NCMOA: Financial Management, Billing Support, and Coding

This domain follows the revenue cycle from preregistration to payment posting and denial follow-up, plus the coding rules that determine what can be billed.

Revenue cycle stages

1. Preregistration and eligibility verification.
2. Registration and financial counseling; collect copays at time of service.
3. Charge capture and coding.
4. Claim submission (CMS-1500 paper form or 837P electronic).
5. Payment posting from the EOB/ERA, with contractual adjustments.
6. Denial management and A/R follow-up; aging buckets at 0–30, 31–60, 61–90, 90+ days.

Coding basics

• ICD-10-CM codes diagnoses; code to the highest specificity supported by documentation.
• CPT codes procedures and evaluation/management services; the E/M level is set by medical decision making or total time.
• HCPCS Level II covers supplies, drugs, and ambulance services.
• Modifier 25 marks a significant, separately identifiable E/M service on the same day as a procedure.
• Never code from a charge ticket alone - the documentation must support the code.

Worked example

Allowed amount for a visit is $250. The patient has a $1,000 deductible with $100 remaining, then 20% coinsurance. The patient pays the first $100 toward the deductible, then 20% of the remaining $150 = $30, for a total of $130. The plan pays $120.

Traps that cost marks

• Upcoding (billing a higher level than documented) and unbundling (separately billing components of a bundled service) - both are fraud exposures.
• Entering a diagnosis code in a procedure field.
• Skipping eligibility verification, then discovering the plan termed last month.
• Missing the payer's timely-filing deadline.
• Posting patient payments without applying the contractual adjustment.