Edwincia Slater Case Study

In Radiology, there is not too many codes used within the department. However, when a doctor orders an exam, often times they

Since the late 1980s, Medicare has reimbursed physician services using the Medicare Physician Fee Schedule (MPFS), which encompasses 10,000 procedure codes. Each code is assigned resource-based relative value units (RVUs), which are designed to reflect physician work, practice expense, and malpractice expense. To adjust for local differences in cost of living, each RVU is modified using geographic practice cost indexes (GPCIs) and then converted to dollars using a “conversion factor.” This system rewards physicians who produce a high volume of services; not surprisingly, Medicare Part B expenditures have grown rapidly.

"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.

Read the article Diagnosis Coding and Medical Necessity: Rules and Reimbursement by Janis Cogley located on the AHIMA Body of Knowledge (BOK) at http://www.ahima.org.

The new system increases the number of procedure codes nearly 20-fold when compared with the old ICD-9 set. We’re talking going from about 4,000 procedure codes to 87,000 procedure codes.

The E/M code's is a big important part in this process. Being a health care professional, using the medical code's. like medicare, medicaid, other private insurance to be reimbursement. If not using the right code, the doctor office, hospital, and urgent care. Will lose a lot of money. So using the right cpt code's insurance companies, office, hospital, and urgent care can be reimbursement correct. Cause CPT code's are formed with 5 digits.

Payment-determination bases are composed of three factors: cost, fee schedule, and price related. In a cost-payment basis the provider’s cost is the main method for payment (Cleverley, 2010). It is essentially a way to formulate fees for medical services. Prior to this practice, medical cost for medical services differ from state to state, which led to a variety of fee schedules. According to Brumley (2015), the varying fee schedules were inefficient for Medicare; therefore, to solve this issue Medicare linked fees to the actual cost of providing specific services. This became a component of the Section O of Title 42 in the code of Federal regulations; which sought to describe the different costs that can be included when it comes to calculating medical fees. The goal was to structure medical fees on a more cost-reasonable basis.

Physicians and other facilities are paid by insurance companies, including Medicare and Medicaid, based on the procedure (CPT) code they submit. These codes must be accompanied by the correct diagnosis or ICD-10 codes.There must be a valid reason for a medical encounter for the physician to be paid, such as pain, refills for medications, or a follow-up for such diseases as diabetes or any chronic condition. If you just submit the CPT or ICD-10 code separately then you will not be paid as both support each other. So it is vital that a medical biller and coder be aware of these rules and how to complete the claim forms properly.

With PPS Medicare has developed diagnosis-related groups (DRGs) that groups clinical conditions together and based off the DRGs of a patient it then in turn provides a reimbursement rate to give the provider (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/acutepaymtsysfctsht.pdf). The theory behind this style of reimbursement is that it give the hospital an incentive to efficiently treat a patient and quickly discharge the patient without wasting any unnecessary medical resources.

The key elements to a healthy and successful medical practice are a reliable and properly trained staff and a sound revenue cycle that produces satisfactory reimbursement. Revenue cycle management starts at the front-end with pre-registration of the patient. Complete and accurate recording of patient insurance and billing information is imperative. Insurance verification plays a major role in the assurance of reimbursement. The front desk should counsel and confirm financial responsibility with the patient during the registration process. Patient encounter is equally as important. Correct coding of patient diagnosis and procedures minimizes the likelihood of claim rejection. The next step in the revenue cycle is claim submission. The claims process begins with the provider treating the patient then sending a bill to the designated payer. Before the bill is sent, a certified coding specialist or medical billing specialist prepares and reviews the claim for any inaccuracies. There are a few ways the claim is submitted, either manually or electronically. Once the claim is submitted, follow-up with third party payers is a necessary step in the

After reading over the material in chapter 14, it is my opinion that selective contracting should not be allowed to exist between providers and payers. Utilizing selective contracting puts both the payer and the provider in a position to possibly limit the quality of care actually needed by the patient for their own benefit. This benefit doesn’t necessarily have to be in the form of a financial gain, but could merely be in the form of a financial security. Selective contracting appears to place of great deal of power within the hands of the payer, who now has the power to control fees charged by providers, through controlling which providers make it on their list of in plan providers.

There are two core design characteristics associated with DRG based payments; “an exhaustive patient case classification system (i.e. the system of diagnosis-related groupings) and the payment formula, which is based on the base rate multiplied by a relative cost weight specific for each DRG”(Mathauer &Wittenbecher, 2013). These values can be set for the components and the potential effect as policy levers as they are evaluated. “Importantly, the qualitative and quantitative effect of a DRG-based payment system is also contingent upon the payment mechanism that is replaced”(Mathauer &Wittenbecher, 2013).

I do agree with you, its going to make it easier for the billing department much easier as for insurance companies it will be a great help for them as well. I do believe this will help them have less questions and les worry's about who's paying for the services. It very understandable there way you explain the different in ICD-9 and ICD-10 its very informative it was a great help to me the way it was explain. Kepp up the good work.

Of the three systems I believe system two, by division is the best system. It focuses on the major departments that also perform procedures. The costs are not even across the board as the expertise of each division are not equal. The care of each of the patients is diversified in system two. When a patient goes to see the doctor, each doctor has a different fee

Unbundling of codes, not entering the assurance code to the most lifted sum or perception specialist reports are an evil entity to getting paid. We don't blame you, regardless. Given the labyrinth of codes and energizes that show on specialist's visit costs in the midst of an extra clamoring day at your training can set back your portions basically. With ICD-10 nearly upon us, coding to the most anomalous measure of specificity is fundamental so get into the inclination now. By virtue of, say, diabetes, you ought to use a fifth digit to decide the assortment: 250.00 for diabetes mellitus sort two, 250.01 for mellitus sort one and 250.02 for diabetes mellitus sort one uncontrolled. It uses your training organization structure's scrubber, which will movement under-coded investigate. In addition, energize a talk between your billers and coders to ensure the past fathom what truncated codes take after.