The CMS-1500 Research Paper

Government and insurance standards also regulate the cost of procedures that have been identified by the coding system. The responsibility of making sure that accurate billing takes place falls to the coder that use the ICD-9 and ICD-10 codes. These codes then tell the biller what to bill. Reimbursement rates for procedures are controlled the US Department of Health and Human Services and state governments. (Department Health and Human Services, 1998) Commercial payers such as Aetna, Blue Cross and Blue Shield, and United Health Care attempt to control pricing by

According to Chtourou (2013), a CDI program focuses on enhancing the accuracy of clinical documentation quality which requires a huge input from CDI specialists, heath information management professionals, coders and clinicians to collaborate together to review the quality of documentation reported/captured in order to ensure accuracy and complete of patient’s clinical encounter. As a healthcare provider, medical records that are incomplete or inaccurate often times, compromise the quality of care reporting and inevitably affect the clinical decision support system of the organization including the accuracy of reimbursement. This is reasonable since the CDI program has emerged as a new paradigm to meet the changing needs of maintaining a sound health record documentation across the healthcare industry (Hauger, 2014). Most of the CDI programs have to a great extent concentrated on boosting the Diagnosis-Related Groups (DRGs) installments by securing clinical documentation to support medical complications and co-morbidities (Hauger, 2014).

"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.

The first area outlined in the intake form is the client’s demographic information that included the client’s date of birth, social, insurance information, etc. necessary to process claims for reimbursement and the client’s provider information, such as primary care, and case management, to ensure fluidity for establishment of coordination of care between providers. The intake form

You may find some of your patients have a non-HIPAA-covered payer (worker’s compensation) as their primary payer and a commercial insurance provider like Blue Cross Blue Shield as a secondary payer. So essentially you will have to first submit using ICD-9 codes, and then submit to secondary payers using ICD-10 codes.

Medicare and Medicaid information can be overwhelming and confusing to both the consumer and the healthcare professional. The information highway known as the World Wide Web (WWW) can provide the answers to questions about these government benefits, but getting clear, informative and accurate knowledge can be overwhelming. O’Sullivan (2011) identified the WWW as “a primary repository for health information for the medically naïve yet technically savvy healthcare consumer.” One internet website that provides information about Medicare and Medicaid is CMS.gov ("Cms.gov centers for”). The Centers for Medicare & Medicaid Services (CMS) is the United States agency that administers Medicare,

RE: E/M codes 8/5/2015 4:37:46 PM Definitely using the correct E/M code's. Document the code's for reimbursement for medicare, medicaid, or private insurance. Not done correct big lose of money. You make a great point on this one

The continue use of ICD-9 codes after the effective date could result in the denial of reimbursement claims. This task can be assigned to the healthcare organization’s management team to determine a solution avoiding a break down in the system. Rahmathulla states, “In instances of an audit, appropriate documentation will make the query process substantially easier while enabling coders to clarify issues without having to query the provider multiple times for answers” (“Migration To The ICD-10 Coding System S187). It is important to accurately document to reduce the amount of claim denials. With the new specificity requirement of the ICD-10 and documentation supporting a claim, lowers the chances of healthcare fraud. The healthcare management team will oversee the process to prevent the risk of exposure.

The CMS-1500 form, also recognized as the Healthcare Financing Administration, and the Professional Paper Claim Form, is used for reimbursement from several government insurance plans including Medicare, Medicaid and Tricare.

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

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.

Due to ICD-9-CMS’ ability to provide necessary detail for patients’ medical conditions or the procedures and services performed on hospital patients, ICD-10-CM/PCS was implemented.

The CMS-1500 was created by the Centers for Medicare and Medicaid Services (CMS). It was to make the processing of billing easier to arrange the diagnosis and services provided to treat patients. The form is divided into two sections, which are the following:

It is nearly impossible to avoid clinical denials entirely. Therefore, the health information management (HIM) department should have strong procedures built as a defense against clinical denials. Ensuring the claim is sent to the payor appropriately is complicated since coders “must not only ensure they are within the parameters of official coding guidance, but also they must review the record to justify the clinical significance” (Brownfield et al., 2014). For example, universal coding guidelines in ICD-10-CM explain that coders should not assign codes for signs and symptoms with an established diagnosis if the signs and symptoms are integral to the established diagnosis. For example, if the patient is experiencing lower back pain and the