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Medical coding and billing chapter 5
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In the medical billing and coding process there are several steps. In the medical billing process physicians prepare and sign documentation of the patients visit. The next step is to post the medical codes and transactions of the patients visit in the practice management program and to prepare claims. The process used to generate claims must comply with the rules imposed by federal and state laws as well as with payer requirements. Claims that are correct help to reduce the chance of an investigation of the practice for fraud and also the risk of liability if an investigation does occur (Valerius, Bayes, Newby & Seggern, 2008). Most physicians depend on their personnel to process their medical bills without looking at the bills before they’re submitted for payment. Some physicians who don’t review the medical billing procedures may not receive the payment they deserve (Adams, Norman, & Burroughs, 2002). There are several errors that can occur in the billing and the coding process. When there’s a problem in the coding process it can cause rejected claims. Some of these problems consist of truncated coding, mismatch between the gender or age of the patient and the selected code when the code involves selection for either criterion, assumption coding (reporting items or services that were not documented, but that the coder assumes were performed), altering documentation after services are reported, coding without proper documentation, reporting services that are produces produced by unlicensed and or unqualified clinical personnel, coding a unilateral service twice instead of choosing the bilateral code, and not satisfying the conditions of coverage for a particular service. These errors can result in denials or payments being delay... ... middle of paper ... ...d practice standards, conduct training and education, and respond appropriately to correct errors. Even though there are numerous problems in the coding and billing process, if the appropriate steps are followed and carefully reviewed then most of the coding and billing errors can be avoided (Valerius, Bayes, Newby, & Seggern, 2008). Works Cited Adams, D., Norman, H., & Burroughs, V. (2002) Journal of the National Medical Association. Addressing Medical Coding and Billing Part II: a strategy for achieving compliance. A risk management approach for reducing coding and billing errors. Retrieved July 14, 2009, from http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=2594405&pageindex=11#page Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd ed.). Boston: McGraw-Hill.
Under the Social Security Act, it is required that hospitals report quality measures for a set of 10 indicators. If hospitals do not report quality measures to CMS there is a reduction in payments. In the hospital readmission area of investigation, OIG reviews Medicare claims in hospital readmission cases to identify trends and oversights of cases. Readmissions are cases in which the beneficiary is readmitted to the hospital less than 31 days after being discharged from the hospital. Hospitals are only entitled to one diagnosed-related group payment if there is a same-day readmission for symptoms related to prior hospital stay. Quality improvement organizations are required to review hospital readmission cases also this is to see if standard of care are met. For coded conditions as present on admission, it is required for acute hospital to report these diagnoses on Medicare claims. The OIG will review Medicare claims for types of facility or providers most frequently transferring patients to hospital
The first step is to pre-register the patient's insurance information into the computer system and making a copy of their insurance cards. The patient's insurance information would then be verified. The patient would then be seen by a medical professional to examine the patient, discuss any test results or provide a diagnosis. Once the patient is ready to check out any payment due would be collected. The medical coder would then go over the patients' medical record and assign any diagnosis codes or procedural codes and then a claim form (CMS 1500) would be completed and submitted. The payment would also receive and posted at this time and document in the patient's record. The CMS 1500 will information from the patient, including the type of
Medical billers often communicate with physicians and other health care professionals to explain diagnoses or to attain further information by means of phones, email, fax, etc. The biller must know how to read a medical record and be familiar with CPT®, HCPCS Level II and ICD-9-CM codes.
Collaborative partnerships, among physicians and case managers, add value to the patient care by orchestrating care progression and coordination, supportive decision-making and cost-effective choices. The interaction of the case managers with multiple departments in a health system allows open communication, resulting in quality metrics demonstrating value in areas such as length of stay, observations, accounts receivable, and appeals or denials of patient care (Miodonski 2011). For instance, a patient presents with a myocardial infarction and a hospitalist orders an upper gastrointestinal series that is not necessary. The case manager in this particular situation seeks the necessity of the tests, preventing unnecessary testing and additional length of stay, ultimately improving the patient’s care and progression. Although hospital costs are avoided in this example, more importantly the case manager coordinated efficient movement and progression of care resulting in improved quality and accountability (Daniels & Frater 2011). There is no room for confusing managed care with case management, as managed care equals cost containment programs mandated by concrete systems. Case
Healthcare providers must make their treatment decisions based on many determining factors, one of which is insurance reimbursement. Providers always consider whether or not the organization will be paid by the patients and/or insurance companies when providing care. Another important factor which affects the healthcare provider’s ability to provide the appropriate care is whether or not the patient has been truthful, if they have had access to health, and are willing to take the necessary steps to maintain their health.
Develop plan of care that meets the needs of the patient in this particular situation.
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
In the past Parallon has had limited opportunities for en masse analysis. Requirements for analysis include unit number, patient number, client information, payor and payment information, and general logic. Improving Parallon’s accounts receivable process required a standardized analysis process. Accounts eligible for analysis do not have Medicare as a primary insurance, and secondary was present. All accounts must be in accounts receivable or collections agency status. Organizing accounts into three specific categories assisted in developing decisions based on account criteria. Account separation methods included accounts without a primary or secondary payment processing, accounts above threshold, and accounts with a denial code. Conflicting processes result in the inability to review denial accounts through this standardized process. Placing thresholds on financial classes limits the amount of errors possible due to contract agreements and rates. Payment percentages determine if accounts meet payment threshold requirements for analysis.
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
The client has a responsibility when it comes to what they need to prep before surgeries or outpatient testing. For example if a patient is going to have a colonoscopy the client must know all the rules and regulation from their provider to prep for this procedure days in advance. The client will be handed specific rules beforehand that will summarize what one must and must not complete to get ready for the procedure. The client must interpret and fulfill these directions. If the client does not follow the instructions as stated then the procedure will not be performed. Not only does the doctor have to fulfill his duty to his client the client has to be responsible on their end to also fulfill the provider needs. Doctor’s must keep in mind, that it is the client’s decision to decline care. A doctor cannot pressure or push a client to
Among them is its emphasis on productivity. Fee for service encourages the delivery of care and maximizing patient visits. As a payment mechanism, it is relatively flexible in that it can be used regardless of the size or organizational structure of a physician’s practice, the type of care provided such in clinic visit, surgery, therapy session, and the place of service such as physician’s office, nursing home, hospital, surgery center or the geographical location of care. Fee for service does support accountability for patient care, but it is often limited to the scope of the service a particular physician provides at any point in time. Although fee for service is easy to understand conceptually, it can be difficult to understand in practice. Patients may struggle to decipher the coding and nomenclature involved in billing, manage the numerous bills and explanations of benefits they might receive, and understand its application in inpatient settings, especially for lab, radiology, and anesthesia services. Because payment is limited to one provider for one interaction, fee for service does little to encourage management of care across settings and among multiple
There are several factors that contribute to the complexity of the revenue cycle. Frequent changes in contracts with payers, legislative mandates, and managed care are just a few examples of reasons why revenue cycle in the healthcare industry is so complex. Furthermore, the problems that arise in the steps of the revenue cycle further complicate the whole process. For example, going through the steps of the revenue cycle efficiently is extremely difficult when it is managed by poorly trained personnel. Furthermore, if a healthcare provider does not have the proper information system to track patient records and billing, receiving reimbursement can become difficult. In addition, one of the main factors that delay payments is denial from the insurance companies. The reason for Denial includes incorrect coding, the certain sequence of care and medical necessity or even delay in submitting claims. Lastly, inefficient patient correspondence can not only hinder the process of revenue cycle but also result in many patient complaints (Wolper, 2004).
Let’s briefly review the steps of the medical billing procedure leading up to the transmission of an insurance claim. When a patient receives services from a licensed provider, these services are recorded and assigned appropriate codes by the medical coder. ICD codes are used for diagnoses, while CPT codes are used for various treatments. The summary of services, communicated through these code sets, make
...d procedures are now being monitored to improve clinical processes. Ensuring that these processes are implemented in a timely, effective manner can also improve the quality of care given to patients. Management of the processes ensures accountability of the effectiveness of care, which, as mentioned earlier, improves outcomes. Lastly, providing reimbursements based on the quality of care and not the quantity also decreases the “wasting” and overuse of supplies. Providers previously felt the need to do more than necessary to meet a certain quota based on a quantity of supplies or other interventions used. Changing this goal can significantly decrease the cost of care due to using on the supplies necessary to provide effective, high-quality care. I look forward to this implementation of change and hope to see others encouraging an increase in high-quality healthcare.
...der to ensure that the quality of its products is upheld (Grover & Vriens 2006, p. 147).