Last Updated 07 Sep 2020

Healthcare Reimbursement

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Healthcare Reimbursement Medical coding is an important process, in which descriptive information (patient medical records) is reviewed, and assigned detailed numeric, or alphanumeric diagnosis, and procedure codes’, for the purpose of reimbursing hospitals’, or physicians’ offices’, for services’ rendered (Ehow. com, 1999-2001; AHIMA. org, 2011). These codes are then translated into payment amounts, to be submitted to insurance companies’, for compensation (Ehow. om, 1999-2001). The hospitals’ and physicians’ rely on “complete coding accuracy”, or codes without “any” errors, or inadequacies (clean claims), to be submitted to insurance companies in a suitable time, in order to be processed, and reimbursed for services’ performed (Campus. ctuonline. edu, 2001-2011).

The more detailed information the coder provides, the more accurate the billing and coding will be (Campus. ctuonline. edu, 2001-2011). Accurate coding is beneficial to the financial business end of hospitals’, and physicians’ offices’ because, if the coding is not correct, insurance companies will not pay the costs for the claims’ (Ehow. om, 1999-2001; AHIMA. org, 2011). Therefore, this can result in thousands of dollars’ in loss revenue for medical organizations’. To date, there are no “National” standards to really determine medical coding productivity (Ehow. com, 1999-2001). Coding productivity is determined by each individual medical organization, establishing their own “principles of productivity”, based on record categories, such as “inpatient or outpatient status (Ehow. com, 1999-2001).

According to the HCPro survey (1999-2001), twenty-nine per cent of facilities used a “three records coded per hour” system, as a “benchmark” (standard), for coding inpatient records’ (Ehow. com, 1999-2001). Furthermore, the American Health Information Management Association (AHIMA), established a certain amount of benchmarks, for coders to get claims in on time also (Ehow. com, 1999-2001); for inpatient charts, there was a benchmark of two to four charts per hour, and for outpatient records, standard coding time, was five to twenty records per hour, depending on the type (Ehow. com, 1999-2001).

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It is important coders meet the requirements, and work to minimize errors (Ehow. com, 1999-2001); the more accurate, and productive the coder is, the more the facility will be reimbursed for services rendered (Ehow. com, 1999-2001). It is crucial for coders to comply with State and Federal guidelines (Ehow. com, 1999-2001). Compliance guidelines are established in the “Internal Classification for Diseases, 9th Revision, Clinical Modification (ICD-9-CM) for coding and reporting, issued by the Center for Medicare, and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS)” (Ehow. com, 1999-2001).

Also, assigning diagnosis and procedure codes is required under the “Health Insurance Portability and Accountability Act of 1996 (HIPPA)” (Ehow. com, 1999-2001). Between the coder and the healthcare provider, it is important for both parties to work together, to “complete precise documentation, coding assignments, and reporting of diagnoses and procedures” (Compliance. uclahealth. org, n. d; Campus. ctuonline. edu, 2001-2011). There cannot be enough importance put on “accurate documentation”, because without accuracy, coding will not be successful (Compliance. uclahealth. org, n. d; Campus. ctuonline. edu, 2001-2011).

In addition to this, under the “National Correct Coding Initiative (NCCI), the consequences of inaccurate coding, or increased errors’, can result in criminal prosecution” (Campus. ctuonline. edu, 2001-2011). Some of the benefits of the “Outpatient Code Editor” (OCE) software, which helps maintain consistency, in processing claims for coders is, “editing claims for accuracy, assigning’ APCs, as well as assigning CMS-designated status indicators’, in addition to computing discounts, determining claim dispositions’, if packaging is appropriate, and helps’ determine payment adjustments, if necessary (Cms. ov, n. d. ). Coding references is an important tool, used to assist coders with more accurate coding by identifying minuscule differences between similar CPT codes from operative reports the first time (Medetrac. com, 2010-2012). The coding clinic is a resource newsletter that provides’ coding advice for HCPCS Level II coders (Casto & Layman, 2011). This newsletter is an important resource, because it “provides actual examples’, correct code assignments’ for new technologies, articles’, and a bulletin of coding changes’ and/or corrections” (Casto & Layman, 2011).

The CPT assistant is a newsletter from the American Medical Association (AMA), used for coding communications, to keep coders up to date, clinical explanations’ for baffling codes, coding consultations’ to answer questions, anatomical illustrations, and information equivalent with the Federal Register (Medetrac. com, 2010-2012). Lab and drug dictionaries are used by coders to alert them to common spelling errors, pronunciations’, and words that are similar in form, and meaning (Medetrac. com, 2010-2012).

Lab and drug dictionaries would eliminate errors’ coders’ could make, when two words sound the same, or have similar spelling (Medetrac. com, 2010-2012); in addition, the dictionaries would present what common abbreviations to use, and not use, in medical orders (Medetrac. com, 2010-2012). This is useful because it would eliminate primary mistakes on the reports. Medical dictionaries is a reference which list drugs, treatments, medical abbreviations, medical terms, definitions, translations, signs and symptoms of common disorders, and practical phases, used in daily communication with patients (Medetrac. com, 2010-2012).

Lastly, anatomy references for coders are used to enhance, and interpret a coders understanding, of medical documentation, and correct code assignments (Codingbooks. com, 2011). After reviewing all the information gathered on the “coding reference, the coding clinic, and the CPT assistant, the lab, and drug dictionaries, the medical dictionaries, and the anatomy reference, the conclusion that has been drawn, is “all” of the references are equally important, when used together to guarantee coding accuracy for all coders.

References

  1. AHIMA. org. (2011). Medical Coding. American Health Information Management Association.
  2. AHIMA. Retrieved November 17, 2011 from http://www. ahima. org/coding/ Casto, B. A. , & Layman, E. (2011).
  3. Principles of Healthcare Reimbursement. 3rd Edition. American Health Information Management Association (AHIMA). Illinois: AHIMA Press. Codingbooks. com. (2011).
  4. Anatomy and terminology for eyes and bars. Anatomy and terminology for coders elearning. Course Overview. Description. Coding Store. Contexo Media. Access Intelligence, LLC. Retrieved November 21, 2011 from http://www. codingbooks. com/books/coding_reference/Anatomy-and-Terminology-for-Coders-eLearning_25. html Cms. gov. (n. d. ).
  5. Outpatient Code Editor (OCE). OCE Purpose: Purpose of the OPPS I/OCE functionality. Centers for Medicare and Medicaid Services. U. S. Department of Health and Human Services.
  6. Retrieved November 21, 2011 from http://www. cms. gov/OutpatientCodeEdit/10_Purpose. asp#TopOfPage Colorado Technical University Online. (2011).
  7. Course materials: Healthcare reimbursements: Regulatory issues and coding compliance. HIT201-1104B-02 Phase 1 Individual Project activity: Healthcare Reimbursement [Multimedia presentation].
  8. Retrieved from Colorado Technical University Online Virtual Campus, November 21, 2011from https://campus. ctuonline. du/Classroom/Pages/multimediacoursetext. aspx? classid=260129&tid=130&uid=251269&HeaderText=Course Materials: HIT201-1104B-02: Healthcare Reimbursement Colorado Technical University Online. (2011).
  9. Course material: Processing physician office claims. HIT201-1104B-02 Phase 1 Individual Project activity: Healthcare Reimbursement [Multimedia presentation].
  10. Retrieved from Colorado Technical University Online Virtual Campus, November 17, 2011 from HIT201-1104B-02: https://campus. ctuonline. edu/courses/HIT201/p1/hub1/14921. pdf Compliance. uclahealth. org. (n. d. ). ICD-9-CM official guidelines for coding and reporting.
  11. Effective October 1, 2008. Retrieved November 21, 2011 from http://compliance. uclahealth. org/Workfiles/PDFs/ICD_9_CM_Official_Guidelines_for_Coding_and_Reporting_Effect ive_October_1_2008. pdf Ehow. com. (1999-2001).
  12. Importance of medical coding for hospitals. Reimbursements. Written by Jacqueline Wilson, Ehow Contributor. Demand Media, Inc. Retrieved November 17, 2011 from http://www. ehow. com/facts_5918637_importance-medical-coding-hospitals. html Ehow. com. (1999-2001).
  13. Medical coding productivity standards. Productivity standards. Written by Cynthia Murphy, Ehow Contributor. Demand Media, Inc. Retrieved November 17, 2011.

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