Hospital
Patient Data Flow Document
Motto: “Doing it Right the First Time”
Summary
Improving and refining the reimbursement process for the hospital requires every employee to take stock and ownership through leadership support and direction. The revenue cycle for the hospital includes all administrative and clinical functions that contribute to the capture, management, and collection of revenue derived from patient services.
Embrace and encourage reimbursement through process re-design; realize commitment to process improvement is not a “quick fix.”
Understand and appreciate the valuable role that every employee plays and how their actions directly impact the reimbursement process.
Recognize it is every employee’s job to accept accountability and to work together in a positive team environment during process change to better serve the patient and the hospital.
Recognize that active involvement is required from all levels of staff, from the front line through management, to commit to a higher level of improvement and dedication.
In order to maximize reimbursement and control costs, every step in the patient data flow process must be done “Right the First Time”.
- Scheduling of all outpatient procedures
- Pre-authorization, eligibility verification, medical necessity, and co-payment collection
- Pre-registration with accurate and complete capture of patient demographic information
- Registration
- Documentation that is complete and legible
- Charging
- Coding, billing and collections
- Denial and contract management
Purpose
The purpose of this document is to identify the data that is captured, describe what it is used for, and explain the consequences when it is absent or incorrect.
Patient Data Flow Steps
1. Scheduling (outpatient only)
Every patient should be registered prior to having a hospital service performed. Based upon the type of service the patient visit may or may not be scheduled. The following demographic information should be obtained at the point of scheduling:
Legal Patient Name
Sex
Date of Birth
SSN
Home Phone
Work Phone
Insurance information
Obtaining insurance information during scheduling is critical for procedures where pre-authorization is required. The insurance name, policy #, subscriber name and subscriber social security number are required to obtain the pre-auth and to remain compliant with HIPAA billing edits.
You should confirm the insurance information prior to updating the patient account.Capturing the correct insurance information is a crucial step in getting paid for the services rendered to the patient. The insurance coverage for a patient may frequently change; never assume the patient data is current…ALWAYS CONFIRM AND UPDATE!
To complete scheduling the following information should be obtained in addition to the patient demographic information mentioned above:
Procedure type w/ CPT code
Diagnosis (sign/symptom w/ICD-9 code)
Ordering Physician
Date/Time
Who Called
The “Reason For Visit” should be captured,with a brief description of the reason for this visit (ie., sign/symptom). Do not input the procedure only. An ICD-9 diagnosis code is required to check for medical necessity against National and Local Medical Review coverage policies.
2. Pre-Authorization
Not obtaining a pre-authorization before a procedure is performed may result in a denial from the insurance payor. Pre-registration involves verifying the insurance eligibility and benefits, obtaining and documenting the pre-auth # or referral IF REQUIRED, confirming Medical Necessity, and informing the patient of their applicable financial obligation (e.g. ABN for Medicare, co-payment). Emergent services may require notification within 24 hours of treatment. Not completing these steps pose a reimbursement risk to the hospital. Several third party payors now have websites whereby a provider can register and connect directly to their individual database to confirm patient eligibility and benefits.
3. Pre-Registration
The Pre-registration process is a fundamental step. The goal is to capture as much patient information as possible prior to the patient arriving to the hospital so the data can be confirmed for accuracy and completeness.
Oftentimes scheduling occurs directly with the physician office and not with the patient; therefore, Pre-Registration is the next step in the patient flow data process. Pre-registration requires selecting the correct scheduled patient account and making a phone call to the patient to confirm the information gathered during scheduling. If you find at pre-registration that the wrong account was scheduled notify the scheduling office to reschedule them under the correct account number. Likewise during registration you must select the correct pre-registered account or a duplicate account will be created.
Pre-registration is an excellent way to reduce the amount of work required at registration. It is preferable to have all of the patient demographic and insurance information captured before the patient presents to the hospital because it reduces the amount of time the patient spends at the facility waiting to be registered. In addition, phone registration enhances patient privacy. The goal of every scheduler or registrar should be to improve customer satisfaction by making the patient encounter a pleasurable experience while gathering the necessary information “Right the First Time”.
The correct patient status (inpatient vs. outpatient) must be determined per a written physician order to ensure the hospital registers and bills the patient in compliance with federal and state regulation. Patient status drives how a department charges for services performed and how the hospital is reimbursed for services performed. If the correct account number and patient status is not captured “Right the First Time” an incredible amount of rework and/or potential lost charges may occur.
All patients are assigned a Medical Record Number (MR#) for life, unique to each individual. The goal is to never have a patient with more than one MR#. Always use the patient’s SSN or Legal Name to identify the patient during the Master Patient Index (MPI) search. Inquire if the patient has ever had any previous names. Confirming or using combinations of the patient’s Name, SSN, birthday, address, and phone number, can help to make a positive ID of the patient. Physicians make decisions regarding patient care by using the data filed by MR# . If you fail to select the correct patient from the MPI a duplicate MR# is assigned which can possibly distort medical decision-making and pose a compliance risk for the hospital. It costs the hospital approximately $30+ to research, correct and combine a duplicate medical record for one patient that was registered wrong.
The MSP “Medicare Secondary Payor” form should be completed for all Medicare patients during Pre-registration. Providers are required to determine whether Medicare is the primary payor or secondary payor for every inpatient admission and outpatient encounter (including recurring patients and referred labs every 90 days) with a Medicare beneficiary. Failure to properly determine the primary payor is a violation of the provider agreement with Medicare. The provider must determine all insurance coverage during the initial point of contact with the patient by interviewing the patient, completing a patient questionnaire, and contacting family members or employers. A completed copy of the MSP questionnaire must be retained in the provider file a minimum of 10 years from the date of service. This can be an electronic copy.
Provider information is used to identify the physician responsible for providing care to the patient. Results are sent to the physician
4. Registration
As stated previously every patient possible should be registered prior to having a hospital service performed. The following mandatory forms should be explained to the patient and a signature obtained (if required): Facesheet, Consent, Privacy Notice, Advanced Directives, Patient Rights/Responsibilities, and when applicable the Important Message Letters (Medicare, Tricare, Uniform Medical), Advanced Beneficiary Notice, Confidential Patient Status, Blood Refusal Statement, and Emancipated Minor Statement
Medicare has developed a list of inpatient only procedures (majority surgical procedures) that must be identified prior to registration. Medicare considers correcting or changing the patient status from outpatient to inpatient post discharge fraudulent. The hospital may not bill for these services if the correct patient status is not obtained prior to admission. This could result in several thousands of dollars in potential write-offs
Required Registration Patient Data Fields:
Legal Patient Name
If the legal patient name is not used (William vs. Bill, JR, SR, III, etc) the wrong patient may be selected and a duplicate MR# will be generated.
Birth date
Sex
Some procedures (hysterectomy, vasectomy) are specific to one sex and claims can and will be denied if the patient’s procedure does not match the required sex.
Maiden/Other Names
Identifying all potential patient names will assist in searching the patient database to ensure the correct patient is selected.
Mothers Name
Demographic Information
Street
City
State
Zip
Home phone
Other phone
Marital Status
Religion
Affiliation
Employer
Name
Street
City
State
ZIP
Phone
Occupation
Next Of Kin
A blood relative or spouse that is close to the patient.
Name
Street
City
State
ZIP
Home Phone
Work Phone
Relation
Person to Notify
A close relative or friend that may be contacted regarding the future care of the patient.
Name
Street
City
State
ZIP
Home Phone
Work Phone
Relation
Guarantor
The designated person financially obligated for payment of service provided. This is a critical data field for minors.
Name
Street
City
State
ZIP
Home Phone
Relation
SSN
Guarantor’s Employer
Name
Street
City
State
ZIP
Phone
Occupation
Insurance
The insurance coverage for a patient may frequently change so don’t ever assume the insurance indicated in a previous account is correct. Always confirm the insurance with the patient and update if necessary. Billing the wrong insurance will result in a denial usually 60-90 days after the service has been rendered. Additional costs related to researching the denial, appealing, and rebilling are avoidable if the insurance was captured “Right the First Time.”
Number/Name
Policy Number
Status
Subscriber (Policy Holder)
Benefit Plan
Coverage Number
Relation to Patient
Effective Date
Expiration Date
**HIPAA requires every patient claim billed to any insurance company must have the subscriber information complete (with subscriber name, social security number, address, and date of birth) or the patient claim will not be accepted and all services performed during that patient visit will be denied. If the patient has not been admitted to the hospital recently the registrar will have to create and complete the subscriber screen information. If the patient insurance information has changed the registrar will have to update and edit the subscriber screen information.
Admits
Patients admitted with either Observation or SDC patient status are assigned a bed similar to a standard inpatient admit. A patient can remain in outpatient status up to 48 hours if Medicare or Medicaid. A written physician order is required to change the patient status to inpatient once the patient meets intensity of service and severity of illness criteria.
According to the Social Security Act, medically necessary services and supplies must meet the following: (1) they are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition; (2) they are provided for the diagnosis or direct care and treatment of medical conditions; (3) they meet the standards of good medical practice within the medical community in the service area; (4) they are not primarily for the convenience of the patient or provider; and (5) they are the most appropriate level or supply of service which can safely be provided.
A written physician order documenting the patient diagnosis and procedure is mandatory to check for medical necessity against National and Local Medical Review coverage policies for Medicare outpatients. The majority of outpatient medical necessity requirements exist in Radiology, Laboratory, and Therapy Services. If the patient diagnosis does not support medical necessity the patient must sign an ABN “Advanced Beneficiary Notice” form notifying the patient that they are financially responsible for all of the non-covered services rendered during the hospital visit prior to performing the diagnostic test / service.
4. Documentation
The patient’s chart must contain information to justify admission and continued hospitalization, to identify signs/symptoms and clinical findings to support the diagnosis, and to describe the patient’s progress and response to medications and services.
Purpose of medical record:
- Provide a means of communication between the physician and other members of the patient’s healthcare team;
- Provide a basis for evaluating adequacy and appropriateness of care;
- Provide data to substantiate insurance claims;
- Protect legal interests of patient, physician, and facility;
- Provide clinical data for research and education.
The medical record documentation should be:
- Comprehensive and complete: The physician should document all diagnosis, procedures, complications, and comorbidities, as well as abnormal test results. Any suspected conditions and what was done to investigate or evaluate them should also be documented to adequately follow the patient’s course of treatment.
- Timely: All physician dictation, signatures, etc. should be completed in the medical record as patient care is provided.
- Legible: The information should be readable
- Well Documented: The information should be documented properly. With complete information in the medical record, coders will be able to properly analyze, code, and report the required information. This ensures that proper payment is received.
5. Charging & Discharge
The risk potential for billing incorrect information to the insurance company is great if the correct patient account and date of service is not selected during charge entry.
Department charges should be billed within 2-days from the date of service (if outpatient account) or 2-days from the date of discharge (if inpatient account) to avoid generating a late charge.
Inputting charges on the wrong patient account or wrong date of service is a common error. For example, if a patient was here today and you are entering the charges tomorrow but fail to input tomorrow as the date of service the charges will reject and cause a great deal of expense in rework with the potential of losing the charges altogether.
Discharge
Capturing the correct departure date, time and disposition is very important. If the date is wrong any department charges billed could potentially fall out of the admit/discharge date range causing the charges to be rejected. The discharge date is the day the patient physically leaves the hospital.
6. Abstracting – Medical Records
The majority of registration or charge entry errors are identified at the point of coding. To research and correct these errors at this point in the patient flow process is very time consuming and expensive; it also delays hospital payment.
CPT & HCPCS codes can be attached to the majority of billable procedures and non-routine supplies by coding or they can be a part of the charge master. Medical Records should use a grouping software package that assists the coders in assigning diagnostic and procedure codes and reviewing charges billed to ensure compliance with CCI “Correct Coding Initiative” edits. CCI edits identify services that have quantity errors or cannot be billed together because one service is a component of another service or are mutually exclusive. The coders can then review these edits and correct the patient account by either removing charges or adding modifiers, as appropriate, to ‘pass’ the edits. Codes assigned by Medical Records include the following:
ICD-9 Diagnosis “xxx.xx” Inpatient and Outpatient
ICD-9 Procedure “xx.xx” Inpatient and Outpatient
CPT “xxxxx” Outpatient only
Inpatient payment is based upon the principal diagnosis, surgical procedures, age, presence of complications and comorbidities and other pertinent data. Outpatient payment is based upon the principal diagnosis and specific services rendered (ie., nursing care, chemo and blood admit, injections, infusions, diagnostic tests,etc.. Inpatient “DRG” and outpatient “APC” payment is fixed based upon what Medicare believes it costs the hospital to perform a service. Patient length of stay is irrelevant in most cases; therefore, being wise in preserving hospital resources is critical in saving money for the hospital.
All department charges and codes must be supported by legible, complete, and comprehensive nursing and physician documentation. Inadequate documentation could mean the difference in thousands of dollars of reimbursement.
Once the claim is satisfactory, the patient abstract is finalized which produces a patient bill to drop to the insurance payor/patient.
7. Billing Accounts Receivable – Patient Financial Services
A standard hospital UB-04 form or an 837 transaction file is the patient bill generated from the patient account. A little over half of all the fields on the claim forms are those data fields capturedduring registration. The rest are fields which have had contributions from coding, charge entry, the charge master and the internal data files in your computer system. The billing office simply captures all this information, they don’t produce it.
Every piece of data we have captured during our patient data flow process maps to a specific field when the claim form is sent to the insurance payor. The billing office then has to make sure that the claim has all the information necessary. If the claim does not have either correct or complete information, the billing office has to correct and complete this information, either at the time the claim is sent or at a much later date when the claim and payment are denied.
PA-700 Patient Data Flow Final DraftPage: 1Last Update: 4/3/2019
Approved by: Revenue Cycle Team