Case Study Of Coding Errors In Medical Billing Practices

"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.

Responsible coder collects post and manages account payments, submitting claims and keeping in touch with insurance companies. If patient information is coded incorrectly or incomplete it could leave an impact that can be brought to a claim. Inaccuracy in patient information can leads to denials, none payment and investigation. It is important to get all the details right by verifying insurance coverage properly. Make sure that the patient’s name is spelled correctly, date of birth and sex of patient are correct; and most important be sure that the policy number is valid.0verall before claims are sent, documentation should be in order and the claim should be checked for completeness and accuracy.

-Inpatient coders have certifications allowing them to work exclusively for hospitals or facilities. An expertise in medical record review is a must, along with an up to date status with coding rule changes, regulations and issues for medical coding, reimbursements and compliance under MS-DRG and Inpatient Prospective Payment Systems (IPPS). Coders should have experience as well as expert knowledge in abstracting information from medical records for ICD-9CM vol. 1-3, specialized payment in MS-DRG and IPPS.

My career that I am researching for my junior project is Medical Coding and Billing. Medical Coding and Billing are two different jobs. Medical Coding is when a patient has any medical procedure or exam such as going to the doctor for the stomach virus or even going to the hospital for a broken bone. They work with the insurance companies by putting a specific number into the computer. There’s CPT Codes which stands for Current Procedural Terminology which is “ Codes to better understand the services their doctor provided, to double check their bills or negotiate lower pricing for their healthcare services. (About Health, 2014).”

I am very familiar with medical coding and understand how it is used because I worked in the medical field for many years, and I used those codes for much of that time. At my last job, I helped with the billing for some time, did the insurance referrals for several years and got the insurance pre-authorizations/pre-approvals

Medicare fraud is illegal and remedies are sought at both a civil and criminal level. If a provider, practice, or institution is found guilty of Medicare fraud, the consequences may include a loss of license, monetary penalties, and the inability to participate in Federal healthcare programs. The Office of Inspector General (OIG), which is a part of the U.S. Department of Health & Human Services, has the ability to exclude individuals who participate in Medicare fraud. The guilty party will be listed on a searchable database on the OIG website. The list is officially referred to as the List of

There are several different things the health information manager can do to help with reimbursement. Ensuring that the proper codes have been assigned and that there is adequate documentation. The health information management department staff may also analyze case mix, manage on going

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

The physician marks the E&M code on the encounter form and the medical assistant will ensure that the documentation in the medical record matches the codes that are checked off. Whenever a medical assistant is unsure about a coding or billing issue the best way to handle the situation is to speak with the physician or reach out to their supervisor or a certified coder. Incorrect coding could lead to denial or delay of insurance claims and it could also lead to fraud or abuse. If I were Lisa’s medical assistant in this situation I believe the best option is to speak with Dr. Parker about the issue. One of the reasons I would speak with him about the issue is because it is unusual for him to check off diabetes unspecified for most of his patients

Administrative expenses have been seen through time not spent finding, filing, and retrieving patient charts. A reduction in employee time equals less money spent by the employer. Budget savings a seen through elimination of transcription, transferring, and transporting of patient charts. Billing components within EMR packages can provide cost savings through generation of direct billing and reimbursement; this process shows great potential for reduction in billing errors. Errors made during the billing/reimbursement process result in dollars lost or not recovered for the organization, which in turn drives up the cost of healthcare. The Centers for Medicare and Medicaid Services reported (in 2003) that a 10% error rate, regarding payments,

Responsible coder collects post and manages account payments, submitting claims and keeping in touch with insurance companies. If patient information is coded incorrectly, or incomplete it could leave an impact that can be brought to a claim. Inaccuracy in patient information can lead to denials, none payment and investigation. It is important to get all the details right by verifying insurance coverage properly. Make sure that the patient’s name is spelled correctly, date of birth and sex of the patient are correct; and most important be sure that the policy number is valid.0verall before claims are sent, documentation should be in order and the claim should be checked for completeness and accuracy.

Committing medical coding fraud or abuse is extremely detrimental to the healthcare industry. They both lead to higher healthcare costs and an increase in the cost needed for medical coverage. In addition, the increasing discovers of these acts are putting a very negative light on healthcare workers, including those who are not committing either act. With the medical world being so complex we often instill and great amount of trust in the persons taking care of medical billing and coding, this trust also makes committing fraud and abuse easier for dishonest people to take advantage of.

Billing and coding specialists, who are also known as health information technicians, are an integral part of the health care system. They are the ones designated to handle the billing and coding system which can be very complex. These professionals are trained to organize the health records of a hospital's patient. It involves the translation of a patient's medical history and diagnosis into clinical codes which are used to process insurance claims. They can be found in the hospitals, outpatient care centers, insurance and coverage providers.

When we were working on few claims we happened to come across Clinical department coding error on Claim# 022153. The CDR code is incorrectly populated with an ISO code.

The health care is an expensive industry, however it plays a significant role in the lives of many. As we continues to find the best way possible to decrease avoidable medical errors and techniques that decreases fraudulent activities, together we can build an industry that is rather effective and at a lower cost. Up coding is a burden in health care and should be a concern to everyone. It has significant budgetary impact and affects everyone from government officials, taxpayers, insurers, and even premiums- payers. Dishonest health care professionals who exploit Federal health care programs for illegal personal gain can result in overpayments that raise Medicare premium and weaken Medicare’s Finances. Most relies on health care profession to submit accurate claims when requesting payment for reimbursement for Medicare covered healthcare equipment’s and services. The failure to accurately do so can have negative health ramifications for both patients the Federal Government. Up coding has created the need for laws that can combat fraud abuse and ensure appropriate quality medical care. The HCFA had a major responsibility that they failed to accomplish. The investigating team from the case study noticed two major concerns, the hospitals system has significant vulnerabilities to upcoding that can easily be avoided and also found that, despite these vulnerabilities, Health Care Financing Administration (HCFA) is not performing routine, ongoing monitoring and analysis of DRG