THE Essential Insights For

CODING
COACH Revenue Optimization April 2022

In This Issue

• Revenue Cycle
Management
(RCM)
• Critical Coding
Questions
• Webinar – Apr 21:
Coordinating
Benefits With VSP
And EyeMed

A Billing And Coding Resource Exclusively For Members Of PECAA, Delivering More With HEA

Your Ultimate Toolkit For Revenue Maximization

As independent eye care practices continue to grow and differentiate themselves in 2022, medical billing and coding are
more important than ever as drivers for practice revenue and growth. We encourage you to take advantage of all the resources
that The Coding Coach provides. If you haven’t already done so, be sure to register for our April 21 webinar (details and a
registration link on page 5). And, we are happy to remind you that you can access more Coding Coach resources by logging
into your member portal. You are also invited to submit your unique coding issues to The Coding Coach billing and coding
experts via our Telephone Hotline: 800.959.2020, Option 2 or Email: [email protected]

Revenue Cycle Management (RCM)

By Kayla Groves, Billing & Coding Advisor

R egardless of the size of your practice or the services offered, Revenue Cycle Management (RCM) is an
essential component to running a successful, profitable practice. The Healthcare Financial Management
Association (HFMA) defines Revenue Cycle Management as, “All administrative and clinical functions that
contribute to the capture, management, and collection of patient service revenue.” 2 In other words, it is a
term that includes the entire life of a patient account from creation to payment. Without well-defined RCM
processes and expectations, essential details or key elements can slip through the cracks, causing revenue loss
or delays in payment.

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CODING
COACH Revenue Optimization
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Scheduling / Visit / Checkout / Accounts

Claim Payment Financial
Insurance Documentation Charge Receivable
Submission Posting Reporting
Verification Coding Entry Management

While the details and flow of the RCM process vary Step 2: Visit/Documentation Coding
from practice to practice, there are common elements
that generally characterize the process, as indicated The next step is visit/documentation coding. In this
in the diagram above. step of the revenue cycle, the office collects any applica-
ble co-pays and/or deductibles. In addition, the provider
As systems are being defined within your practice, documents the visit and assigns ICD-10 diagnosis codes
consider the diagram’s elements and structure. Each and appropriate CPT/HCPCS codes. Since your team
element or box represents a step that leads to a suc- verified the patient’s insurance in the first step of the
cessful outcome for every patient encounter or visit. RCM process, you can collect the correct amount due
Let’s take a closer look at each element and consider for the visit prior to the exam. In addition, by verifying
the office’s flow and areas of training/education. benefits before the patient’s exam, you can make the
patient aware of the amount due at the time of service.
Step 1: Scheduling/Insurance Verification
Step 3: Checkout/Charge Entry
The first step within Revenue Cycle Management
is scheduling/verifying the patient has active Checkout/charge entry is the next step in the revenue
medical and/or vision insurance coverage. The cycle. In this step, you collect any additional fees beyond
specific benefit structure under the insurance plan will the co-pays and deductibles collected in step two. For
aid in determining the patient’s financial responsibilities. instance, if you need to run additional tests during the
Obtaining the benefits information allows staff to be visit due to clinical findings, the patient’s out-of-pocket
informed and ready to collect any balances the patient expense may be greater than the amount collected
is responsible for at the time of the visit. In addition, before the exam. The most common example of this is
collecting the correct co-payments, deductibles, when a patient comes in for a comprehensive vision exam
co-insurance and non-covered service amounts at yet presents a medical problem that must be addressed,
the appointment will positively impact the practice’s changing the exam to a medical visit. New co-pays and/
accounts receivable. Insurance coverage can be or any applicable deductible are then collected after the
verified through a clearinghouse, the insurance carrier’s exam is complete. The checkout step also includes setting
website and/or phone. up follow-up appointments, recalls and entering charges
into the practice management (PM) system.
It is important to determine if you are in-network or
out-of-network for a specific insurance plan. Keep Step 4: Claim Submission
in mind that just because you are in-network with a
certain insurance company, you may not be in-network The next critical step of the RCM process is claim
with all the plans they offer. If you are in the process submissions. In this step, the office scrubs the claims
of contracting with the health plan but the approval and transmits them to payers via a clearinghouse. Claim
and/or credentialing process has not yet been finalized, scrubbing is the process of verifying that all CPT codes
hold off seeing patients under that plan until you are accurate and attaching the correct ICD-10 codes.
receive approval. Payers may not backdate the Proactively scrubbing claims can help identify and
contract approval dates. address any potential problems that could cause a claim
rejection or reduction in payments.

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CODING
COACH Revenue Optimization
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Step 5: Payment Posting last month’s newsletter, your A/R reports can help
alert you to common billing mistakes and help you
Next comes payment posting. In this step of the reve- pinpoint changes that need to occur within the office
nue cycle, the office reviews the accuracy of the Expla- to make sure payment is received promptly.
nation of Benefits (EOB) document. Double-checking
the accuracy of an EOB is a crucial step in the revenue Step 7: Financial Reporting
cycle process to make sure the practice is receiving the
correct amount owed. This step also includes receiving The last step is financial reporting, which is among
electronic funds transfers from the insurance carrier, the most critical steps of the revenue cycle process. It
posting payments to the patient’s ledger/account, includes daily reconciliation of all payments, accounts
adjusting payments, applying write-offs appropriately receivable reviews, monthly financial reporting, and
and sending out any patient statements. comparing metrics and industry benchmarks. Review-
ing these reports can help you identify any areas of
Step 6: Accounts Receivable Management needed improvement that can help increase the
practice’s profits.
Accounts receivable management comes next. This
step of the revenue cycle includes pursuing outstand- The Revenue Cycle Management Flowchart below
ing insurance/third-party accounts, applying any pa- offers a detailed outline of the daily, weekly and monthly
tient refunds, reviewing patient balances, assessing any tasks that affect revenue. As the office structure and
denials and reworking denials/rejections. Just because daily flow are reviewed, keeping these steps in mind will
an insurance carrier denies a claim does not mean that help build efficiency and profitability. This diagram is in-
the denial is appropriate. It’s crucial to understand the tended to provide a visual mapping of the revenue cycle
rules when determining which claims you can appeal and should be modified or enhanced as the practice’s
and what can be billed to the patient. As mentioned in needs change and grow.

Revenue Cycle Management Flowchart

Administration Front Office Claim Processing Back Office

Claim Payment A/R Financial

Pre-Claim Pre-Visit Visit Charge Entry
Submission Posting Management Reporting

Provider Patient Complete Claim Live Check Refunds Daily Cash/CC

Credentialing Scheduling
Check-In Registration Scrubbing Posting Patient & Ins. Reconciliation

Contracting Verify Accurate Claim Error eRA/EFT Denial Daily EFT/eRA

Registration
Registration Coding Corrections Payments Resolution Reconciliation

Fee Schedule Encounter Review Payer

Insurance Manual and Denial Tracking Monthly
& Pricing Documentation Payer Policy Acceptance
Verification Auto-Posting & Prevention Reconciliation
& Coding Reports

Clearinghouse Optical Charge Billable Visits

Appointment EDI Review EOBs Monitor Insurance
Enrollment Capture & Enter & Charges
Reminders Management for Accuracy Resubmissions Auditing
in EHR Accounted For

Document Pt
EFT Enrollment Collect Patient Patient Billing KPI /
Revenue to Collections
Revenue Statements Benchmarking
Collect

Patient
Check-Out
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CODING
COACH Revenue Optimization
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The goal of RCM is to create a way for your office Most practices have areas of opportunity within their
to collect payments more effectively and efficiently, own Revenue Cycle Management process. The experts
directly impacting your practice’s financial health and at PECAA are happy to assist in evaluating your own
providing for a more seamless experience for your RCM process and identifying areas for improvement.
patients. There are many steps involved in RCM, and To take advantage of this unique member benefit,
in many cases, it may make sense to hire a Revenue email The Coding Coach at [email protected].
Cycle Management company. The benefits of out-
sourcing RCM include:
References
• Faster claims submission and cash flow turnaround; 1 Hotline and email access are available to all members of PECAA, Delivering more
with HEA for a limited time period. Thereafter, hotline access will be reserved for
• Access to coding expertise and experience; select membership tiers.
2 Healthcare Financial Management Association. https://www.hfma.org/
• Automation that results in increased payments; and
• Depth in billing expertise and claims follow-up.

Critical Coding Questions

The frequently asked questions below are excerpted from the extensive Coding Coach Online Library, providing
expert guidance on both day-to-day issues and major policy changes, that is now available to you as an exclusive
member benefit to access at your convenience through the member portal.

Question: What is a good faith estimate, and can it be provided orally?

Answer: On December 27, 2020, the No Surprises Act was signed into law. The No Surprises Act addresses
situations in which patients receive surprise medical bills when they obtain care from an out-of-network
provider. The Departments of Health and Human Services, Treasury and Labor have developed several
regulations to implement the law. This law went into effect on January 1, 2022, at which point it was
required to provide a good faith estimate to uninsured patients. If an estimate is provided orally, it must be
reiterated in writing. You can learn more about the good faith estimate by clicking on the following link:
https://www.aoa.org/AOA/Documents/doctor%20resources/No-Surprises-Act.pdf

Question: I received a letter from an insurance carrier stating that my utilization of specific E/M codes
was higher than peers in my area. Should I be concerned?

Answer: If your office codes and documents correctly for each encounter based on the guidelines, you should not
be concerned. Your specialty and clientele may differ significantly from your peers, and you should not consider
other providers’ billing protocols when selecting the correct E/M codes for the services you have rendered.

The Coding Coach Hotline

You are also invited to submit your unique coding issues to The Coding Coach billing and coding experts via our
Telephone Hotline: 800.959.2020, Option 2 or Email: [email protected].

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 THE Essential Insights For
CODING
COACH Revenue Optimization
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THE Essential Insights For

CODING
COACH Revenue Optimization

Coordinating Benefits
With VSP And EyeMed
How To Maximize Coverage
By Coordinating Benefits Free Live Webinar
Thursday, April 21, 7:30 PM ET
During this webinar, you will learn how to:
• Maximize medical and vision coverage while
Click To Reserve Your Spot Now!
preventing duplicate payments
• Coordinate benefits with VSP Brought To You By

• Coordinate benefits with EyeMed.

The Coding Coach is published to provide you with helpful information for accurate chart documentation and billing of
Medicare and other third-party insurance claims. Every attempt has been made to ensure current regulatory information
is provided. Final determination rests with specific Medicare carriers or third-party payers. PECAA assumes no legal
responsibility for the use or misuse of the contents of this newsletter.

© 2022 PECAA, Delivering more with HEA April 2022, p. 5