options in, 89 rescheduling and canceling appointments in, 104–105 scheduling appointments for new patients in, 101–102 scheduling repeat appointments in, 102–104 searching for available time slots in, 99–101 toolbar in, 86, 87 transferring appointment information in, 120 verifying insurance eligibility in, 105–109 viewing and printing schedules in, 117–118 Office Hours toolbar, 86, 87 Office Hours window, 86, 88, 90, 95 Office Notes tab, 393 Office visits entering payments made during, 211–216 walkout statements/receipts for, 207, 220–223 Copyright ©2016 McGraw-Hill Education Medicare explanation of, 238 fee schedules for, 275–276 filing claims under, 373 Medicare Physician Fee Schedule (MPFS), 275–276 Medisoft appointment scheduling in, 75–105 (See also Appointment scheduling) auto log off and unapproved codes in, 78–79 changing program date in, 62–64 claim management in, 248–249, 262 CMS-1500 in, 242–248 creating backup files while exiting, 66–68 creating reports in, 327–329, 359–362 databases and, 49–50 dates in, 62–64, 249–251, 331–333 defined, 49 deleting data in, 61–62 editing data in, 58–61 entering data in, 58 entering insurance information in, 168–175 entering insurance payment in, 279–287 entering new patient information in, 130–144 exiting, 66 file maintenance utilities in, 71–76 installation of, 44–45 navigating cases in Medisoft, 159–162 organization of patient information in, 129–130 packing data in, 72–73 privacy and security features of, 76–79 purging data in, 74–75 rebuilding indexes in, 72 recalculating patient balances in, 75, 76 restoring backup file in, 69–70 saving data in, 61 Security Setup option, 76 toolbar in, 55–57 transferring information to ­electronic health record from, 120 user logins and audit controls in, 78 using help feature in, 54, 64–66 Medisoft Help button, 57 Medisoft menus Activities menu, 51–52, 89, 106, 387 defined, 50 Once-a-month billing, 315 Other Information tab, 134–137 Outstanding copayment reports, 347 Overdue balance reports, creating, 111 Copyright ©2016 McGraw-Hill Education p Pack Data tab, 73 Packing data, 72–73 Paper records, CMS-1500, 242–246 Patient account ledger reports, 348–351 Patient aging reports, 335–336 Patient balances See also Collection issues added to collection list, 387–395 collection letters to address, 395–399 collection process for, 374–377 laws governing collection of, 377–378 overdue balance report for, 111 payment plans for, 378–381 recalculation of, 75, 76 referred to collection agencies, 381–383 remainder charges in, 94 uncollectible, 384–385 Patient by Diagnosis reports, 351 Patient by Insurance Carrier reports, 351, 352 Patient-centered medical home (PCMH) defined, 6–7 features of, Patient day sheets, 336–340 Patient/Guarantor dialog box adding new patient to, 138–141 adding payment plan in, 380, 381 editing patient information in, 150 Name, Address tab in, 131–134 Other information tab in, 134–137 Payment Plan tab in, 137–138 tabs in, 130–131 Patient information for cases, 162–168, 197–200 editing, 149–150 entered for new patients, 130–144 on insurance identification cards, 17, 19 in Office Hours, 88 organized in Medisoft, 129–130 searching for, 144–149 transfered to electronic health records, 120, 151–152 Patient information form, 17, 18 Patient ledgers, 348–351 Patient List button, 56, 87 Patient List dialog box, 98, 129, 145, 147, 159 Patient Payment Plan List dialog box, 379 Patient portals, 13 Patient Protection and Affordable Care Act See Affordable Care Act (ACA) Patient Quick Entry button, 56 Patient Recall Entry button, 57 Patient Recall List button, 87 Patient Recall List dialog box, 112–114 Patients See also Established patients; New patients appointment scheduling for new, 101–102 (See also Appointment scheduling) checking in and checking out, 17, 18, 23, 109–110 collection issues related to, 374–377 creating recall list for, 111–115 data on, 49 electronic health records as ­support for, 13 Medisoft features to protect ­privacy of, 76–79 preregister of, 16 printing list of, 358 referral requirements for, 94 verifying identity of, 17 verifying insurance eligibility and benefits for, 105–109 Patient statements creating, 307–311 defined, 307 editing, 311–313 example of, 317 generation of, 27 printing, 313–316, 318 remainder, 309, 315–317 standard, 309 walkout, 207, 220–223 Payers, 238 See also Third-party payers Pay-for-performance models, 6–7 Payment day sheets, 341–342 Payment plans, 137 assigning patient account to, 380–381 creating patient, 378–380 defined, 378 Payment Plan tab, 137–138 Payments See also Claims ­(insurance); Collection issues; Copayments; Third-party ­payers Affordable Care Act and, applied to charges, 213–215, 297–299 bundled, capitation, 281, 299–306 color coding to indicate status of, 213, 215 copayments, 94, 105, 214, 216–220 creation of walkout receipt for, 220–223 defined, 197 establishing financial responsibility for, 16–17 following up on, 27 made with nonsufficient funds check, 227–228 processing refund for, 223–227 recalculating patient balances, 75, 76 received by mail, 297–299 receiving and processing, saving information on, 216 at time of office visit, 211–213 time-of-service, 17 zero-amount, 304 Payment schedule, 274 Payment statements/reports accounts receivable reports, 334–336 billing/payment status, 342–344 insurance aging, 336 monthly, 335–336 patient aging, 335–336 patient statements, 307–318 payment day sheets, 341–342 walkout, 207, 220–223 Permissions option, 76, 77 Personal tab, 162–165 PHI See Protected health information (PHI) Physical safeguards, 36–37 Physicians Affordable Care Act and, 5–8 decision support for, 13 PMP See Practice management ­programs (PMP) PMP databases, 8–9 Point-of-service (POS) plans, 240 Policyholders, 169, 238 Policy tab, 168–170 Policy tab, 171–172 Policy tab, 172, 173 Practice analysis reports, 344–346 Practice exercises for appointments and registration, 411–415, 428 for cases, transactions, and claims, 416–422, 429–430 for reports and collections, 423–426, 431–433 Practice management programs (PMP) See also Medisoft defined, functions of, 8–9 insurance eligibility verification in, 106–107 INDEX     481 482     INDEX Purge Data tab, 74 Purging data, 74–75 q Quick Balance button, 57 Quick Ledger button, 57 r RA See Remittance advice (RA) Real-Time Eligibility Verification dialog box, 106 Rebuilding indexes, 72 Recalculate Balances Tab, 76 Recalculating balances, 75, 76 Recall list adding patients to, 113–115 creating, 112–113 defined, 112 function of, 111–112 Receipts, walkout, 207, 220–223 Referral source reports, 347 Referring provider, 166–167 Referring Provider List button, 56 Referring provider reports, 346 Refresh Data button, 249 Refunds, processing patient, 223–227 Registries, 14 Reimbursement examples of, 276 for indemnity plan, 274 for managed care plan, 274–275 for Medicare, 275 Remainder charges, 94, 391 Remainder statements, 309, 315–317 Remittance advice (RA) defined, 25 electronic, 25 examples of, 26, 277 steps to process, 276–279 Repeat appointments, 102–104 See also Appointment scheduling Repeat Change dialog box, 102, 103 Report Designer function of, 327, 329 to modify reports, 360–362 Reports See also specific types of reports accounts receivable, 334–336 aging, 335–336 analysis, 342–347 collection tracer, 399–400 custom, 327, 356–358 data selection for, 329–334 day sheets, 336–342 electronic health records and, 14 Medisoft, 327 navigating in Medisoft, 352–355 options to create, 327 overdue balance, 111 patient ledger, 348–351 printing procedures for (See Printing procedures) standard Medisoft, 327, 351, 352 standard patient list, 351–352 using Medisoft Report Designer to produce, 327, 359–362 using MPIC program to exchange information for, 363 Reports menu, 53, 327, 336, 337, 352, 353, 395 Report transmission code, 177–178 Report Type Code, 177 Rescheduling appointments, 104–105 See also Appointment scheduling Resource List button, 87 Restore dialog box, 70 Restore warning box, 70 Restoring data, 69–70 See also Backup data Revenue cycle management (RCM), 27 s Safeguards administrative, 35–36 physical, 36–37 technical, 37 Scheduling See Appointment ­scheduling Search Again button, 87 Search Data button, 327 Search dialog box, 329, 330, 339 Search feature Field box, 145–147 Locate buttons option, 147–149 Search for box, 145–147 Search for Open Time Slot button, 87 Secondary insurance carrier, 171–172 Security See also Privacy audit controls, 78 Auto Log Off feature, 78–79 HIPAA requirements for, 35–37, 76–79 HITECH requirements for, 76–79 Medisoft features to ensure, 76–79 user logins and, 78 Security Setup option, 76 Shortcut menu, 62, 93, 206 Shortcuts Copy Address button as, 133 to cut and paste, 104 entering data with F8 function key as, 142 to open patient or case, 129 searching with Locate window as, 148 Show/Hide Hints button, 57 Sponsor, 175 Copyright ©2016 McGraw-Hill Education Preferred provider organizations (PPOs), 105, 239 Premiums, 238 Preregistering patients, 16 Previous Claim button, 248–249 Primary Insurance box, 250 Primary insurance carrier, 168–170 Print Appointment List button, 87 Print button, 327 Print Claim button, 207 Print Grid button, 160 Printing procedures for patient account ledgers, 349–351 for Patient by Insurance Carrier report, 352 for patient day sheets, 338–340 for patient lists, 358 for patient statements, 313–316, 318 for procedure codes list, 358 for provider schedules, 117–118 for reports, 327–329 for walkout receipts, 220–223 Print Report Where? dialog box, 329 Privacy See also Security HIPAA requirements for, 30–31, 377 HITECH Act and, 76–79 Medisoft features to ensure, 76–79 Notice of Privacy Practices, 31–35 Procedure code database, 50 Procedure Code List button, 56 Procedure codes See also CPT codes defined, 20 printing list of, 358 Procedure day sheets, 340–341 Procedures, 19 Program Options dialog box, 78–79 Progress notes, 161 Prompt payment laws, 372–373 Protected health information (PHI), 31, 35 Provider box, 250 Provider List button, 56, 87 Providers See also Medical ­practices attending, 250 breaks for, 115–117 database of, 49 fee schedules for, 275, 276 looking up, 97–98 referring, 166–167 schedules for, 88, 117–118 Provider’s daily schedule, 88 Provider selection box, 88 Standard patient lists reports, 351–352 Standard reports See also Reports Medisoft, 351, 352 types of, 327 Standard statements, 309 Standard Unique Employer ­Identifier, 30 Statement Management button, 56 Statement Management dialog box, 307–308, 311 Statements See Patient statements t Uncollectible accounts, 384–385 United States, healthcare rankings in, User logins, 78 u z Unapplied deposit reports, 347 Unapplied payment/adjustment reports, 347 v View Eligibility Verification Results button, 56 View Statements button, 160 Vision claims, 187 w Walkout receipts/statements, 207, 220–223 Warn on Unapproved Codes box, 79 Window menu, 53–54 Windows System Date, 251 Workers’ compensation, 180, 238 Write-off, 384–385 x X12-835 Claims Payment and ­Remittance Advice, 29 X12-837 Health Care Claim or Equivalent Encounter ­Information (837P), 29, 242 Zero amount payment, 304 Copyright ©2016 McGraw-Hill Education Tab key, 58 Technical safeguards, 37 Telephone Consumer Protection Act of 1991, 378 Third-party payers See also Health insurance applying payments to charges, 287–297 defined, 238 entering insurance payment in Medisoft from, 279–286 reimbursement from, 274–275 remittance advice processing and, 276–279 standard fees of, 274 Tickler Item dialog box, 391, 392 Ticklers creating, 387, 391 defined, 387 entering, 391–393 Timely filing, 373 Time-of-service payments, 17 Toolbar, 55–57 Tools menu, 53 Transaction database, 50 Transaction Dates boxes, 249–250 Transaction entry for adjustments, 197 billing/reimbursement (See Medical documentation and billing cycle) for charges, 197, 200–211, 229–230 (See also Charges) color coding in, 206–207 editing, 208 function of, 197 for nonsufficient funds checks, 227–228 for patient refunds, 223–227 for payments, 197, 211–220 (See also Payments) printing walkout receipts and, 220–223 saving, 207 selecting patient and case for, 197–200 Transaction Entry button, 56 Transaction Entry Chart drop-down list, 59 Transaction Entry dialog box, 60, 197, 198, 200, 201, 209–211, 220, 224, 226, 227, 266, 267 Transaction Entry Save Warning dialog box, 61 Transactions tab, 257–258, 312 TRICARE, 169, 173–175 Truth in Lending Act, 378 INDEX     483 .. .computers in the medical office Copyright ©2016 McGraw-Hill Education SUSAN M SANDERSON, CPEHR Ninth Edition COMPUTERS IN THE MEDICAL OFFICE, NINTH EDITION Published by McGraw-Hill... the Medical Office Discusses the changes taking place in the field of healthcare Covers the medical documentation and billing cycle and the role that computers play in that cycle Also covers the. .. lining the bookshelves or filing cabinets of a medical office The information technology that had transformed other areas of life such as shopping, banking, and entertainment was not having the