Assignment 1: Medical Case Analysis

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

Step 3 - Financial Responsibility - Once we have established the patients co-pay or deductible we then let them know of the charges.

Most claims today are submitted through an electronic format directly or indirectly through a “clearinghouse” where claims are grouped and sent to the payer. Two primary payment grouping algorithms are DRG’s and APCs, both are used by Medicare for hospital payment and many commercial payers. Providers and payers use claims editing software to detect possible errors in claim submission to assure maximum payment for medical services and to shorten an amount of time from claim submission to payment. CMS has developed the National Correct Coding Initiative (NCCI) to promote national correcting coding methodologies and to control improper coding leading to inappropriate payment (Cleverley 26). CMS also has designated edit checks called the outpatient code edits (OCE). The OCE uses claim-level and line item-level information in the editing process. Each category in the OCE has six dispositions which help to ensure all Fiscal Intermediary/Medicare Administrative Contractor (FI/MACs). The four claim-level is rejection, denial, return to provider, and suspension; and the two-line item-level is rejection and

10. Once it's complete you will file the claim and ensure you have a copy. Be sure to review the claim prior to sending it out for any possible mistakes that could have been

MEDICAL CODING QUALIFICATIONS AND CERTIFICATION Medical Coding is a career in which professionals use numeric and alphabetic codes to help submit and process medical claims. The coder abstracts information from the patient records and combines that information with coding guidelines to assign the right code for the information provided by physicians, hospitals, and other healthcare professionals. Insurance companies look at these codes to understand the diagnosis, treatment, and prescriptions for proper payment of these services. Accordingly, the medical coding profession requires a worker to have a strong grasp of numbers and be detailed oriented. (AC Search & Media, Inc.)

Pamela Williams is the Medical Necessity coder I shadowed on this day. Her responsibility as a medical necessity coder is to approve physician orders. When physicians order tests for their patients, Ms. Williams has to verify that CMS will pay for the specific test. In the event the order is rejected, she will contact the physicians. This could be the most difficult part of the job for her. Before she contacts the physicians, several steps would have to be taken. CMS requires a very high level of specificity when submitting orders. The majority of the time when providers are filling out order forms, they are not abiding by the strict guidelines CMS has. It is her job to help the providers reach the level of specificity

All employees have the RHIT certification; one coder also has CCS for coding. The HIM technicians assemble and analyze records they handle release of information, handle the deficiency room, and they assist any doctors with dictations or transcriptions. The coders are strictly for coding but, if it is needed, they may help with dictation also.

The E/M codes just like any other codes that a billing and coding specialist use is extremely important in receiving the proper reimbursement. Its it very vital to always cross reference your codes in order to get the proper information. The negative impact that processing an incorrect code can be an extreme issue for that medical office. The insurance can see that as fraud and can cause some lawsuits if the code does not get fixed to the proper issue. As a billing and coding specialist knowing how to properly code and with no faults is the difference between fraud and receiving a full reimbursement. There needs to be little to no fault when processing the proper codes.

The current systems and past practices that affect the CAC system is that the reliability of code selection must be tested and verified. Currently coders use encoders to assist with code selection. The CAC if reliable and accurate will benefit the healthcare facility with fewer coding errors, fewer resubmissions to payers, and enhanced job opportunities for the coding professional.

Coders must ensure the accuracy of the claims they submit by using valid diagnosis and procedure codes. Also with the roll out of ICD-10 they should be using the highest level of specificity (Fortney, 2014). Claims must be submitted using the current approved CMS-1500 (02-12) form with uppercase letters. The insured name must be listed in addition to the patient’s name if not the same. The patient’s name must be listed by last name, first name, followed by middle initial, commas can be used, but no periods. Additionally, the patient’s name must be entered as it appears on their insurance card. The address should be entered on three lines without the use of punctuation. Birth dates are required to be in an eight digit format. If information is not applicable it should be left blank and n/a should never be entered in the field. If a provider fails to enter the insured information correctly or omits information it could result in a rejected claim. If it is necessary for a provider to request pre-authorization for services or supplies that authorization number should be entered on line 35 field 23 (CMS, 2012). There are occasions where a payer may request supporting documentation to back up charges that have been submitted. The provider must ensure each page of supporting documentation has patient identifier information in the event it becomes separated

A coder looks up codes in a CDT-5 (Current Dental Terminology 5th Edition) just as a medical coder uses a CPT (Current Procedural Terminology) guide book. Dental coders can find procedure codes in the HCPCS Level II book as well. The guidelines are pretty much the same for billers and coders in the dental field versus the medical field. Every examination, procedure, and surgery must have preauthorization from a third- party payer, so the appropriate code can be submitted.

An automated reviewed mostly initiated by the computers software program checks elements claims information that was provided or attached to the claim at the time of submission. The implementation of (CCI) Correct Coding Initiative in which Medicare subjects their claims to. Helps catch errors before the claim is processed. This process gathers EOB, the limitations for filing claims from the day of service and/or preauthorization and referrals. Acknowledgment of services not covered, correct code linkage, and that correct

Patients are responsible for paying a co-payment when visiting a doctor. After the patient is seen, the provider submits claim forms to the insurer for the services rendered. Once the claims are processed the insurer will reimburse the provider (Austin & Wetle, 2012). If a patient goes out-of-network, they are required to pay the provider in full. Afterwards the patient can submit a claim for reimbursement.

Pre-registering patients: The main function of the first step is to schedule and update appointments as well as gather personal and insurance information about new and existing patients. New patients provide personal and insurance information to the scheduler, and pre-existing patients update any personal or insurance information with the practice that has changed.

Patients who are covered by insurance often have deductible/co-payments that need to be collected at the beginning of each visit. If a patient did not make a co-payment at the beginning of visit, front desk staff should remind the patient of payment once visit is over. If staff is unable to do so, at the next appointment, they should inform patient of the missed co-payment and the co-payment for the current date of service. Co-Pay balance should be kept at a fairly low amount. If a