Inpatient Billing Cheat Sheet: The Superbill
An Inpatient Billing Cheat Sheet is a valuable resource for billing and coding staff, helping them navigate the complex billing process efficiently and reduce errors. It can be especially useful in fast-paced healthcare environments where accurate billing and timely claim submission are critical for optimal revenue management. The content of the cheat sheet should be regularly updated to reflect any changes in coding guidelines, payer requirements, or industry regulations.
What are Super Bills?
Super Bill is a recorded list of all services rendered to a client. It also contains other vital information along with patient visits like practice information, CPT codes, ICD-10 codes, referring physicians, and other relevant data. They’re different from regular medical bills in that insurers use them to pay patients rather than providers.
Do not throw your superbills!
Many individuals often underestimate the potential reimbursement they can receive from their Superbills, especially for out-of-network (OON) services. This misconception arises from the assumption that their insurance won’t cover such care. However, people can easily verify their out-of-network benefits at no cost and determine the reimbursement they may be eligible for by using SuperBill’s OON benefits calculator.
Other terms of Super Bill
The other names for Super Bill are Charge Slips, Fee Tickets, and Encounter forms. These pre-printed documents record the fees connected with a patient visit through procedure codes and diagnostic codes that are necessary to bill insurance companies.
Super Bill Components
Patient and Provider Information
Collecting accurate patient information including name, contact information, insurance details, and demographic information are required. In the same way, the provider information such as name, National Provider Identifier number (NPI), and practice address are needed. For accurate billing and a seamless reimbursement process, the above details are needed.
Service Information and Coding
To ensure accurate billing and claim filing, a superbill must include comprehensive service information, such as the date of service, place of service, process description, time spent on services, Balances due or paid, and associated diagnosis codes. ICD-10 numbers record diagnoses, while CPT codes identify specific medical procedures or services. Proper coding is essential to avoid claim denials or reimbursement delays and to reflect the care provided accurately.
Supporting Documentation
Including supporting documents like progress notes, treatment plans, test results, or referrals on the superbill can enhance credibility and validate the medical necessity of the services provided. Adherence to proper documentation procedures and privacy laws is crucial when integrating sensitive patient information. This additional data facilitates a smoother reimbursement process and reduces the chances of claim denials.
Provider Signature
The signature of the provider is required by insurance companies to process claims and validate for data accuracy on the superbill. Ensuring precise and compliant provider signatures on the superbill is crucial for healthcare professionals, and they can achieve this by diligently adhering to established procedures and maintaining up-to-date licensure and credentialing information. By doing so, healthcare practitioners can confidently and securely endorse the superbill, guaranteeing accuracy in the billing process and meeting all regulatory requirements.
How to make Super Bills more user friendly?
According to a Medical Economics report, an extensive review of 60,000 physician billing audits conducted by the American Academy of Professional Coders (AAPC) revealed a concerning trend. It was discovered that over a third of the examined records exhibited either under-coding or under-documentation issues. This finding implies that each physician, on average, risked losing approximately $64,000 in potential revenue or faced potential financial risks due to these billing inaccuracies.
Let’s see how a small modification with Super Bills can help in a big time. Prepare handy cheat sheet that clearly describes what’s required for each level, this could be a spot on the back if in case of paper. If you are using digital charge capture tool, customize CPT descriptions to incorporate the necessary information.
(99221–99239) Hospital Inpatient services
(99363–99368) Case management services
(99374–99380) Care plan oversight services
(99495–99496) Transitional care management services
(99499) Other evaluation and management services
Diagnosis Favorites List
By implementing this feature, administrators can customize the frequently used diagnostic codes for each specialty and prioritize the codes preferred by individual physicians. This streamlines the coding process, saving valuable time and eliminating the need to search through an exhaustive list of codes. Consequently, it accelerates coding procedures, improves accuracy, and ultimately leads to faster billing and reimbursement turnaround times.
Aggregate Items Together
Consider the practice of bundling charges when using a digital charge capture solution or even when contemplating its adoption. By bundling CPT codes that consistently receive charges together in a single selection, you streamline the process, eliminating the need for extra clicking. Additionally, you can further optimize efficiency by incorporating specific modifiers that consistently apply to certain CPT codes directly into the charge, ensuring all relevant information is gathered accurately from the outset.
Benefits of Mobile Charge Capture with Superbills:
Superbills, when combined with a digital capture tool, offer even greater advantages and efficiencies for medical practices. Here are some benefits of using a digital capture tool alongside superbills:
Electronic Data Entry: A digital capture tool allows healthcare providers to electronically enter data directly into the superbill. This eliminates the need for manual handwriting and reduces the chances of transcription errors, ensuring more accurate and legible documentation.
Real-Time Updates: Digital capture tools can be easily updated to reflect changes in CPT codes or other billing information. This ensures that the superbills always contain the most current and accurate coding options, reducing the risk of using outdated or incorrect codes.
Integration with EHR/EMR Systems: The digital charge capture tools can seamlessly integrate with Electronic Health Records (EHR) or Electronic Medical Records (EMR) systems. This integration enables automatic transfer of data from the superbill to the patient’s electronic record, saving time and improving data consistency.
Faster Billing and Reimbursement: Digital capture tools facilitate faster processing of superbills and billing information. As the data is electronically captured and transmitted, it accelerates the billing and reimbursement cycle, leading to quicker payments for medical services rendered.
Accessibility and Portability: Digital capture tools can be accessed on various devices like tablets, smartphones, or computers. This makes it easier for healthcare providers to carry the tool with them during patient encounters, ensuring that all relevant services are documented promptly.
Reporting and Analytics: Digital capture tools can provide valuable insights through data driven reports where practices can use this information to track commonly performed procedures, identify billing patterns, and optimize their billing and coding processes for better financial performance.
Coding Assistance: Some digital capture tools come with built-in coding assistance or decision support features. These features can help providers select the appropriate CPT codes by guiding them through the coding process based on the documented services.
Secure Data Storage: Digital capture tools often offer secure data storage and backup options. This protects sensitive patient information and ensures compliance with data privacy regulations.
Customizable Templates: Digital capture tools allow practices to create customizable templates for different specialties or specific patient conditions. This flexibility ensures that superbills are tailored to meet the unique needs of each medical practice.
Reduce Paper Usage: By using digital capture tools, medical practices can significantly reduce their reliance on paper, contributing to environmental sustainability and reducing administrative clutter.
Reorganize your Super Bills
· Save time in searching and scrolling by placing the categories and codes at the top of the page or menu. Determine the most frequently used CPT codes and diagnosis codes in your practice. Place these at the top or in easily accessible sections to save time during data entry.
· When organizing the codes within a digital charge capture solution, it is essential to consider the most logical and practical categorization. One approach could be grouping them based on their nature, such as procedures, visits, and other relevant classifications. Alternatively, you might find it more beneficial to categorize the codes according to the place of service.
· Empower providers with the flexibility to create their personalized CPT code list while maintaining the utmost clarity in code descriptions that are easy to understand and avoid ambiguous terms that may lead to confusion.
· Regularly review and remove codes that are rarely or never used. A concise superbill will reduce clutter and make it more user-friendly.
· Stay current with the latest CPT code changes and revisions. Update your superbill regularly to reflect any new or modified codes.
· Use an effective billing software that allows customization of superbill templates, and which can modify easily.
A digital charge capture tool would be the ideal fit to customize the CPT codes and make the Super Bills super friendly for the Hospitalists with high efficiency, accuracy benefiting both the healthcare providers and patients.
