Organization and Management

CPT coding has been around for centuries and physicians are continuing to use this system in order

Healthcare is one of the biggest and most important fields throughout the world. Within healthcare, there are several careers such as medical billing and coding which contribute for a better healthcare. Medical billing and coding plays an important behind-the-scenes that role in the health care system. The majority of medical billing and coding “specialists rely on their knowledge of anatomy, medical terminology, health conditions, and medications to assign diagnostic and procedural codes for each patient encounter” (Ewing, 1999).

What is Medical coding? (Herzing University, 2009) says, “Medical Coding is the act of billing patients and health insurances for the medical check up they received”. In other words, medical coding is the process of a medical coder recording a patient’s diagnosis. The medical coder has certain responsibilities when it comes to managing codes. Those responsibilities include: attaching health care codes, comprehending the codes, and meeting the guideline of the codes.

Due to the advances in technology, medical practitioners are more able to retrieve medical information. Coding systems, such as ICD-10-CM, CPT, and HCPCS are used to code and enter such information into a database. These coding systems are useful in administrative and statistical purposes. The Center for Medicare & Medicaid Services, CMS uses a prospective payment services, which was effected in 2012 and 2013 to ensure better health care at lower costs (CMS, 2015).

Medical coding audits assess and evaluate performances based on detail accuracy, coding applications, and related outcomes.

One example is recognizing conditions that may affect a certain region of the body, such as a patient being diagnosed with rhinosinusitis and was prescribed a two-week regimen of antibiotics. From the medical report, the biller/coder must be able to apply proficient knowledge of medical terminology. The coder should be able to break down the medical term rhino-sinus-itis. The anatomy for rhino is nose, the physiology of the nose is the lined membranes which is sinus and the condition is (-itis, the inflammation of). Understanding the basic body function enables the biller/coder to translate the provider’s medical documentation for correctly coding and billing. The diagnosis code was always the same for each billing would be for the initial evaluation of a new patient outpatient or billing and coding for an established patient

Mapping considers different purposes, levels of detail, and coding guidelines of source (terminology being mapped from) and target (terminology being mapped to).

Coding systems are standardized systems used in over 100 different countries to decrypt all services, conditions and items to be billed to a patient or their insurance provider. There are two main coding classifications systems: International Classification of Diseases (ICD) and Current Procedural Terminology (CPT). Currently, ICD is in its 10th edition making the current complete system name ICD-10. ICD-10 uses up to seven

The implementation of ICD-10-CM required advance preperation in health organizations. Staff needed to be trained on the changes and software had to be updated to accomadate the new system. There are several changes that should improve the coding process and therefore impact the coding professional. One major change is that all codes are alphanumeric which increases the number of codes that can be used. Another change is that the length of codes changed from five digits to seven characters. Also, some three-character categories have not been used. These three changes should allow for easier expansion in the future to avoid any more major revisions in the near future. The increased digits also allows for more specifity in the codes for

Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. For diagnostic coding in medical practices, defined as the main reason for the patient’s encounter with the provider. Diagnosis codes are generally used as a representation of admitted episodes in health care settings. A number of diagnostic coding systems are currently implemented across the world to code the stay of patients within a typical health setting such as a hospital. Under the hospital inpatient rules, the principal diagnosis is listed first. This principal

In the prior weeks, I had noted that many health care professionals utilize many different methods of practice, as well as implement a certain something to each of the medical cases that reflects that clinician’s style. No matter the endless routes to get to a diagnosis or the many diverse recommendations of treatment for that diagnosis, codes are the same. The medical field having a universal set of codes for diagnoses and procedures/interventions is very important because this set of codes keeps all clinicians, medical facilities and insurance companies on the same page. From what I read, the universal set of codes consists of two volumes

Of the coding topics discussed in this unit , I believe that Level of Specificity , which is the level of detail . And detail is very important in diagnosis coding . Coding must be done to its highest level to receive maximum reimbursement for claims submitted. I also believe that combination codes are very important also, because the combination code can only be assigned when that code fully identifies the diagnostic condition involved, or when the Alphabetic Index so directs. I think they are important because it could very well make the coding very confusing . I also think that there are no areas of coding that are not as relevant as the other , I believe we should know everything possibly to be known about coding , to give us the

There exists many data coding standards in healthcare. The ICD is the international standard of the classification of diseases used by a multitude of healthcare professionals  (“International Classification of Diseases”, 2016). Its latest version, ICD-10, has numerous benefits including helping doctors more correctly report conditions and differentiate payment by treatment type, more efficient disease management, and helping to prevent fraudulent claims as a result (Schwartz, 2013). In terms of current use, more and more countries have used it for reporting morbidity. In the United States, it has been the official standard for death certificates since 1999 (Brouch, 2000). For the future, ICD-11 is stated to be released to include recent advancements in healthcare and medicine and will allow open access for editing (“International Classification of Diseases”, 2016). LOINC® is used to standardize data for laboratory and medical clinic measurements (McDonald et al., 2003). Benefits include helping separate lab systems interpret shared lab test data, improving the efficiency of ordering lab tests from many labs, and also aiding in generating public health clinical data (“3.2 Benefits of LOINC”). Current usage is categorized into three areas:  laboratory,  clinical, and HIPAA specific proposals. The majority of US federal agencies and public health departments like New York State

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ISBN 1947-833X Proceedings of 1st Global Business Summit Conference (GBSC 2009), Kelantan, Malaysia University of Technology Mara Malaysia, Shah Alam, 15-17 June 2009, Volume 2, pp. 128-137