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Insurance Abstract
A method, system and computer program product for generating an
electronic bill having optimized insurance claim items based on
an insurance carrier of a patient are provided. The method includes
receiving insurance carrier data which identifies a patient's insurance
carrier and patient data which identifies a patient. The method
also includes receiving treatment data which identifies a drug administered
to the patient and a procedure performed on the patient on a date
of service. The treatment data is processed to obtain nurse documentation,
such as treatment and/or flow sheets. An electronic bill is automatically
generated having optimized reimbursable insurance claim items including
predetermined codes based on the treatment data and the insurance
carrier data to facilitate approval of the bill by the insurance
carrier.
Insurance Claims
1. A computerized method for generating an electronic bill having
optimized insurance claim items based on an insurance carrier of
a patient, the method comprising: receiving insurance carrier data
which identifies a patient's insurance carrier and patient data
which identifies a patient; receiving treatment data which identifies
a drug administered to the patient and a procedure performed on
the patient on a date of service; processing the treatment data
to obtain nurse documentation, such as treatment or flow sheets
or drug inventory and reorder forms; and automatically generating
an electronic bill having optimized reimbursable insurance claim
items including predetermined codes based on the treatment data
and the insurance carrier data to facilitate approval of the bill
by the insurance carrier.
2. The method as claimed in claim 1, wherein the treatment data
also identifies at least one of: a drug dosage, time spent in administering
the drug and supplies used in administering the drug.
3. The method as claimed in claim 1, wherein the treatment sheet
includes at least one of: route taken to administer the drug, the
names of the drugs in the same concurrent infusion and time spent
to administer the drug.
4. The method as claimed in claim 1, further comprising applying
an appropriate modifier to at least one claim item on the bill.
5. The method as claimed in claim 1, further comprising adding
at least one predetermined code required for reimbursement of the
drug or the procedure.
6. The method as claimed in claim 1, further comprising verifying
that HCT level is recorded and meets a minimum level required for
reimbursement of the drug by the insurance carrier.
7. The method as claimed in claim 1, further comprising generating
remarks containing at least one of: a predetermined code, drug name,
drug dosage, drug waste and route taken in administering the drug.
8. The method as claimed in claim 1, further comprising generating
remarks to document when the patient provides the administered drug
to ensure reimbursement for administration of the patient-provided
drug.
9. The method as claimed in claim 1, wherein the drug is a chemotherapy
or non-chemotherapy drug administrated to the patient and wherein
the method further comprises issuing the appropriate code for the
administration of the chemotherapy or non-chemotherapy drug.
10. The method as claimed in claim 1, further comprising applying
a predetermined code to distinguish between types of administrations
and any concurrent infusions.
11. The method as claimed in claim 1, further comprising determining
a correct set of codes and respective quantity fields to bill the
correct representation of infusion times, drug quantities, including
waste and administration counts.
12. The method as claimed in claim 1, further comprising disallowing
multiple drug administrations unless a predetermined code is included
on the bill.
13. The method as claimed in claim 12, further comprising generating
a claim item with an associated predetermined code wherein a total
dosage of the drug is substantially equal to a sum of the dosages
of the multiple drugs.
14. The method as claimed in claim 1, further comprising ordering
the claims and sequencing the claim items of the claims in a manner
to facilitate approval of the bill by the insurance carrier.
15. The method as claimed in claim 14, wherein related administered
drugs and their respective predetermined codes are grouped together
in a single claim.
16. The method as claimed in claim 1, further comprising issuing
prompts for supplies by insurance carrier, issuing prompts for office
visits and tracking of chemo follow-up visits.
17. The method as claimed in claim 1, further comprising precisely
estimating drug waste.
18. The method as claimed in claim 1, further comprising collecting
and generating documentation in the treatment sheet to corroborate
the claim.
19. The method as claimed in claim 1, further comprising monitoring
and issuing alerts pertaining to elapsed infusion times, supplies,
drug package and vial sizes, and other services.
20. The method as claimed in claim 1, further comprising generating
various reports with the application of different fee schedules
and the usage of drugs by package and vial sizes.
21. A system for generating an electronic bill having optimized
insurance claim items based on an insurance carrier of a patient,
the system comprising: a processor operable to execute computer
program instructions; a memory operable to store computer program
instructions executable by the processor; and computer program instructions
stored in the memory to perform the steps of: receiving insurance
carrier data which identifies a patient's insurance carrier and
patient data which identifies a patient; receiving treatment data
which identifies a drug administered to the patient and a procedure
performed on the patient on a date of service; processing the treatment
data to obtain nurse documentation, such as treatment or flow sheets
or drug inventory and reorder forms; and automatically generating
an electronic bill having optimized reimbursable insurance claim
items including predetermined codes based on the treatment data
and the insurance carrier data to facilitate approval of the bill
by the insurance carrier.
22. The system as claimed in claim 21, wherein the treatment data
also identifies at least one of: a drug dosage, time spent in administering
the drug and supplies used in administering the drug.
23. The system as claimed in claim 21, wherein the treatment sheet
includes at least one of: route taken to administer the drug, the
names of the drugs in the same concurrent infusion and time spent
to administer the drug.
24. The system as claimed in claim 21, wherein the instructions
perform the step of applying an appropriate modifier to at least
one claim item on the bill.
25. The system as claimed in claim 21, wherein the instructions
perform the step of adding a predetermined code required for reimbursement
of the drug or the procedure.
26. The system as claimed in claim 21, wherein the instructions
perform the step of verifying that HCT level is recorded and meets
a minimum level required for reimbursement of the drug by the insurance
carrier.
27. The system as claimed in claim 21, wherein the instructions
perform the step of generating remarks containing at least one of:
a predetermined code, drug name, drug dosage, drug waste and route
taken in administering the drug.
28. The system as claimed in claim 21, wherein the instructions
perform the step of generating remarks to document when the patient
provides the administered drug to ensure reimbursement for administration
of the patient-provided drug.
29. The system as claimed in claim 21, wherein the drug is a chemotherapy
or non-chemotherapy drug administrated to the patient and wherein
the instructions perform the step of issuing the appropriate code
for the administration of the chemotherapy or non-chemotherapy drug.
30. The system as claimed in claim 21, wherein the instructions
perform the step of applying a predetermined code to distinguish
between types of administrations and any concurrent infusions.
31. The system as claimed in claim 21, wherein the instructions
perform the step of determining a correct set of codes and respective
quantity fields to bill the correct representation of infusion times,
drug quantities, including waste and administration counts.
32. The system as claimed in claim 21, wherein the instructions
perform the step of disallowing multiple drug administrations unless
a predetermined code is included on the bill.
33. The system as claimed in claim 32, wherein the instructions
perform the step of generating a claim item with an associated predetermined
code wherein a total dosage of the drug is substantially equal to
a sum of the dosages of the multiple drugs.
34. The system as claimed in claim 21, wherein the instructions
perform the step of ordering the claims and sequencing the claim
items of the claims in a manner to facilitate approval of the bill
by the insurance carrier.
35. The system as claimed in claim 34, wherein related administered
drugs and their respective predetermined codes are grouped together
by the instructions in a single claim.
36. The system as claimed in claim 21, wherein the instructions
perform the steps of issuing prompts for supplies by insurance carrier,
issuing prompts for office visits and tracking of chemo follow-up
visits.
37. The system as claimed in claim 21, wherein the instructions
perform the step of precisely estimating drug waste.
38. The system as claimed in claim 21, wherein the instructions
perform the step of collecting and generating documentation in the
treatment sheet to corroborate the claim.
39. The system as claimed in claim 21, wherein the instructions
perform the steps of monitoring and issuing alerts pertaining to
elapsed infusion times, supplies, drug package and vial sizes, and
other services.
40. The system as claimed in claim 21, wherein the instructions
perform the step of generating various reports with the application
of different fee schedules and the usage of drugs by package and
vial sizes.
41. The method as claimed in claim 1, further comprising generating
various fee schedules to accommodate data entry into a billing software
system and to facilitate financial analysis of patient encounters.
42. The method as claimed in claim 1, further comprising tracking
of drug usage in order to maintain inventory and to activate the
ordering of drugs for the practice.
43. A computer program product for generating an electronic bill
having optimized claim items based on an insurance carrier of a
patient, the product comprising: a computer readable medium; and
computer program instructions recorded on the medium and executable
by a processor for performing the steps of: receiving insurance
carrier data which identifies a patient's insurance carrier and
patient data which identifies a patient; receiving treatment data
which identifies a drug administered to the patient and a procedure
performed on the patient on a date of service; processing the treatment
data to obtain nurse documentation, such as treatment or flow sheets
or drug inventory and reorder forms; and automatically generating
an electronic bill having optimized reimbursable insurance claim
items including predetermined codes based on the treatment data
and the insurance carrier data to facilitate approval of the bill
by the insurance carrier.
Insurance Description
BACKGROUND OF THE INVENTION
[0001] 1. Field of the Invention
[0002] The present invention relates to methods, systems and computer
program products for generating an electronic bill having optimized
insurance claim items.
[0003] 2. Background Art
[0004] Currently, oncology physicians record the services for the
treatment of a patient on a paper checklist. This paper is often
called an: Encounter Form; a Superbill; or, in the case of hospital
and office examination visits, a Face Sheet. These items are checked
off and blanks are filled in to record the therapy and services
provided during a patient visit. The sheets of paper tend to be
incomplete and prone to errors. They are passed on to human medical
billers specialized in oncology billing, who translate the information
into a series of medical codes and billing quantities in order to
obtain reimbursement from insurance carriers. The codes and requirements
change frequently and vary significantly among the different carriers.
The ordering of these codes obtain affects timely reimbursement.
[0005] The U.S. patent to Rensimer et al. (U.S. Pat. No. 6,154,726)
discloses a system that allows the ability to record, transfer,
or save medical data from a portable system to a database system.
Also disclosed is a means of archiving patient information and generating
clinical status codes that can be used for reimbursements from insurance
companies.
[0006] The U.S. patent to Evans (U.S. Pat. No. 6,347,329) discloses
a system comprising a pen-based portable computer with wireless
access to electronic patient records. The system may incorporate
legacy files, such as paper files, from a patient's chart.
[0007] The U.S. patent to Gilbert (U.S. Pat. No. 6,381,576 B1)
discloses a database program employing diagnostic and treatment
information data structure that contains both clinical and financial
information permitting effective filtering and analysis of Current
Procedural Technology (CPT) codes as to accuracy and appropriateness.
[0008] The U.S. patent application publication to Porterfield (2002/0077854)
discloses a system for determining the best possible billing scenario,
in order to maximize reimbursements.
[0009] The U.S. patent application publication to Ibok et al. (2002/0116219)
discloses a method for wireless accessing a medical record via a
PDA, laptop, personal computer (PC) or other telephony device. Also
disclosed is a method for secure information transmission using
an authentication scheme. The system also includes an interface
with existing legacy information.
[0010] U.S. patent application publication 2003/0074228 discloses
an electronic medical record that is directed towards use in chemotherapy
applications.
[0011] Electronic medical records in billing scenarios are shown
by the following U.S. patents and publications: U.S. Pat. Nos. 6,223,164;
6,655,583; 2002/0091540; 2002/0120466; 2003/0083903; 2004/0204961;
2004/0199404; 2004/0128163; 2002/0123907; 2002/0087358; and 2002/0022972.
SUMMARY OF THE INVENTION
[0012] An object of the present invention is to provide an improved
method, system and computer program product for generating an electronic
bill having optimized insurance claim items.
[0013] In carrying out the above object and other objects of the
present invention, a computerized method for generating an electronic
bill having optimized insurance claim items based on an insurance
carrier of a patient is provided. The method includes receiving
insurance carrier data which identifies a patient's insurance carrier
and patient data which identifies a patient. The method also includes
receiving treatment data which identifies a drug administered to
the patient and a procedure performed on the patient on a date of
service. The treatment data is processed to obtain nurse documentation,
such as treatment or flow sheets or drug inventory and reorder forms.
An electronic bill is automatically generated having optimized reimbursable
insurance claim items including predetermined codes based on the
treatment data and the insurance carrier data to facilitate approval
of the bill by the insurance carrier.
[0014] The treatment data may also identify at least one of: a
drug dosage, time spent in administering the drug, and supplies
used in administering the drug.
[0015] The treatment data may also identify at least one of:
[0016] whether the patient brought in a drug, drug name and route
of administration;
[0017] oncology office visits (especially chemo follow-up visits);
[0018] other services (lab work, port flush, etc.);
[0019] patient answers to questions, comments and progress notes,
ECOG and Karnofsky values;
[0020] patient vitals, blood work, and symptoms;
[0021] vial size used and actual waste quantities; and
[0022] date of service and cycle and day/week.
[0023] The treatment sheet may include at least one of: route taken
to administer the drug, the names of the drugs in the same concurrent
infusion, and time spent to administer the drug.
[0024] The treatment sheet may also include at least one of:
[0025] any of the treatment data items;
[0026] patient name, date of birth, total chemotherapy infusion
time, total non-chemotherapy infusion time, signature lines for
the doctor and nurse, insurance carrier, primary and secondary diagnosis;
and
[0027] doctor name and practice.
[0028] The method may further include applying an appropriate modifier
to at least one claim item on the bill. However, it is possible
that a claim may not need any modifiers.
[0029] The method may further include adding at least one predetermined
code required for reimbursement of the drug or the procedure. For
example, both the J-Code and sometimes a DX2.
[0030] The method may further include verifying that HCT level
is recorded and meets a minimum level required for reimbursement
of the drug by the insurance carrier.
[0031] The method may further include generating remarks containing
at least one of: a predetermined code, drug name, drug dosage, drug
waste and route taken in administering the drug.
[0032] The method may further include generating remarks to document
when the patient provides the administered drug to ensure reimbursement
for administration of the patient-provided drug.
[0033] The drug may be a chemotherapy or non-chemotherapy drug
administrated to the patient. The method may include issuing the
appropriate code for the administration of the chemotherapy or non-chemotherapy
drug.
[0034] The method may further include applying a predetermined
code to distinguish between types of administrations and any concurrent
infusions.
[0035] The method may further include determining a correct set
of codes and respective quantity fields to bill the correct representation
of infusion times, drug quantities, including waste and administration
counts.
[0036] The method may further include disallowing multiple drug
administrations unless a predetermined code is included on the bill.
[0037] The method may further include generating a claim item with
an associated predetermined code. A total dosage of the drug may
be substantially equal to a sum of the dosages of the multiple drugs.
[0038] The method may further include ordering the claims and sequencing
the claim items of the claims in a manner to facilitate approval
of the bill by the insurance carrier.
[0039] Related administered drugs and their respective predetermined
codes may be grouped together in a single claim.
[0040] The method may further include tracking of chemo follow-up
visits.
[0041] The method may further include precisely estimating drug
waste.
[0042] The method may further include collecting and generating
the appropriate documentation in the treatment sheet to corroborate
the claim.
[0043] The method may further include suggesting charges via prompts.
[0044] The method may further include tracking of elapsed infusion
times.
[0045] The method may further include tracking cycle-day/week and
providing default dosages.
[0046] The method may further include generating various fee schedules
to accommodate data entry into a billing software system and to
facilitate financial analysis of patient encounters.
[0047] The method may further include the tracking of drug usage
in order to maintain inventory and to automate the ordering of drugs
for the practice.
[0048] Further in carrying out the above object and other objects
of the present invention, a system for generating an electronic
bill having optimized insurance claim items based on an insurance
carrier of a patient is provided. The system includes a processor
which is operable to execute computer program instructions. The
system further includes a memory which is operable to store computer
program instructions executable by the processor. Computer program
instructions are stored in the memory. The computer program instructions
receive insurance carrier data which identifies a patient's insurance
carrier and patient data which identifies a patient. The computer
program instructions receive treatment data which identifies a drug
administered to the patient and a procedure performed on the patient
on a date of service. The computer program instructions process
the treatment data to obtain nurse documentation, such as treatment
or flow sheets or drug inventory and reorder forms. The instructions
automatically generate an electronic bill having optimized reimbursable
insurance claim items including predetermined codes based on the
treatment data and the insurance carrier data to facilitate approval
of the bill by the insurance carrier.
[0049] The treatment data may also identify at least one of: a
drug dosage, time spent in administering the drug and supplies used
in administering the drug.
[0050] The treatment sheet may include at least one of: route taken
to administer the drug, the names of the drugs in the same concurrent
infusion and time spent to administer the drug.
[0051] The instructions may apply an appropriate modifier to at
least one claim item on the bill.
[0052] The instructions may add a predetermined code required for
reimbursement of the drug.
[0053] The instructions may verify that HCT level is recorded and
meets a minimum level required for reimbursement of the drug by
the insurance carrier.
[0054] The instructions may generate remarks containing at least
one of: a predetermined code, drug name, drug dosage, drug waste
and route taken in administering the drug.
[0055] The instructions may generate remarks to document when the
patient provides the administered drug to ensure reimbursement for
administration of the patient-provided drug.
[0056] The drug may be a chemotherapy drug administrated to the
patient, and the instructions may issue the appropriate code for
the administration of the chemotherapy drug.
[0057] The instructions may apply a predetermined code to distinguish
between types of administrations and any concurrent infusions.
[0058] The instructions may determine a correct set of codes and
respective quantity fields to bill the correct representation of
infusion times and administration counts.
[0059] The instructions may disallow multiple drug administrations
unless a predetermined code is included on the bill.
[0060] The instructions may generate a claim item with an associated
predetermined code wherein a total dosage of the drug is substantially
equal to a sum of the dosages of the multiple drugs.
[0061] The instructions may order the claims and sequence the claim
items of the claims in a manner to facilitate approval of the bill
by the insurance carrier.
[0062] Related administered drugs and their respective predetermined
codes may be grouped together by the instructions in a single claim.
[0063] Still further in carrying out the above object and other
objects of the present invention, a computer program product for
generating an electronic bill having optimized insurance claim items
based on an insurance carrier of a patient is provided. The computer
program product includes a computer readable medium. The computer
program product further includes computer program instructions recorded
on the medium and executable by a processor to: receive insurance
carrier data which identifies a patient's insurance carrier and
patient data which identifies a patient; receive treatment data
which identifies a drug administered to the patient and a procedure
performed on the patient on a date of service; process the treatment
data to obtain nurse documentation, such as treatment and/or flow
sheets; and automatically generate an electronic bill having optimized
reimbursable insurance claim items including predetermined codes
based on the treatment data and the insurance carrier data to facilitate
approval of the bill by the insurance carrier.
[0064] The above object and other objects, features, and advantages
of the present invention are readily apparent from the following
detailed description of the best mode for carrying out the invention
when taken in connection with the accompanying drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
[0065] FIGS. 1-79 are screenshots generated by a computer programmed
with one embodiment of a computer program product of the present
invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
Improve Cash Flow by Expediting Claim Approval
[0066] An objective of the computer application is to increase
cash flow. Two avenues pursue this: expediting claim approval and
maximizing reimbursement. The first is by striving to obtain the
approval of claims during an insurance adjudicator's initial review;
thereby, avoiding additional intervention. Namely: resubmissions,
phone calls, and Statuses. The computer application pursues this
by consistently: [0067] 1. Applying the appropriate Modifier to
claim line items. A 25 Modifier is necessary for Office Visits on
the same day as chemotherapy or non-chemotherapy, except if the
insurance is Blue Cross. A 25 Modifier is also required for Level
I Office Visits to Medicare when there are no other services provided
on the same day. A 59 Modifier is required for Hydration unless
it is the primary procedure for the day. Refilling and maintenance
of portable pump (96520) and Introduction of needle or intracatheter,
vein (36000) always require a 59 Modifier. Medicare requires a 59
Modifier for Phlebotomy, therapeutic (99195). A 76 Modifier is required
for the reimbursement of Introduction of needle or intracatheter,
vein (36000) to multiple sites. [0068] 2. Verifying the coding of
the proper primary diagnosis code for certain procedures. For example,
a Phlebotomy, therapeutic (99195) requires Hemochromatosis (2750)
or Polycythemia Vera (2384). [0069] 3. Providing a secondary diagnosis
code for certain procedures that demand one for reimbursement, e.g.,
Urinalysis (81000) in an oncology setting requires a secondary diagnosis
code of 7910 (Proteinuria). The user defines this relationship in
ProcsAndCodes.
[0070] 4. Including a secondary diagnosis code, when it is required
for the reimbursement of a drug. The application allows the user
to optionally define one secondary diagnosis per drug (or procedure)
in ProcAndCodes. Some drugs require a different secondary diagnosis
codes depending upon the primary diagnosis of the patient, which
the application accommodates through logic within the program code.
TABLE-US-00001 Program Logic for Procrit (Q0136) and Aranesp (J0880)
SECONDARY If DX1 Description DX2 DIAGNOSIS 1400 to Cancer 28522
Anemia in Neo- 20497 plastic Disease 28529 Anemia of Chronic Disease
2859 Anemia 585 Chronic Renal Failure 2859 Anemia 2387 Myelodysplastic
Syndrome 2859 Anemia
[0071] TABLE-US-00002 Suggested Secondary Diagnosis Entries in
ProcsAndCodes DRUG J-CODE DX2 SECONDARY DIAGNOSIS Cimetidine J3490
78701 Nausea with Vomiting Atropine J0460 78791 Diarrhea Prochlorperazine
J0780 78701 Nausea with Vomiting Dexamethasone J1100 78701 Nausea
with Vomiting Diphehydramine J1200 78701 Nausea with Vomiting Anzemet
J1260 78701 Nausea with Vomiting Filgrastim/ J1440 2880 Agranulocytosis
Neupogen Filgrastim/ J1441 2880 Agranulocytosis Neupogen Polygam/
J1563 27903 Oth Selective Gammunex Immunoglobulin Defic Kytril J1626
78701 Nausea with Vomiting Iron J1750 2809 Anemia/Iron Deficient
Mannitol 25% J2150 59582 Irradiation Cystitis Sandastatin Lar J2353
78791 Diarrhea Oprevelkin/ J2355 2874 Secondary Neumega Thrombocytopenia
Zofran J2405 78701 Nausea with Vomiting Pamidronate/ J2430 1985
Malignant Neoplasm Aredia Bone & Bone Marrow Aloxi J2469 78701
Nausea with Vomiting Neulasta J2505 2880 Agranulocytosis Metocloropramide
J2765 78701 Nausea with Vomiting Solumedrol J2930 78701 Nausea with
Vomiting B-12 J3420 2810 Folate Deficiency Anemia Zometa J3487 1985
Malignant Neoplasm Bone & Bone Marrow Lupron J9217 1985 Malignant
Neoplasm Bone & Bone Marrow Faslodex J9395 1985 Malignant Neoplasm
Bone & Bone Marrow
[0072] 5. Ensuring that the HCT Level is recorded and meets the
required minimum level (38.5 or less), as necessitated for the reimbursement
of certain drugs, such as: Procrit (Q0136) and Arenesp (J0880).
[0073] 6. Creating Remarks containing J-Code, Drug Name, Amount
Used (Dosage plus Waste), Route (Injection, IV, or Push), and NDC
Number for drugs, which do not have their own unique J-Code assigned
to them and now share J3490 or J9999 with other drugs. [0074] 7.
Generating the necessary Remarks to document a patient bringing
their own drug, assuring reimbursement for the administration of
that drug. The computer application includes: J-Code, Dosage, and
Route in the Remarks. [0075] 8. Issuing the appropriate G-Code for
chemotherapy injections to distinguish between Hormonal and Non
Hormonal Agents among the chemotherapy J-Codes. At this time, Faslodex,
Lupron, and Zoladex comprise the set of Hormonal Chemotherapy Injections.
[0076] 9. Applying the proper G-Code to distinguish between: Chemotherapy
Injections, Pushes, and Infusions; and Non-Chemotherapy Injections,
Pushes, Sequential Infusions, and Concurrent Infusions. Also, determining
the correct set of G-Codes with their respective quantity fields
to bill the correct representation of infusion times and administration
counts. [0077] 10. Providing the proper coding for 5FU pump administration.
To infuse the drug 5FU for more than eight hours, pumps are used.
Usually, the patient receives a Push followed by either a Pump Refill
or Pump Initiation procedure. Generally, Medicare only allows one
administration code per drug per day of service, but pumps are an
exception to this rule. The computer application disallows multiple
5FU administrations unless a pump administration code is included.
Then the billing algorithm generates three claim lines: the code
for Push, the code for the pump administration; and the J-Code for
the 5FU with a total quantity representing the sum of both dosages.
The application records both dosages next their respective routes
in the Treatment Sheet for the patient's chart. The billing algorithm
applies a 59 Modifier to Pump Refills. [0078] 11. Building claims
and sequencing claim line items in a logical fashion to facilitate
adjudication, accommodating the most restrictive format, the HFCA
1500 six-line claim.
[0079] The application contains a billing algorithm, which subdivides
a patient encounter into Units for Approval, exhibited to an insurance
adjudicator as packets of claim lines. Each packet begins with one
or more closely related procedure codes pertaining to the same specific
administration and technique followed by the J-Codes of the drugs
administered by that method.
[0080] Instead of a deluge of haphazard codes, the adjudicator
views an orderly series of services separated into Chemotherapy
Infusions, Pushes, Injections, Therapeutic/Diagnostic Infusions,
Pushes, and Injections; as well as Hydrations and Pump Administrations.
Immediately, after each of these techniques, follow the administered
drugs. This assists the adjudicator by presenting coherent groups
easily recognized as being complete and appropriate with all the
necessary secondary diagnosis codes and modifiers. They appeal to
the insurance adjudicator's need to easily decipher the required
prerequisites, increasing the likelihood of approval. If rejected,
the biller can more easily reprocess them, since they form distinct
and cohesive subsets.
[0081] E.g., Hydration as: 36000 Introduction of needle or intracatheter,
vein followed by G0346 Hydration followed by J7030 Saline. Note:
For clarity, the algorithm places Introduction of needle or intracatheter,
vein (36000) before the associated hydration, infusion, or push
that flows through it.
[0082] E.g., A non-chemotherapy infusion as: G0348 Intravenous
infusion, for therapy/diagnosis; each additional hour, up to eight
hours with a quantity of three followed by Intravenous infusion,
for therapy/diagnosis; G0349 Additional sequential infusion, up
to one hour with a quantity of one followed by J2150 Mannitol.
[0083] E.g., Chemotherapy pushes as: G0358 Chemotherapy administration,
intravenous; push technique with a quantity of three followed by
J9040 Bleomycin, J9000 Adriamycin, and J9360 Vinblastine.
[0084] One could consider a Port Flush to be a Unit for Approval,
but currently, there are no reimbursable J-Codes to accompany it.
In addition, Office Visits and Lab Procedures do not have J-Codes
associated with them. Since, these procedure codes have no contextual
relationships with other claim lines, sequencing them is not important.
They occupy the last lines of the last claims for the patient encounter.
Likewise, the algorithm places saline (except when the insurance
is Blue Cross) and other supplies among the final lines for the
encounter.
[0085] The algorithm endeavors to present the Units for Approval
on separate six-line HFCA 1500 formats for the sake of clarity to
the adjudicator, but not at the expense of generating extra claims
needlessly. For example: An Injection procedure code with its accompanying
drug only consumes two claim lines, which would result in four blank
HFCA 1500 lines. Another Unit for Approval could fit on the same
claim.
[0086] For non-chemotherapy drugs, the billing algorithm insures
that there are not more than three unique Secondary diagnosis codes
on the claim. The HFCA 1500 Claim format has a limit of four unique
diagnosis codes per claim. Since one must be primary, only three
remain for use as unique secondary diagnosis codes.
[0087] The billing algorithm encodes the Units for Approval for
a specific Date of Service constructing a series of packets packaged
into claims. Each Unit of Approval is discernable as there are one
or more procedure codes at the beginning followed by one or more
J-Codes at the end, resulting in all drugs in proximity to their
respective techniques and administration. Within the same claim,
a G-Code always has at least one of its related J-Codes following
it. However, because a procedure may administer many drugs, the
algorithm may have to split some of the drugs to the beginning of
the next six-line claim. The algorithm splits off the least expensive
drugs in the packet.
[0088] Generally, all chemotherapy items would be on the first
and second claims; followed by non-chemotherapy items flowing into
additional claims and Laboratory, Office Visits, and Supplies would
appear on the last claims. Together all of the claims represent
the complete patient encounter for the Date of Service.
[0089] While this describes the overall strategy of the billing
algorithm, the first claim for a patient encounter demands some
specific tactical ordering of claim lines: [0090] 1) An Initial
G-Code appears on the first line of the first Claim, except if there
is an Introduction of needle or intracatheter, vein (36000). The
procedure code 36000 always appears before the procedure using the
needle or intracatheter. Thus, the Initial G-Code would appear on
the second line. [0091] 2) If there are additional hours (G0360
or G0348), they appear next. [0092] 3) The most expensive drug administrated
by the preceding G-Codes follows. [0093] 4) If the encounter warrants
reimbursement for the Medicare Demonstration Project, then the three
G90nn-Codes fill the remaining lines of the first claim.
[0094] At this point, an adjudicator should readily approve the
Demonstration Project Codes for reimbursement. Answers to all three
of survey questions are readily apparent, as they are together in
one group. It is evident that the patient received chemotherapy
by a Push or Infusion, since one of these chemotherapy administration
G-Codes appears immediately before the administered chemotherapy
drug.
[0095] All of this is determined by looking at only one claim.
Because these line items make up such a simple claim (similar to
boilerplate), the entire claim is almost certain to obtain immediate
approval. Inclusion of the most expensive chemotherapy drug into
this first claim makes good sense because the adjudicator should
not find anything to doubt. [0096] 5) For claims to Blue Cross,
there are no Demonstration Project Codes to bill. In their place,
the billing algorithm generates claim lines for the Saline Supplies
because Blue Cross requires them to be in the same claim with the
Primary (Initial) Procedure Code. [0097] 6) If are at least two
available lines remain and there are more procedures to bill, the
algorithm generates another procedure code and drug(s). The algorithm
never generates a procedure code without at least one J-Code following
it. If there are still more J-Codes associated with the procedure,
they spill onto the beginning lines of the second claim. [0098]
7) If there are no more procedures to bill, the algorithm fills
the remaining lines of the first claim with supplies and/or Office
Visits/Labs/Misc. [0099] 8) The billing algorithm then resumes its
overall strategy of generating claims and claim lines for the remaining
services.
[0100] The method described is subject to modification as better
strategies become apparent or as reimbursement criteria changes,
e.g., Medicare eliminates the Demonstration Project Codes.
Improve Cash Flow by Maximizing Reimbursement Revenue
[0101] The second avenue to improve cash flow is maximizing reimbursement
revenue. The application accomplishes this by reminding the user
of additional expense items eligible for reimbursement, that are
not generally well known, often because they vary by insurance.
For example: [0102] 1. Medicare currently pays for the Demonstration
Project Codes, but only if the patient received chemotherapy administered
by a Push or Infusion and answered all three of the Survey Questions.
The doctor can insist that the application always bill for the Demonstration
Project, which results in the computer application forcing the user
to answer all three of the Survey Questions when the Date of Service
qualifies for the reimbursement. The application does not force
answers or bill the Demonstration Project Codes for patients that
received chemotherapy by Injection or for patients that do not have
a cancer diagnosis. For example, Multiple Sclerosis (340) patients
receiving Mitoxantrone/Novantrone (J9293). [0103] 2. Carriers will
reimburse for drug waste. The computer application provides a Waste
field next to the dosage of each drug administered. If the treatment
resulted in Waste, recorded by the nurse or estimated by the application,
it is included as part of the reimbursement quantity. The application
currently uses the HCPS Billing Quantity to provide a minimum estimate
for Waste. However, it can under report much of the entire amount;
Proper entry by the nurse is important. The application is able
to store the actual vial sizes in ProcsAndCodes. By subtracting
the entered dosage from the drug and vial size selected by the nurse,
the application can obtain a precise Waste estimate; covering most
instances involving Single-Use Vials. [0104] 3. Medicare will not
provide for the reimbursement of 99211 (Level I Office Visit) on
the same day that a patient receives chemotherapy or non-chemotherapy,
but most insurance carriers will. When a patient receives chemotherapy
or non-chemotherapy and the insurance will reimburse for an office
visit on that same day, the computer application prompts the user
for a Level I Office Visit (99211). The user can accept or deny
this charge or issue a higher level of Office Visit. Hence, the
application issues prompts offering 99211 for Blue Cross, Blue Care
Network, Medicaid, Other Insurances, and PPOM, but not for Medicare.
The Application strives to reduce the volume of Explanation Of Benefits
(EOB) error messages to prevent important messages from being lost.
Thus, the application blocks the user from billing a Nurse Charge
to Medicare on Dates Of Service with chemotherapy or non-chemotherapy,
thereby avoiding the denial messages. [0105] 4. Blue Cross will
pay for up to three Chemotherapy Follow Up Visits within thirty
days of the last date of chemotherapy with no co-payment to the
patient. The application tracks these visits and notifies the user
when the patient is eligible for reimbursement of a Chemo Follow
Up Visit. If the user issues an Office Visit Charge and the computer
application determines that this visit qualifies as a Chemo Follow
Up, the computer application prompts the user for confirmation.
If the user concurs, the billing algorithm generates the Office
Visit Charge with a V672 secondary diagnosis code, preventing a
co-payment bill to the patient. The billing algorithm ensures that
a 25 Modifier is not present, since it would result in a rejection
by Blue Cross. [0106] 5. Blue Cross will not pay for Saline Supplies
unless they are in the same claim as the primary procedure code.
Therefore, for Blue Cross, the billing algorithm places charges
for Saline Supplies in first claim, since it always contains the
Initial G-Code. [0107] 6. A Port Flush does not normally qualify
for reimbursement, since the procedure and its supplies are almost
always bundled with other services. If a nurse provides a port flush
with no other procedures other than Labs on the same day, a Port
Flush (G0363) is reimbursable. The supplies, i.e. Saline Sterile
5 cc and either Heparin or Heplock, are bundled into the Port Flush
procedure. G0363 pays more than a Nurse Charge (99211) will, even
if you include the fees for the Saline and either Heparin or Heplock,
which are no longer reimbursable anyhow.
[0108] The computer application lists any Selected port flush supplies
in the Patient Treatment Sheet, but never bills them because they
are always bundled expenses. They are not reimbursable. They only
result in adding to the volume of rejection messages in the EOB,
making it more difficult to identify inappropriately denied revenue.
[0109] If the user selected a Port Flush and services other than
Labs were performed, the application records the Port Flush in the
Treatment Sheet, but does not bill it because it is not reimbursable.
[0110] If the user selected port flush supplies, i.e. Saline Sterile
5 cc and either Heparin or Heplock with no other services, except
Labs and the user did not select G0363 (Port Flush), the application
issues a prompt suggesting a Port Flush.
[0111] When the computer application identifies an encounter with
port flush supplies along with a Nurse Visit (99211) and no other
services, except for Labs, the computer application suggests the
alternative charge. [0112] 7. For Blue Care Network, PPOM, and Other
insurances (That is--not Blue Cross, Medicaid, or Medicare), if
the Introduction of needle or intracatheter, vein occurred, the
practice can receive additional reimbursement by billing procedure
code 36000. The computer application queries for this procedure
on every Infusion, Push, and Hydration. The application records
the procedure in the Patient Treatment Sheet regardless of insurance,
but only bills it to Blue Care Network, PPOM, and Other. For Blue
Care Network, PPOM, and Other, the application queries for a second
site. If there were two separate IV Sites for this patient, the
application includes a 76 Modifier with the second 36000. [0113]
8. Blue Care Network, PPOM, and Other insurances will pay for Chemo
Kits, when billed as 99070 for PPOM and A4221 for Blue Care Network
and Other. Blue Cross, Medicaid, and Medicare insurances consider
the kits to be bundled and will reject the charges. If the insurance
is Blue Care Network, PPOM or Other and the patient received chemotherapy
or non-chemotherapy by a Push or Infusion; the computer application
offers the billing of 99070 or A4221. For PPOM, which requires Remarks
accompanying the charge, the computer application generates a Remarks
Field containing "Chemo Kit". [0114] 9. Drugs Etoposide
(J9181 & J9182), Taxotere (J9170) and Taxol (J9265) require
special Non-PVC Tubing (S1016). This is a Bundled Expense to Blue
Cross, Medicaid, Medicare, and PPOM. Because Blue Care Network and
Other commercial insurances will reimburse this as a separately
expensed item, the computer application detects these drugs and
when the insurance is Blue Care Network or Other, offers to bill
for the tubing. [0115] 10. Huber Needles (A4212), used during Port
Flushes, are a Bundled Expense to Blue Cross, Blue Care Network,
Medicaid, Medicare, and PPOM. However, Other commercial insurances
will reimburse this as a separately expensed item. The computer
application monitors the use of 5 cc of Saline with either Heplock
or Heparin. If the insurance is Other, the application prompts for
the billing of a Huber Needle (A4212). [0116] 11. There are Pump
Supplies (A4222) used in the Initiation or Refill of a Pump. Blue
Cross, Medicaid, Medicare, and PPOM consider these expenses bundled.
However, it is payable by Blue Care Network and Other insurances.
Therefore, the computer application checks for pump administration
codes and issues a prompt suggesting the billing of Pump Supplies
(A4222) if the insurance is Blue Care Network or Other. [0117] 12.
Allowable reimbursement items change over time and vary by region,
which will result in changes to the application as needed.
[0118] Another endeavor of the computer application to maximize
reimbursement revenue is to validate that the user has entered the
proper amounts of drugs, supplies, and times into the computer application.
[0119] To ensure that the practice is obtaining full compensation
for all of the infusion times, the computer application checks the
actual infusion times against the expected infusion times. Actual
times that are lower than expected would cause the computer application
to query the user, asking if the entered time is indeed what was
desired.
[0120] There is a tendency for nurses to record infusion time as
the time stated in the Protocol. The Protocol specifies infusion
times in quarter hour or half hour increments. Medicare billing
units are to the nearest hour with 30 minutes or less to be `rounded
down`. In addition, Medicare defines Infusions of 15 minutes or
less to be Short Infusions, requiring the biller to bill them as
a Push. However, the Medicare billing units are for Actual time.
It is very possible that the Actual time will differ from the stated
Protocol time.
[0121] The computer application offers the user the option to enter
the actual start and stop times from which the computer application
can calculate the elapsed time. These serve as journal entries,
logged in the Patient Treatment Sheet for supporting documentation.
In addition, the user can use the application in real time for Hydration
and Infusions. Auto Start and Auto End Buttons serve as a stopwatch.
[0122] For Infusions close to billing unit thresholds, the computer
application alerts the user, notifying that a `rounding down` of
an Additional Hour of Infusion Time is about to occur or that an
Infusion is going to be billed as a Push. This gives the user an
opportunity to confirm that the correct Actual elapsed time has
indeed been entered and allows the user to make corrections and
to record specific time of day entries if desired.
[0123] The nurse must infuse a drug for more than 90 minutes in
order to bill for an Additional Hour. The program notifies the user
when it cannot generate an Additional Hour of Infusion Time because
the infusion time is close to, but not greater than 90 minutes.
[0124] For "Short Infusions", the application notifies
the user, with a message, Warning: Infusion times of 15 minutes
or less will be billed as pushes. The application reports this as
an Infusion on the Treatment Sheet, but bills it as a Push.
[0125] The computer application offers the user the option to enter
Cycle-Day/Week for each patient chemotherapy encounter. The computer
application provides a list of patient encounters with the Cycle-Day/Week.
Omissions in the Cycle-Day/Week series are evidence of missing patient
encounters. Perhaps, they were misplaced or forgotten. This would
result in lost revenue if not discovered.
[0126] Because of the effort to remember every treatment item,
the computer application offers the ability to select a previous
patient encounter using Cycle-Day/Week as a guide and copy it with
a new Date Of Service. This saves keystrokes, but also the listed
drugs, supplies, and procedures serve to remind the user of what
to bill. The application does not copy the patient Vitals and Comments,
since they are likely to change.
[0127] This will be by deducting the error from a future claim,
causing confusion for the billing department, and wasting more staff
time.
[0128] To facilitate accurate data entry of individual claim lines
into the billing software, the computer application generates a
total dollar amount for each claim in the Superbill. The computer
application assigns a dollar amount to each claim line according
to the fee schedule established by the practice in ProcsAndCodes.
It is highly recommend that these dollar amounts be identical to
the fees in the billing software for the practice. Upon completion
of data entry for a claim, most billing software products show a
dollar total. If the fee schedule of the computer application is
identical to the fee schedule in the billing software these totals
should agree. Thus, the biller can conclude that the claim items
have been transferred into the billing software accurately.
[0129] The computer application allows multiple fee schedules to
be established. This allows the practice to maintain a fee schedule
of allowed amounts for each carrier. The user can direct the computer
application to apply different sets of fees to the Superbill. Hence,
the practice can see the expected revenue for each patient encounter
by insurance carrier. If the practice also creates a fee schedule
with the practice's estimated cost of each claim line, the user
can generate a `variable cost` report. That is--a report showing
the estimated variable cost for each encounter. When compared to
the expected revenue for the encounter, an estimate of marginal
profit per encounter can be determined.
[0130] The computer application tracks the usage of pre-mixed drug
bags and drug vials in order to maintain inventory for the practice.
In ProcsAndCodes, each drug has an associated: Items on Hand; a
minimum and maximum threshold for ordering; and a reorder quantity.
The application produces a report showing the usage of drugs during
a date range. For practices that perform "just in time inventory
controls", the usage of drugs by vial size during the previous
week can be used to determine the anticipate order to be placed
for the following week. The computer application provides for the
update of number of Items on Hand as drug shipments are received.
Improve Office Productivity
[0131] The computer application instantly improves office productivity
because it eliminates the necessity of a chemotherapy nurse to translate
the patient's chart into a superbill by hand. The nurse does not
have to learn medical reimbursement coding rules and procedures.
The nurse merely records the patient treatment, as a matter of normal
charting necessity.
[0132] However, the success of any computer application depends
upon the accuracy and completeness of the data entered. Using a
computer keyboard and mouse does require extra effort over hand
written notes. The computer application makes every attempt to maximize
the utility of the entered data by automating other tasks, normally
performed by the nurse. The strategy is that the more the nurse
is "rewarded" through the elimination of laborious and
tedious tasks, the more conscientiously the nurse will embrace the
use of the computer application.
[0133] Toward this end: [0134] 1. The computer application allows
the nurse to enter the dosages only in the appropriate unit of measure
for the patient's chart rather than the HCPS Billing Units that
are required for billing. [0135] a. For example, the nurse will
enter the Mannitol dosage in grams. The billing algorithm automatically
converts it to HCPS Billing Units of 50 ml. [0136] b. The nurse
will enter Aloxi in multiples of 0.25 mg. The billing algorithm
converts the dosage to the equivalent HCPS Billing Units of 25 mcg,
resulting in a Billing Quantity of 10 or multiples thereof. [0137]
c. The nurse will enter Kytril as milligrams. The billing algorithm
converts this into the HCPS Billing Units of 100 micrograms. Thus,
a dosage entry of 1 mg results in a HCPS Billing Quantity of 10.
[0138] d. The nurse administers certain drugs and fluids (5FU, Mannitol,
Mesna, Procrit, Saline, Vidaza) multiple times. If the drug's definition
in ProcsAndCodes indicates Multiple entries allowed, the program
permits the reporting of multiple drug entries. The application
lists each entry in the Treatment Sheet in the sequence reported
by the nurse. The billing algorithm generates a claim line with
one J-Code, summing the multiple dosages to calculate the appropriate
HCPS Quantity. [0139] e. The nurse can select the package size of
drugs or supplies, such as Saline, that have multiple J-Codes to
designate different package sizes. The application reports the total
dosage in the Treatment Sheet, but bills the multiple J-Codes with
their respective HCPS Quantities.
[0140] 2. In ProcAndCodes, the user can provide default dosages.
This is especially useful for drugs that have the same dosage regardless
of patient BSA. The application also provides a default dosage per
BSA for certain drugs. TABLE-US-00003 Suggested Default Dosages
in ProcsAndCodes DRUG J-CODE DOSAGE MEASURE Anzemet J1260 100 mg
Neupogen J1440 300 ug Neupogen J1441 480 ug Kytril J1626 1 mg Aloxi
J2469 .25 mg Neulasta J2505 6 mg
[0141] 3. From ProcsAndCodes entries, the application knows which
drugs are Single Use Vials. The application estimates the minimum
Waste for Single Use Vials by subtracting the Dosage from the product
of the HCPS Billing Quantity times the HCPS Billing Units. The application
pre-fills the Waste field with this estimate, which is often close
enough. The nurse modifies the estimate as necessary. (For Multiple-Dose
Vials, the Waste field remains blank, until the nurse enters an
amount.) The application also allows for the selection of different
vial sizes for drugs that have multiple Single-Use Vial sizes, but
only one J-Code. This allows the application to provide a precise
Waste value, accurate in most cases, to relieve the nurse of calculating
Waste with by hand. [0142] 4. The application generates a Treatment
Sheet, which itemizes for a patient Date of Service: Drugs Administered,
Dosages, Waste, Routes of Administration, and Times for both chemotherapy
and non-chemotherapy Infusions. Also, included are the patient's
name and primary diagnosis. For Medicare patients, the application
also includes the answers to the Survey Questions. Blank signature
lines for the nurse and doctor appear at the bottom. This comprises
the beginning of an Electronic Medical Records (EMR) System to which
the practice can augment additional patient chart entries. With
the additional entries, the application holds a significant variety
of patient data, capable of answering simple questions. Querying
the application instead of searching and pulling patient charts
saves the practice a significant amount of time. For example, the
nurse can order drugs for next week's treatments solely by accessing
the application without the pulling of individual patient charts.
The more times the practice views each data item, the more they
can attest to its accuracy. [0143] 5. If the patient received chemotherapy,
the application prompts for Cycle-Day/Week, as optional input from
the user. When entered, the application includes them in the Treatment
Sheet. The application does not permit duplicate Cycle-Day/Week
entries nor does it assign a Cycle-Day/Week to a Date of Service
when there was no chemotherapy performed. [0144] 6. The computer
application allows the user to enter Progress Notes for each patient
encounter and patient Vitals (Blood Pressure, Temperature, Pulse,
ECOG and Karnofsky Performance Status). In addition, the nurse can
enter Height and Weight, from which the DuBois and Dubois Body Surface
Area (BSA) is calculated. When provided, these are included in the
patient Treatment Sheet. The nurse can place the Treatment Sheet
into the patient's chart, eliminating the task of consolidating
other notes and slips of paper. Sometimes carriers demand progress
notes, which the application can store in its database. The nurse
or biller can merely print them and avoid retrieving the patient's
chart. This is especially valuable when the biller is off site.
The application is able to store blood laboratory results and patient
symptoms, including them as part of the Treatment Sheet. The application
provides a Blood Work Tab and a Symptoms Tab for data entry. The
application checks the blood work values for reasonableness, rejecting
absurd values and highlighting abnormal values. The application
provides the user with the ability to define a standard set of values
for seven different symptoms (nausea/vomiting, diarrhea/constipation,
pain, fatigue, numbness, shortness of breath, and mucositis). For
example, the patient often describes pain values on a scale of one
to ten. [0145] 7. The computer application generates Flow Sheets
automatically. These are sheets of paper illustrating patient progress
resulting from chemotherapy and the administration of therapeutic
drugs. Essentially, this is a one-page summary of the drugs administered
over a series of days to compare against subsequent blood results
for the patient. For each Date of Service, this contains the Cycle-Day/Week
and each drug administered with Dosage. Also, included for each
day are the patient's Vitals, Symptoms, and Blood Work. The application
allows the user to designate a series of individual Dates of Service
from a list annotated with corresponding Cycle and Day/Week entries.
The application prints the selected entries on the Flow Sheet. To
accommodate the vast number of different blood tests, the application
only prints results with non-blank values of the Flow Sheet. [0146]
8. Because many patients receive the same chemotherapy regimen,
the computer application allows the user to copy the encounter of
one patient to another patient. If the patient encounters are similar,
the user avoids data entry time for most of the encounter. Again,
the application copies the drugs and administrations, but not Infusion
Times, or Vitals.
[0147] An objective of this application is to minimize the total
number of rejection messages that appear on EOBs. Of significant
concern are rejections that are superfluous, not requiring follow-up
or rebilling. These typically result when a practice attempts to
maximize revenue by billing for items that are not reimbursable
in all instances. A practice might bill the Medicare Demonstration
Project for every Medicare patient encounter, resulting in rejections
for Dates of Service that do not qualify, i.e., patients that did
not receive chemotherapy, patients that received chemotherapy by
Injection or Multiple Sclerosis patients receiving chemotherapy.
[0148] It is difficult for the staff to remember the few exceptions
as to when this charge is not appropriate; so, they bill it for
all Medicare encounters. However, this results in legitimate rejection
messages from Medicare. These additional rejections tend to obfuscate
the truly important rejections that the biller needs to recognize
as soon as possible for prompt follow-up. In addition, the Accounts
Receivable becomes deceiving because the illegitimate expenses overstate
the expected revenue stream. The biller must apply numerous Write-Offs
to the billing software during the posting of payments, reconciling
invalid charges. If Medicare mistakenly approves these charges,
Medicare will later seek to reclaim the money. This will be by deducting
the error from a future claim, causing confusion for the billing
department, and wasting more staff time.
Operating Environment
[0149] Currently, the computer application runs as a Stand Alone
Windows Application with no prerequisite software. It can run on
Windows 98, Windows 2000, or Windows XP (Home or Professional).
The user can install the software on any PC, but most will prefer
to have the computer application located on a workstation located
in the nurse's area. Because this area is usually quite small and
cramped, we have found it advantageous to implement the computer
application on a small laptop with a 12-inch screen. In order to
reduce incidents of virus and spy ware corruption, it is also desirable
for the workstation to be dedicated only to this computer application.
[0150] For these reasons, plus the desire to have a limited set
of hardware/software operating system environments, SOS-Medical
Software provides both the hardware and the software as part of
the product package. At this time, the operating environment consists
of a 12-inch screen laptop with a laser printer to be entirely dedicated
to running the computer application. It may be desirable to have
the work station connected to the internet or at least to a telephone
line, so that a remote access program, such as PC Anywhere can allow
remote maintenance and error correction.
[0151] For larger practices and clinics, a networked configuration
will be required. Larger users will have several nurses performing
treatment on any patient arriving for treatment. Therefore, each
nurse will require each laptop to be able to access any of the patients.
The simplest approach will be to establish one laptop as the server
with the other laptops operating as clients.
[0152] While we are entertaining the possibility of 10-inch screens
or even PDA devices, the small resolution somewhat prohibits these
implementations. However, redesign of the screen layouts may eventually
facilitate these options. A clinic that desires real time collection
of treatment data at each patient chair would motivate this implementation.
Each device would then be part of a network with a central server.
[0153] The current backup plan uses the hard drive, preformatted
CD-R/W or DVD-R/W Discs, and a USB Jump Drive. The application initiates
its own daily backup to the hard drive automatically, then mirroring
a daily backup to the USB Jump Drive when it is present. Backups
are archived after encryption and compression to the Discs. The
user should place the Jump Drive in a safe that is both fireproof
and waterproof each evening and reinserted at the beginning of each
workday.
[0154] A Web environment is advantageous for the implementation
of the application, since this would eliminate many of the logistical
issues with software updates and back up complexities. The data
for each doctor is stored and backed up at the remoter server. With
updates only occurring at the server, the code and the database
structures would always be current.
[0155] FIG. 1 shows the Icon the user will click to start the application.
This document illustrates the implementation using the 12-inch laptop
implementation.
[0156] The workstation is password protected by a Windows password.
A password in the System BIOS, can add further security to the application.
[0157] The user merely double clicks on the Computer Application
Icon near the middle of the screen to start the application. Returning
to the desktop and double clicking on the computer application icon
again can start subsequent instances of the application. This would
be desirable if a nurse wanted to record information for multiple
patients in real time.
[0158] The laptop facilitates privacy by closing the top of the
laptop between sessions. When the user reopens the laptop, Windows
requires the user to enter the password. After entering the password,
the desktop reappears with the set of application windows that were
present when the user closed the laptop.
[0159] FIG. 2 is a screenshot of a Patient Information Window.
This is the first window presented to the user, typically a chemotherapy
nurse. It serves as the "Main Menu" for the application.
At the top are buttons to maintain the supporting tables of the
application: DXcodes; ProcsAndCodes; DoctorsAndFees; and BillingReports.
The contents of these tables will become evident during the explanation
of the main functions of the application.
[0160] Also, at the top is: SurveyOnOff. If there is a practice
that does not want to bill for the Medicare Demonstration Project,
this button allows the billing feature to be turned off. The button,
BillingReport, leads to report functions of the application. In
DoctorsAndFees, the user can enter or edit the Doctor Name and/or
the Practice Name. The fee schedule for the practice is also loaded
and updated here.
[0161] Find by name: allows the user to select a patient already
in the application's database. The user Left clicks on Find by name:
resulting in a drop down list of patients that exist in the database.
The drop down list presents: Patient Last Name; Patient First Name;
and Date of Birth. The user can scroll down and select the patient
name or type the beginning letters of the last name. The application
will present the first patient that matches the character string
entered. When the desired patient is located, the application fills
the fields to the left with the database contents for this patient.
[0162] An alternate selection method is available with Find by
acct #: This allows the user to select a patient by the patient's
account number that is used by the doctor's internal record keeping
system; most likely the office's medical billing system. We have
also found that some practices like to use this field to store the
Social Security Number of the patient. Find by acct #: presents
a drop down list with type ahead searching similar to that of Find
by name:
[0163] After the user selects a patient, clicking on the Make Changes
button allows modifications to the patient fields. There is also
a button to Delete Patient. If the patient does not exist in the
database, the Add Patient allows the user to enter a new patient.
[0164] When adding a patient to the database, the following fields
are relevant: [0165] 1. Key is for internal use only by the application.
[0166] 2. Patient Last Name and First Name are required. [0167]
3. Account Number is optional. [0168] 4. Insurance is required.
A drop down box allows the user to select either: [0169] a. Blue
Care Network. [0170] b. Blue Cross. [0171] c. Medicaid. [0172] d.
Medicare. [0173] e. PPOM. [0174] f. Other. [0175] g. Unknown. If
Unknown is selected, the claims are not be generated because the
application does not know what rules to apply. Unknown only serves
as a `place holder` allowing the entry of treatment data, while
awaiting the correct insurance entry. [0176] h. County Health Plan.
These are patients with a `promise` of obtaining Medicaid. Since,
Medicaid is the anticipated insurance, Medicaid reimbursement rules
are applied. The application suggests that the practice assign this
insurance to these patients, so that a practice knows how exposed
they are when Medicaid coverage is delayed. If the patient obtains
Medicaid insurance, the practice should update the field to Medicaid.
[0177] 5. DX1 is the Primary Diagnosis for the Patient. The user
selects from a drop down list containing an alphabetical sequence
of Diagnosis Codes and Descriptions defined by the user. Upon selection
of a particular Diagnosis, the application displays the accompanying
Diagnosis Code in the adjacent field to the right. If the Diagnosis
is not in the list, the user can define a new Diagnosis Code with
a Description "on the fly". Currently, the application
uses the ICD-9-CM Codes, but will use the new international ICD-10
Codes, when they become required. [0178] 6. DOB is optional. This
field differentiates patients that have the same name (e.g. Robert
Smith). In order to abbreviate the amount of patient data that the
user enters, the application does not require Social Security Number,
which is the normal method to uniquely identify patients. The application
calculates the patient's age, which it displays to the right to
assist in identifying the patient. The computer application also
includes a photographic image of the patient (not shown). [0179]
7. Referred by is optional. [0180] 8. Last Date of Chemo is sometimes
required in the Remarks section of a claim; Chemo Follow Up Visits
to Blue Cross being one example. The application automatically generates
and updates this field. However, the biller can enter an initial
value if this is an existing patient to the practice, but new to
the application. [0181] 9. Comments for the patient are optional.
Typically, this would pertain to insurance or billing information.
[0182] 10. Height and Weight, when provided, allow the application
to perform the Dubois and Dubois Body Surface Area (BSA) calculation.
[0183] Clicking the Save Record button commits these fields into
the database. The Cancel button allows the user to abort any changes
made or the addition of a new patient. The application presents
both of these buttons during Add Patient and Make Changes.
[0184] After the user has added or selected a patient, they may
proceed by clicking on Enter Treatment Sheet or Enter Billing Info.
Both of these buttons proceed to allow the entry of treatment data
for a particular Date of Service.
[0185] Enter Billing Info is oriented for billers working from
a conventional paper superbill. A typical superbill lists various
drug and administration codes under different sections of a preprinted
form. The application provides a series of input screens as tabs
attempting to match the most common layouts for superbills. Hence,
a biller can tab quickly to Survey, Fluids, Non-Chemo, Chemo, or
Office Visits/Labs/Misc. The application sequences the drugs in
the drop down boxes by J-Codes, which billers are intimately familiar
with, allowing the biller to quickly reach the drug they are looking
for. Upon completion of input, the generated Superbill is directly
viewable.
[0186] Enter Treatment Sheet is oriented for nurses. Instead of
Fluids, Non-Chemo, and Chemo tabs, there is one Treatment Sheet
tab. Within this tab, the nurse enters the services performed. Since,
the application lists them in the Patient Treatment Sheet in the
order of entry by the nurse, reporting the services in the actual
administration sequence is preferred. Upon completion of input,
a Treatment Sheet is directly viewable.
[0187] Nurses will typically enter data by way of the Enter Treatment
Sheet button. Billers or Billing Agencies that use the standard
paper superbills would enter data by way of the Enter Billing Info
button.
[0188] List All Bills provides a list of patient encounters from
which the user can view saved patient encounters for editing and
printing purpose. In addition, it allows the user to copy a patient
encounter to another Date of Service.
[0189] Copy Bill From Other Patient provides the ability to copy
encounter data from one patient to another.
[0190] FIG. 3 is a screenshot illustrating the start of data entry
for a Medicare patient. This window resulted from clicking on Enter
Treatment Sheet from the Patient Information Window. The window
has the text, `CLICK FOR: [patient name]`, in order to locate it
on the Windows Task Bar at the bottom of the screen. As mentioned
previously, the application has the capability to allow entry of
patient treatment data in real time. To accommodate multiple patients
in real time, users can start subsequent instances of the application.
Each patient's window is readily located on the Windows Task Bar
and clicked when it is time to enter real time data for a particular
patient.
[0191] The top portion of the window repeats some of the identifying
characteristics of the patient from the previous window. The application
displays the patient's age to assist in identifying the patient.
The computer application also accommodates a photographic image
of the patient for further identification (not shown).
[0192] The bottom left of the upper section of the screen allows
for Cycle-Day/Week entries, as optional input from the nurse. If
the nurse recorded chemotherapy data, but did not enter Cycle-Day/Week,
the application will issue a prompt, encouraging their entry, which
the nurse may decline. The application prevents the entry of duplicate
Cycle-Day/Week values for a patient. If the nurse entered values
for these fields and there was no chemotherapy performed, the application
will reject the values, as Cycle-Day/Week only applies to chemotherapy.
[0193] The application displays a calendar to the right of the
window. The application does not allow the entry of future dates.
The application highlights tomorrow's date to force the nurse to
overtly select a date. Although the application can participate
in a real time environment, where there is an advantage to default
to the current day, most of the nurses seem to be using the application
after the treatment has concluded. It is typical for the nurses
in many practices to do their charting at the end of the week, increasing
the likelihood for incorrect date entries. Hence, the application
forces the nurse to select the Date of Service (DOS) on every encounter.
If the nurse has not entered a date and clicks View Treatment Sheet,
the application will issue a message stating, "You must enter
a Date of Service".
[0194] After the user clicks the DOS, the application displays
the DOS field at the top right of the window in mm/dd/yyyy format.
Clicking on the date causes the calendar to reappear, which allows
the date to be changed. If the DOS already exists in the database,
the application issues: This patient already has a bill for this
DOS will appear after clicking View Treatment Sheet.
[0195] The content of the upper portion of the window remains fixed
throughout the selection of the various tabs. The user can change
the contents of the modifiable fields (DOS and Cycle Day/Week) at
any time.
[0196] The remainder of the window consists of a series of tabs
containing logical groupings for patient treatment data. This window
opened at the Survey Tab because Mary Medicare has Medicare insurance
and the doctor's practice has elected to participate in the Medicare
Demonstration Project. The nurse may enter the Survey answers at
this point or click on one of the other tabs and return to this
tab later. There is no required order for entry of any of the tabs
and the entries do not have to be complete because the nurse can
always return to a tab making additions, deletions, or changes to
the data. The application is persistent in its quest to maximize
reimbursements. If the nurse had forgotten to return to the Survey,
the application will remind the nurse that the Survey is incomplete
and force the nurse to return to the tab and complete the answers.
[0197] FIG. 4 is a screenshot of the Survey tab. Here you can see
that the nurse selected a DOS of Sep. 21, 2005, since it appears
to the right of DOS in the upper right corner of the window and
the Calendar has disappeared. To change the date, the user clicks
the DOS causing the Calendar to reappear.
[0198] At this point, the nurse may select the appropriate survey
answers by selecting from the drop down box for each Survey question.
The application checks to verify that there are answers to all three
questions after the nurse clicks the View Treatment Sheet button.
If the nurse did not answer all three questions, the application
presents the Survey tab, instructing the nurse to complete the Survey.
If for some reason, the nurse desires to waive the Survey, the nurse
may deactivate the Survey by clicking on SurveyOnOff at the top
of the window. Clicking SurveyOnOff a second time reactivates the
Survey.
[0199] FIG. 5 illustrates entry of treatment data when selecting
a drug or fluid. Here the nurse has selected the Treatment Sheet
tab. At the left, the nurse can select from the drugs and fluids,
predefined in ProcsAndCodes. Because they appear in alphabetic sequence
by Drug Description, the drugs should be given names familiar to
the nurse. In this case, entering the letter r, positioned the drop
down to the first entry beginning with r, Rituxan.
[0200] FIG. 6 illustrates entry of treatment data when selecting
an administration. The patient is to receive Rituxan by Infusion.
The drop down box shows the default Admin choices available for
a drug. These choices can be limited per drug by settings in ProcsAndCodes.
Some Drugs can only be administered by: (Push or Pump only); (Injection
or Infusion only); (Injection only); (Push or Infusion only); (Push
only); or (Infusion only). The default is (Infusion or Push or Injection).
[0201] FIG. 7 illustrates entry of treatment data when selecting
an infusion. Because the nurse selected Infusion, this prompt appears.
The application is about to display an Infusion Clock for the nurse
to establish the Infusion Time. The nurse proceeds by clicking on
OK.
[0202] FIG. 8 shows a treatment screen with an Infusion Clock.
The nurse has clicked the OK button, which displays the Infusion
Clock. The nurse can click on Auto Start to start a stopwatch for
real time recording of the infusion. When the infusion is completed,
the nurse would click on Auto Stop. Then when the user clicks Set
Inf Time From Clock, the elapsed time is calculated and recorded
as the Inf Time for the Infusion.
[0203] As an alternative, the nurse can enter the Start Time and
End Time in Military Time as log entries. Again, when the nurse
clicks Set Inf Time From Clock, the elapsed time is calculated and
recorded as the Inf Time for the Infusion.
[0204] The third alternative is for the nurse to enter Inf Time
as hh:mm and Click on Set Inf Time Manually, resulting in hh:mm
as the Inf Time for the Infusion.
[0205] FIG. 9 shows a treatment screen with an Infusion Clock and
waste for a Single Use Vial drug. The nurse has entered 1:35 in
Inf Time (hh:mm) and clicked on Set Inf Time Manually. The application
assigns the time of 01:35 to the Infusion for Rituxan, since it
is the highlighted drug. The application transfers the 01:35 to
the Rituxan line in the column Inf Time. The application clears
the 01:35 in the Inf Time (hh:mm) box to accommodate the next Infusion
or Hydration time entry.
[0206] Had the nurse entered 1:30, the application would have notified
the nurse: Rounding Down additional hour of Infusion Time because
Time is 1:30. Infusion time of 1:31 would Round Up. Rounding Down
will be done for billing purpose only. The time you enter is still
recorded as is. Confirm the Infusion Time is actual and accurate.
[0207] Rituxan comes in 100 mg and 500 mg Single Use Vials. The
nurse cannot use any remaining portion on another patient or encounter.
The remainder is reimbursable when included in the billing quantity.
Both vial sizes have the same J-Code (J9310) with a HCPS Billing
Unit of 100 mg. The application estimates the Waste by presuming
the vial size is the same as the HCPS Billing Unit. In this case,
the application has estimated seven vials to provide 675 mg, leaving
25 mg as Waste. Therefore, the total amount of drug expended is
700 mg. When dividing by the HCPS Billing Units of 100 mg, the billing
algorithm determines a HCPS Billing Quantity of seven. The FeeAmount
in DoctorsAndFees is $600 per HCPS Unit yielding a Charge of $4200.00.
The application highlights the estimated Waste in red to catch the
nurse's attention in case the nurse needs to modify the amount of
waste.
[0208] However, if the vial size were actually 500, the Waste would
be 325 mg, yielding a Charge of $6,000.00, a significant difference
in reimbursement, illustrating how important it is for the nurse
to monitor this field. To improve the estimate of Waste, the program
application also provides the ability to select the drug by vial
size.
[0209] At this point, you can see the Total Charge is $4200.00,
as displayed in the upper right portion of the window. However,
this does not include the administration fees because parsing of
the applicable Medicare G-Codes has not taken place, yet. Nor should
they be, because the entire encounter needs to be examined in its
entirely before the Initial G-Code can be determined, which significantly
affects the Total Charge.
[0210] FIG. 10 shows a treatment screen with a subsequent chemotherapy
drug and administration. The patent received 45 mg of Fludarbine
by Infusion over a one-hour period. The nurse entered the appropriate
quantity. Since the Infusion Clock was already in the window, the
prompt stating: Infusion clock is being displayed . . . does not
appear again. The application highlights Fludarbine after the nurse
selects it. Therefore, any clock entries made will apply to this
drug. If the nurse forgets to make the time entry and clicks View
Treatment Sheet, the application issues an error message.
[0211] Fludarbine comes in a Single-Use Vial. There is only one
vial size of 50 mg, which is equal to the HCPS Billing Unit. The
application estimate of 5 mg is probably accurate, but the nurse
can modify the Waste if necessary. Perhaps the nurse spilled the
previous vial or the previous vial had expired and the manufacturer
will not provide for an exchange.
[0212] Notice that the Fee for Fludarbine is $400.00 and Total
Charge is now $4600.00. Remember Admin Fees will not be determined
until the nurse clicks View Treatment Sheet.
[0213] FIG. 11 shows a treatment screen with a non-chemotherapy
drug and administration. The nurse reported that the patient received
25 mg of Diphehydramine by Infusion. It occurred over a 30-minute
period. Hence, the nurse entered 00:30 into the Inf Time (hh:mm)
box. Clicking on Set Inf Time Manually would transfer it to the
Diphehydramine line.
[0214] Note: Medicare defines an Infusion Time of 15 minutes or
less as a Short Infusion and requires the practice to bill it as
a Push. When this is about to occur, the application will inform
the nurse: Infusion times of 15 minutes or less will be billed as
Pushes.
[0215] Diphehydramine comes in a Single-Use Vial. There is only
one vial size of 50 mg, which is equal to the HCPS Billing Unit.
Therefore, the application estimate of 25 mg is probably correct,
but the nurse could modify the Waste. Notice the Total Charge increased
by $5 to $4605.00.
[0216] Had the patient brought in his own drug and had it administered,
the nurse would have clicked the Rx radio button, indicating that
the application should not bill the J-Code representing the drug
charge to Medicare. Common examples are: J1750 (Iron); Q0136 (Procrit);
J3487 (Zometa); and J2505 (Neulasta).
[0217] In the column labeled Conc is a drop down list that defaults
to Sequential, but the user can select Concurrent. The Medicare
G-Code system requires a different administration code for a non-chemotherapy
drug when it is infused simultaneously with another drug, i.e.,
Concurrent with any other chemotherapy or non-chemotherapy infusion.
The field only appears when a non-chemotherapy Infusion is being
reported. Here, the nurse has reported that the patient was administered
Diphehydramine as a sequential infusion.
[0218] FIG. 12 is a treatment screen with fluids. The nurse reported
the bags of Saline used during the chemotherapy session. The nurse
administered 500 ml of Normal Saline to the patient followed by
250 ml and then another 500 ml. Both bags served as a Dilutant to
the administered drugs. The application reports each bag on the
Treatment Sheet in the order administered. The billing algorithm
bills the two 500 ml bags as one J7040 with a quantity of two.
[0219] Dilutant is the default Admin for bags of Saline. The other
value is Hydration; described in detail later. The application's
billing algorithm will not generate G-Codes for the Saline because
there is no reimbursement for its administration, except during
Hydration. The application tallies the Fees for the Saline itself
in the Charge column.
[0220] The Port was flushed with a dosage of 500 units of Heplock.
Since the HCPS Quantity is in units of 10, the billable HCPS Quantity
is 50. In DoctorsAndFees, the Fee to be charged was defined to be
$0.10 per HCPS Quantity resulting in a line item charge of $5.
[0221] Insurance carriers do not provide reimbursement for Heplock,
Heparin, or the 5 cc of Saline. These supplies are bundled. The
application reports them in the patient's Treatment Sheet, but does
not bill for them. The application calculates the supply fees because
they once were reimbursable and might be again in the future.
[0222] The port flush administration is also bundled. It is not
reimbursable, except in one very narrow circumstance. This is when
a nurse performs a port flush and there are no other services for
the day, except for Labs. The nurse selects the Port Flush administration
in the Office Visit/Labs/Misc tab; so, there is no need to have
Admin values for the port flush supply J-Codes. Hence, the Admin
values for the port flush supplies are all blank, as you can see
in their drop down boxes.
[0223] The computer application can determine when a port flush
is reimbursable and offers G0363 (Port Flush) if the nurse has not
already selected it. If the nurse has selected 99211, OV Brief (Nurse
Visit) instead of Port Flush, the application offers G0363, Port
Flush, in its stead.
[0224] This is the end of the Treatment Sheet entries. Although,
there appears to be only one more line for data entry, there is
a scroll bar to the right that can be used to access more lines
on the form.
[0225] FIG. 13 illustrates the entry of Vitals/Comments. The nurse
has jumped over to the Vitals/Comments tab. The nurse recorded the
patients Blood Pressure, Temperature, and Pulse. The nurse also
made entries for the Karnofsky and ECOG performance status. In addition,
the nurse entered Progress Notes. This can be especially handy to
the billing department when a carrier denies a claim and demands
to see Progress Notes. There does not have to be any manual searching
through patient charts. As we will see, the application can print
them out in the Treatment Sheet for the patient's chart or for forwarding
to the insurance carrier.
[0226] FIG. 14 illustrates the entry of Office Visits/Labs/Misc.
The nurse has clicked on the Office Visits/Labs/Misc tab and selected
an OV Brief (99211). The nurse is also reporting a Complete blood
count. You can see all of the choices for Labs/Misc near the bottom
of the form. Total Charge now appears as $4706.00. Since this seems
to complete the patient encounter, the nurse clicks on View Treatment
Sheet.
[0227] FIG. 15 shows a treatment screen with missing infusion time.
The nurse forgot to click Set Inf Time Manually after entering the
30 minutes for the Infusion of Diphehydramine. The application discovered
this, issuing the prompt and highlighting Diphehydramine for correction.
The nurse clicks OK and then clicks on Set Inf Time Manually to
transfer the 30 minutes from the clock to the Infusion time for
Diphehydramine. The nurse proceeds by clicking on View Treatment
Sheet.
[0228] FIG. 16 shows a prompt noting missing Cycle-Day/Week values.
The application suggests the recording of the Cycle and Day/Week.
This is probably a good idea because the nurse can add it to the
patient's chart by printing the Treatment Sheet that the application
is about to produce. In addition, the application displays a list
of Superbills with the included Cycle-Day/Week entries. Any omissions
in the series could mean a Superbill is missing. Perhaps an encounter
was misplaced and not entered into the application. The nurse enters
the Cycle and Day and clicks on OK.
[0229] FIG. 17 shows a prompt forcing the user to enter missing
Survey questions. The application has detected that the doctor's
practice has decided to participate in the Medicare Demonstration
Project, but apparently, the nurse did not answer all of the Survey
Questions. Had the patient not received a Chemotherapy Infusion
or Chemotherapy Push, the application would not have issued this
prompt because the Demonstration Project only reimburses in those
instances. In addition, the patient must have a cancer as a primary
diagnosis. The nurse clicks the OK.
[0230] FIG. 18 illustrates that the application presented the Survey
Tab to the user in order to complete the Survey questions. The nurse
forgot to answer the question regarding Fatigue. All three questions
must have answers in order to receive any reimbursement; so, the
nurse enters Quite a bit and clicks on View Treatment Sheet.
[0231] FIG. 19 shows the blocking of a 99211 charge for a Medicare
patient. This prompt appeared because Medicare does not pay for
a 99211 if there is chemotherapy or non-chemotherapy on the same
DOS. This will result in a rejection message in the Explanation
of Benefits. One of the objectives of this application is to minimize
the number of rejections, especially those that are innocuous. The
application seeks to reduce the deluge of messages in the EOBs in
order not to lose sight of rejections, requiring prompt follow up.
Even if by chance Medicare makes payment on the charge, it is only
a matter of time before Medicare discovers the mistake and seeks
to reclaim the money. This will be by deducting the error from a
future claim, causing confusion for the billing department and end
up costing more in the long run. Probably the most negative aspect
is that they will overstate the Accounts Receivables, falsely indicating
revenue that is not there.
[0232] Note: Medicare only denies payment for 99211 Level I (Nurse)
Office Visit Brief. Medicare allows Higher-level Office Visits when
billed with a 25 Modifier.
[0233] After clicking on OK, another prompt appears.
[0234] FIG. 20 shows a prompt asking the nurse if they used a peripheral
IV. The computer application always asks the nurse if there was
a peripheral IV. Although, Medicare will not reimburse for this
service and the application will not attempt to bill Medicare, the
question is relevant for complete documentation in the patient's
Treatment Sheet. There was no administration of a peripheral IV,
so, the nurse clicks on No.
[0235] FIG. 21 is a screenshot of the top half of a Treatment Sheet.
The Treatment Sheet generated for the encounter appears for review
by the nurse. It has been broken into two parts here to paste it
into this document. It shows the services performed, as well as
the recorded Vitals and Comments. The Treatment Sheet records the
waste for all of the drugs here.
[0236] FIG. 22 is a screenshot of the bottom half of a Treatment
Sheet showing signature lines for the doctor and nurse. At this
point, the nurse may print the Treatment Sheet and put it into the
patient's chart. Notice there are two lines. One is for the doctor's
signature and the other is for the nurse to sign.
[0237] FIG. 23 shows the selected radio button to release the Superbill
for billing. When the nurse clicks on Close, the application presents
this window. The nurse elects to take the default action and clicks
Done.
[0238] FIG. 24 shows a prompt confirming that the computer application
saved and released [the Superbill] for billing. The Treatment Sheet
is stored for later printing at any time. Because the nurse released
the Superbill to billing, no further changes should take place to
the encounter. The application locks the encounter, preventing any
further changes until the user intentionally unlocks the encounter.
After the nurse clicks OK, the Patient Information Window appears.
[0239] FIG. 25 shows the Patient Information Window. Notice the
application updated the Last Date of Chemo. While not relevant for
a Medicare patient, it is applicable for the billing of Chemo Follow-Up
Visits for Blue Cross patients. Let's have the nurse click on List
All Bills.
[0240] FIG. 26 shows all of the saved encounters for Mary Medicare.
The application presents all the saved patient encounter records
to the nurse. The application has set the Status for the last encounter
to Billed with the Date and Time when the nurse last released it.
[0241] For the biller to obtain the Superbill, under Options to
the right of Bill, the biller clicks on Print/View.
[0242] If the insurance for the patient has been changed in the
Patient Information Window, the user must Change Status to Open
the bill and then Edit followed by View Superbill to generate a
new Superbill with the rules for the new insurance.
[0243] FIG. 27 is a screenshot of the top half of the Superbill.
This is the Superbill for the patient's Date of Service (DOS). The
billing algorithm parsed the Treatment data. G0359, Chemotherapy
administration, intravenous infusion technique; up to one hour,
single or initial substance/drug was determined to be the Initial/Primary
Procedure. The billing algorithm parsed the remaining Admin's and
generated the following G-Codes with their respective quantities.
[0244] For Claim # 1, G0359, Chemo IV infusion, single/initial
hour drug, 1st hour (abbreviated description for G0359 from ProcsAndCodes)
is listed first because it is the Initial G-Code. Each additional
hour of Chemo infusion up to 8 hrs (abbreviated description for
G0360) immediately follows. The G0360 has a quantity of one, since
the G0359 accounted for the first hour and the billing algorithm
rounded up the additional 35 minutes yielding the additional hour.
[0245] The most expensive chemotherapy drug, Rituxin, is right
behind the two G-Codes that represent its administration. Its dosage
of 675 mg resulted in seven HCPS Billing Units. The application
has already documented the 25 mg of waste in the Treatment Sheet.
[0246] The three Demonstration Codes are next because if they are
not in the same claim as a chemotherapy infusion or push, Medicare
will not provide for their reimbursement.
[0247] There can only be six lines per HFCA 1500 Claim; so, the
application calculates a Claim charges subtotal to assist the biller
with verification of correct data entry into the billing software.
When the biller enters the first claim into the billing system,
the billing system should agree with the Claim charges subtotal
of $4,657.00. Otherwise, a data entry error probably occurred during
data entry or the Fees are different in the billing system. It is
recommended that the Fees be identical between this application
and the billing system in order to verify data entry. The application
then generates the next claim.
[0248] Not every billing software system limits data entry to six
lines to mirror the HFCA 1500 Claim Format. Some will accept more
than six lines for data entry. The computer application also generates
the accumulated Bill Charges for the entire encounter, which can
serve as balance total for the biller to verify data entry.
[0249] FIG. 28 is a screenshot of the bottom half of the Superbill.
The second claim begins with G0362, Chemotherapy administration,
intravenous infusion technique; each additional sequential infusion,
(different substance/drug) up to one hour followed by the additional
chemo drug, Fludarbine. The dosage equated to a HCPS Billing Quantity
of one.
[0250] Next is G0349, Intravenous infusion, for therapy/diagnosis
(specify substance or drug); additional sequential infusion, up
to one hour. The infused non-chemotherapy drug, Diphehydramine,
follows with a HCPS Billing Quantity of one. In addition, the billing
algorithm knows that a secondary diagnosis of Nausea with Vomiting
(78701) is a prerequisite for its reimbursement. The required secondary
diagnosis code for this drug is set in DrugsAndProcs.
[0251] Because Port Flush Services and Supplies are bundled expenses,
the billing algorithm does not bill the J-Codes for the Heplock
and the 5 cc of Sterile Saline. The billing algorithm has listed
the bags of Saline with a quantity of two for the 50 ml bags and
a quantity of one for the 250 ml bag. The Claim Charges for Claim
# 2 total $597.00.
[0252] Last is the charge for the Complete Blood Count. Since,
all billable expenses are now complete, another Claim charges total
appears, as well as the Bill charges for the patient encounter.
This should balance with the billing system with a total for $17.00
for the third claim and a complete total for the entire encounter
for $5,271.00. Like the Treatment Sheet, the user can print the
Superbill at this point. There is another option to print the Superbills
by a range of Bill Release Dates (Invoked through BillingReports).
Close returns to the prior window.
[0253] FIG. 29 shows the two encounters for Mary Medicare again.
The application shows that the bill was originally released for
billing on Sep. 22, 2005 at 10:40 PM. When a user clicks on Change
Status and confirms by clicking Yes, the application copies the
date and time to the Original Release Date. The next Submit for
Billing revises the Status with the new Release Date. From the time
stamp, the nurse and biller can determine if they can simply swap
the new bill with the old bill. If there is a substantial difference
in the dates, the biller will immediately see the need to rebill
for any added, deleted, or modified charges that appear on the new
Superbill.
[0254] Close returns to the Patient Information Window.
[0255] FIG. 30 illustrates selecting another patient from the Patient
Information Window. The nurse has returned to the Patient Information
Window. The nurse entered the letters hy to the right of Find by
name: In our small "Sandbox" database, the fictitious
patient with a last name of Hydration appears. In a real setting,
more characters of the last name might be necessary. At this point,
the nurse presses the Enter key with the following result:
[0256] FIG. 31 shows the selection of Heidi Hydration. Heidi Hydration
appears with her basic patient information. Let us pretend the user
this time is a biller. Thus, the biller clicks, Enter Billing Info
and is positioned at the Fluids tab. The application does not present
a Survey tab because Heidi is not a Medicare patient. The application
presented the Calendar for the DOS and the biller clicked on the
day representing Sep. 19, 2005.
[0257] FIG. 32 shows the Fluids Tab after the user has selected
Hydration. Let us pretend the biller is working off a standard paper
superbill, not this application's Superbill, but one drafted by
the doctor's practice. This practice documents the actual start
and stop times recorded by the nurse on the superbill. In addition,
on this superbill, the nurse has checked off services for Hydration,
Phlebotomy, and Venipuncture, but forgot to communicate the administration
of a Peripheral IV.
[0258] The biller has already selected an Admin of Hydration (The
default of Dilution was overridden by selecting Hydration from the
Drop Down Box) for J7040 with a Dosage of 500 ml. Hydration has
a billable G-Code based on duration. The application is about to
display a Hydration Clock for the user to establish the Start Time
and End Time. Notice the Total Charge of $15.00 to the left of View
Treatment Sheet. The application has begun to tally the total charges
for this patient encounter. ProcsAndCodes has a Fee of $15.00 for
J7040.
[0259] FIG. 33 shows the Hydration Clock. The biller has clicked
the OK button resulting in the display of the Hydration Clock. The
Hydration Clock acts just like the Infusion Clock explained before.
Here it is more obvious that the clock is for Hydration because
this entire tab is devoted to Hydration. With the Treatment Sheet
method of data entry, the user knows the clock is for Hydration
when the application highlights a line with an Admin of Hydration
in the light blue, we saw before.
[0260] FIG. 34 shows the entered Start Time a |