Correct Medical Billing and Coding in the Healthcare Industry Medical billing and coding is one of today's topics. When services are billed for patients, they must be coded based on the documentation the physician has dictated in the patients chart to receive payment from the insurance company. As the physicians office and/or hospitals practice correct medical billing and coding, this will prevent audits being brought forth in their practice and/or hospital.
Kenny, Christopher,Correct Coding for Dialysis Billing Providers must ensure proper coding to avoid returned claim, 2012.
This article is geared for those in the medical field who do coding and billing in hospitals for dialysis. The author is educating the coders and billers how to correctly code for dialysis billing. He mentions that The Centers for Medicare and Medicaid, issued a transmittal that has revised the Medicare claims processing manual as it pertains to hospitals billing for dialysis procedures that are non covered under the ESRD benefit for emergency dialysis. In addition, the author discusses how the hospitals should utilize Healthcare Common Procedure Coding System billing code G0275 and code 90935 for hemodialysis. Only to bill G0275, if the hospital is a ESRD facility, emergency services, and when dialysis is performed with related procedures, such as a vascular access procedures or when performed following treatment for an unrelated medical emergency. The author also continues to elaborate on procedure code 90935, in that, this code should be used for hospital inpatient, whether they have ESRD or not and has Part B coverage only. As the billers and coders take note of the correct coding, for dialysis and hemodialysis, they will receive a reimbursement for both procedure codes of $436.56, each time they are billed. This method of correct coding /billing for those who bill strictly for dialysis and hemodialysis,will generate their organization a wealth of revenue.
NATIONAL INTELLIGENCE REPORT®.Celebrating Our 33rd Year of Publication CMS Recommends Fee Crosswalk for New Lab Codes, Gap-Fill Payment for New Molecular Pathology Codes. Vol. 12, Iss. 16, September 6, 2012
This article discusses the importance of the fee crosswalk for new lab codes and gap-fill payment for new molecular pathology codes. The discussion around the lab codes, it draws on The Centers for Medicare and Medicaid services, in that they have posted its preliminary payment determinations for the 16 new CPT laboratory test that are to be added to the Medicare Part B fee schedule, effective, January 1, 2013.
The author is educating the coders and billers as of the date when the change took effect and how this change will impact CMS and their contractors.
The change took place, August, 2012, CMS presented the 2013 pricing determinations for 101 new CPT molecular pathology codes and 10 multianalyte assays with algorithmic analyses CPT codes. Included in the new lab codes are one chemistry code, two immunology, eight tissue typing and five microbiology. As these new codes are cross walked the codes will be paid at a similar code rate. The new molecular pathology codes, CMS, has proposed that the gap-fill method in 2012 in pricing the MDx codes, will be payable under the Part B clinical Lab Fee Schedule. The new molecular codes will replace the staking codes that Medicare currently uses for molecular tests. The codes include 92 tier 1 analyte specific codes high volume 81200- 81383 and tier 2 resource level codes for low volume procedures of 81400-81408.
The author shares this information regarding the coding crosswalk change for the codes mentioned, this change allows CMS and the contractors to have opportunity to have control over how the tests are performed, which will benefit how their cash flow is controlled.
Miller, Douglas E., Fox-Smith, Kristin. (2012). Pharmacy revenue cycle audits can bring unexpected returns. Retrived on December 2, 2012 from. Http web.ebscohost.com.oak.indwes.edu/ehost/pdfviewer/pdfviewer?sid=clb681ad-84e7-4c1c- af7b-1d681071272%40sessionmgr14&vid=20&hid=17.
This article addresses Pharmacy revenue cycle, in that the pharmacy needs to be aware if they have small errors. The errors will impact the hospitals with a loss of substantial dollars in their bottom line.
The author addresses how hospitals need to conduct financial audits in the pharmacy revenue. This will allow the hospitals to have opportunities to increase and/or decrease their expenses, as it applies to pharmacy revenue. It has been noted that all to often audits focus little attention on pharmacy revenue and this has left the finance leaders, which include hospitals, health systems, and freestanding specialty care facilities not even aware of the problems that could arise in the pharmacy revenue center.
The author provides examples of pharmacy revenue losses. Such as, incorrect pricing, product underbilling or overbilling, erroneous coding or improper charge description master mapping.
With all this said, the author describes the processes that can be put in place to ensure pharmacy revenue cycle errors can be caught. Some examples, creating a position for a payment specialist to the pharmacy team who has the skill set to verify patients eligibility for various drug benefits. Another example would be to find errors for the CDM mapping will consist of a full review and clean up. This process can be labor intensive, however, it will provide cost effective when revenue is correct and payments are considered. As the author concludes, it pays to put processes in place to ensure correct pharmacy revenue is submitted to the insurance companies to receive the full reimbursement and this will help the organization to move forward to new opportunities to grow their business.
This article is discussing the disappointment of the skilled-nursing facilities in that there was a suggestion that CMS contractors need to take a look at therapy reimbursement due to a HHS inspector general's office report that said there were 1.5 million in inappropriate Medicare payments to the facilities in 2009. Also, in December 2010, it was noted that skilled-nursing facility therapy coding was shifting to increase levels, when there was not a change in patient population.
The author stresses the findings and solutions of the HHS inspector general's office report. The report stated the inappropriate payments were related to upcoding. The AHCA officials have stated the government's clear target of the facilities has been a major source of inappropriate coding and/or fraud, which is misguided. Thur the findings. The inspector general has recommended that CMS implement a fraud prevention system to identify skilled-nursing facilities, so they are aware of those facilities billing at a higher paying resource utilization groups. With this implementation in place, this will allow CMS to monitor compliance with new therapy assessment, they can now change the current method to determine the level of therapy needed, this will ensure the appropriate payments and will too improve the accuracy of reporting the skilled-nursing facilities and to be able to identify the facilities billed in error according to the report.
The author stressed with this proven method, the skilled-nursing facilities will now be able to bill their claims with ease and now be on the HHS inspector generals list as an organization with a process improvement in which their revenue received will be legitimate.
Lubell, Jennifer(2012). Doctors shift focus to compliance as ICD-10 deadline set. Physicians win a one-year reprieve on upgrading to the more complex code sets as the administration finalizes a delay to October 2014. amednews staff. Posted Sept. 10. Retrieved on November 27, 2012. From. Retrieved from http://www.amassn.org/amednews
This article discusses organized medicine has secured a one year delay in the deadline to move the ICD 10 diagnosis coding for physicians, hospitals and their coding and billing staff, in which they are focusing on the transition from ICD-9. The delay has come about because the AMA and other physician organizations are believers that Washington did not push the date far enough out, due they are concerned about the costs and the burdens that will incur with the upgrade. As of August 24, 2012. Centers for Medicare and Medicaid services effectively changed the date for ICD-10 to Oct. 1, 2014. The author addresses that there will be a need for the physicians to understand the ICD-10 codes. The example provided in the article was that currently there are a total of two current codes in the ICD-9 system for a fractured kneecap. When the ICD-10 codes become in place, there will be 480 codes for a fractured kneecap. Also, to note that for the physicians and their staff, currently there are 13,000 codes, when the ICD-10 is implemented, there will be 68,000 codes. This will be overwhelming to the offices that are not prepared for the change. The author concludes with, the ICD-10 change takes place in October, 2014. The biggest message the author is trying to get across is there will be lost revenue, which most likely will result in thousands of dollars per physician and the additional time that will be required by the physician and their coding and billing staff to implement processes in place to ensure they are coding to the specificity of the ICD-10 code sets. As noted in the article the AMA has estimated their will a loss in revenue for large practices as much as $2.7 million dollars. It will be a huge reward for all physicians and hospitals if they educate, train and implement processes in place before the ICD-10 code sets are put in place. This will allow the physicians, hospitals, coders and billers to lessen the impact of financial loss and to gain a better understanding of the ICD-10 code sets.
Smith, Catherine, RN, CDMS, CPC, (2012).Medical Coding and Billing Services. How You’re Putting Your Business at Risk by Not Taking Advantage of Medical Coding and Billing Services. Retrieved on November 28, 2012 from httpwww.sva.com/industries/healthcare-consultants- Healthcare- Services-Medical-Practice-Management.
This article describes why medical coding and billing services are the best way to implement quality and overall success for a practice. Healthcare is a field in which a mistake could cost a practice a nice price. As we all know, healthcare is a regulated field. The biggest piece is when the physician does not document their medical office or hospital notes according to the AMA guidelines, after they have cared for their patients. This is reason why medical coding and billing professionals are the ones who assist to elevate this confusion as the coders and billers that are experienced review all documentation after the physicians and hospitals have dictated the services. The coders and billers will review the medical notes to ensure they are aligned with the super bill as to what the physician or hospitals have marked.
Also, the author addresses how medical coding and billing services can assist to facilitate compliance to incorporate strict coding regulations. This will offer assistance to get the job done correctly and in a timely manner, which consists of enforcing regulations that a business may not had the time to focus on, which will allow a business to be optimize their overall revenue.
If there is medical coding that is not accurate, it will impact the revenue and patient base, due patients will be alarmed by their records being coded with the incorrect procedures as for what they were seen by their physician or hospital. This will impact the reimbursement of the procedures and in turn will bring on an audit of accounts in the practices. If a practice is aware they have struggled and/or are struggling for this reason, a practice should quickly employ an medical coding and billing service to provide success for their office.
Overview of the process involved in medical billing and coding (2012). Retrieved on November 28, 2012. from http://www.whatishowto.net/2012/09/14/overview-of-the-process-involved-in- medical-billing-and-coding/
This article explains the importance of being a medical biller and/or coder technician. Their roles are crucial in maintaining medical revenue. Medical billing and coding go hand and hand. One person can do both tasks to manage the revenue for a practice. To become a medical biller or coder, it is appropriate for them to have graduated a program that will have certificated them as a biller or coder technician.
The author provides insight on the primary role of a coder and biller technician, in the following aspects:
The medical biller and coder verifies insurance benefits. This will allow for both the patient and physician to understand what is covered and what is not covered. After the biller/coder technician identifies what is covered and what is not covered, they can speak with the patient privately to advise the patient of their coverage, if the patient was not aware before they arrived to their appointment. If the patient does not have insurance at all after the verification has been done. This is where the biller/coder technician has the opportunity to allow the patient to be seen or they can request payment before the patient can be seen.
The coder/biller keeps record of the patients demographics to input in the system to ensure the information is correct as the requirements of the insurance carrier, when the claim is filed electronically. The coder/biller will charge the appropriate code according to the medical office notes dictated during the service, after the code has been entered, there will be a charge attached to it. The claim will be then submitted to the carrier, which has been provided from the patient, during the insurance verification process. After the claim has been submitted within 30 to 45 days, the biller/coder will either receive a payment or denial. If the coder/biller receives a payment, then they will post the payment, contractual write off or coinsurance to the patients accounts. If the charges come back denied, it is the biller/coders responsibility to either call the insurance carrier, if they do not understand the reason for the denial. If the coder/biller understands the denial, they will need to appeal the denied charge by retrieving the medical records, in which they will submit an appeal letter to address why the claim should be reconsidered. Usually, once the claim is appealed the insurance carrier usually will reprocess the claim for payment, in the instance the claim has not been reconsidered for payment, the biller/coder needs to understand the denial, to advise their hire ups if the denial is becoming a trend, so there can be follow up from the compliance officers. If the claim has been denied for non covered services , the responsibility will fall on the patient. If there is a trend with the denied charge, this will give the management team heads up to prepare the charge will not be paid, so they can account for this loss in revenue, going forward.
Medical biller/coder technicians are a crucial part of a physicians practice and they continue to provide the management team of a status reports and concrete feedback to allow the practice to understand their revenue and to drive their practice to maintain a level of success.
Gill, Brian J, MD, MBA (2007). Increase reimbursements with electronic coding, billing. Retrieved on December 2, 2012, from.www.aaos.org/news/bulletin/aug07/managing2.asp
This article is geared towards orthopaedic practices and the decline in reimbrusement from insurance payors. The author addresses the increase or decline of insurance companies, such as private pay insurances, in that the practices decline was at 38.7 percent of total revenues to 17.1 percent of total revenues, between 1988 and 2004. During the same time period, managed care programs had a increase of 11.6 percent to 33.9 percent of total revenues. Medicare/Medicaid payments increased also 26.4 percent to 31.2 percent of total revenues.
Since there has been a tremendous change in reimbursement, orthopedic surgeons must bill correctly. As the author mentioned previously the overhead expense has increased and the reimbursement has declined. This is why it is imperative that orthopedic practices are proactive in their approach to ensure correct billing and coding is present, this has to come from several sources, such as the payors, hospitals, practice administrators and other physicians who bill in the same group.
The author addresses the concern, as when the payors consistently change reimbursement amounts, this is where processes need to be put in place, to ensure correct coding is monitored, this can be done thru technology, which includes electronic billing and quick turn around times of the acceptance or denial. This will aid in the orthopedic practices to ensure the physicians documentation support the billing and coding is sent out correctly, which in turn, will increase reimbursement.
Veazie, Judy I., CPAM. (2012). Ten training tips for billers and other staff. The receivables report. Retrieved on December 2, 2012. from http//0-web.ebscohost.com oak. Indwes.edu/ehost/pdfviewer/pdfviewer?sid=bdd094-6eea-435b-b2ef- 4eed6163ca74%40sessionmgr14&vid=4&hid=8
This article is focused on training and the challenges it can bring with billers and other staff. The author is providing some simple solutions to assist to decrease challenges as they arise when trying train a biller. The ten simple steps are as follows: Establish a formal training team, this will allow the associates to be prepared for expanded duties as they arise. Cultivate those on the team who have displayed a “I can do” attitude. As they work with others while training them, they will promote a positive environment. Procedures that are used daily; understand what is involved, so when training the associates, the team will be able to articulate. Create a manageable training session. For example, when training the associates, ensure all tasks are broken down into levels. When training, ensure the associate has a good experience. To remember how you felt when you started a new position and/or had to be trained on a new task. This will keep you balanced to focus on the training and associates pleasant experience. Be aware of learning styles, when training several associates. Provide the associates to be able to receptive to several different learning styles. For example, some associates maybe visual learners, so provide visual aids, some may be audio learners, provide them the opportunities to jot down notes as you walk them through a process. Preplan the training process. This will assist in determing what is required to assist the associate in their training needs. For examaple, create an associate training checklists; create training outcomes. Evaluae the associate by creating a assessment and have the associate complete the assessment in the timeframe you specifed. If the simple steps are followed, this will ensure the biller will have a grap on the process to ensure correct billing and coding is to the insurance payors.
Holmes, Tamara E. (2010) How to Fight Medical Billing Errors. Looking closely at your bills could save you thousands. Black Enterprise; Oct2010, Vol. 41 Issue 3, p45-45, 1p
This article puts emphasis on medical billing errors. The author is describing the patients experience with insurance company in that she went to have a breast biopsy and the results came back negative. The patient was very pleased with the results, until she received her bill of $9,500.00 . Her insurance company denied her claim to state pre existing condition. The patient had previous mammograms in the past, due to rule outs of cancer. The patient contacted the insurance company to try and appeal the denial, with no luck. The patient did further research and found a company that said they could assist her. They specialized in coding and billing.
The author describes how the company the patient had sought out, contacted the insurance company and convinced them to lower the bill to $1,800.00. This provided the patient with a $7,500.00 savings.
According to the AMA there are nearly 20% of claims processed incorrectly. This is where medcial billers and coders can play a big part in ensuring the documention in the patients chart is what should have been billed to the insurance company, this will save the physician's office, the patient and the insurance company grief, time and pentalies that maybe involved for billing appropriately.
