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The promise of ICD-10-CM

October 5, 2011 in Medical Billing/Coding

The health­care indus­try is mak­ing sig­nif­i­cant strides toward the adop­tion of elec­tronic health records (EHRs). How­ever, increased deploy­ment of EHR tech­nol­ogy only par­tially addresses the cru­cial need for bet­ter health infor­ma­tion in the U.S. The full ben­e­fits of an EHR can only be real­ized if we improve the qual­ity of data that EHRs are designed to manage.

The cur­rent clas­si­fi­ca­tion cod­ing sys­tem used in the U.S., ICD-9-CM, is a 30-year old sys­tem and can no longer accu­rately describe today’s prac­tice of med­i­cine. Con­tin­u­ing to use this sys­tem jeop­ar­dizes the abil­ity to effec­tively col­lect and use accu­rate, detailed health­care data and infor­ma­tion for the bet­ter­ment of domes­tic and global health­care. By fail­ing to upgrade, we could find our­selves build­ing an infra­struc­ture that does not pro­vide the infor­ma­tion nec­es­sary to meet the health­care demands of the 21st century.

Despite annual updates, ICD-9-CM does not meet our health­care needs. Ter­mi­nol­ogy and clas­si­fi­ca­tion of numer­ous con­di­tions and pro­ce­dures are out­dated and incon­sis­tent with cur­rent med­ical knowl­edge and appli­ca­tion. ICD-9-CM also can­not address the increas­ing pres­sure for more spe­cific codes, espe­cially codes that rep­re­sent new tech­nol­ogy. Out­dated codes pro­vide inac­cu­rate or lim­ited data and insuf­fi­cient detail related to health diag­noses, pro­ce­dures and technologies.

Med­ical care has changed dras­ti­cally since ICD-9-CM was imple­mented. Many new health­care diag­noses and ser­vices can no longer be described accu­rately using ICD-9-CM. For exam­ple, the ter­mi­nol­ogy used to clas­sify asthma in ICD-9-CM is out­dated, result­ing in an inabil­ity to assess the effi­cacy of treat­ment pro­to­cols that are based on the cur­rent clin­i­cal clas­si­fi­ca­tion of asthma types.

Spe­cific Gains

Upgrad­ing ICD-9-CM to ICD-10-CM, a U.S. ver­sion of ICD-10 devel­oped by the World Health Orga­ni­za­tion, and ICD-10-PCS, a pro­ce­dural cod­ing sys­tem designed by the Cen­ters for Medicare and Med­ic­aid to replace the cur­rent inpa­tient pro­ce­dural cod­ing sys­tem included in ICD-9-CM, will pro­vide supe­rior infor­ma­tion for mea­sur­ing health­care ser­vice qual­ity, safety and the effi­cacy of care. This data impacts qual­ity reports and report cards, out­comes and per­for­mance mea­sure­ment, clin­i­cal research, case man­age­ment and pay-for-performance programs.

So why is the U.S. health­care sys­tem the only devel­oped coun­try that has not adopted ICD-10? Per­ceived cost is a huge fac­tor. How­ever, delay­ing its imple­men­ta­tion will actu­ally increase future imple­men­ta­tion costs as imple­ment­ing a new cod­ing sys­tem will require sys­tems and appli­ca­tion upgrades. This can be avoided if imple­men­ta­tion is planned with other sys­tem changes to max­i­mize impact and reduce complexity.

Not only does ICD-10 lever­age our invest­ment in EHR and mod­ern tech­nolo­gies, but it also will give the U.S. health­care system:

* Bet­ter data for patient safety, qual­ity of care analy­sis and reimbursement;

* Increased capac­ity to iden­tify and respond to pub­lic health or bio­log­i­cal threats;

* The abil­ity to achieve full ben­e­fit from the use of SNOMED-CT as the clin­i­cal lan­guage of medicine.

Although reim­burse­ment con­sid­er­a­tions should not drive code set revi­sions, accu­rate and spe­cific coded data should be used to sup­port appro­pri­ate reim­burse­ment. The level of speci­ficity in ICD-10-PCS will pro­vide pay­ers, pol­icy mak­ers and providers with more detailed infor­ma­tion for estab­lish­ing appro­pri­ate reim­burse­ment rates, eval­u­at­ing and improv­ing the qual­ity of patient care, improv­ing effi­cien­cies in health­care deliv­ery, reduc­ing health­care costs, and effec­tively mon­i­tor­ing resource and ser­vice utilization.

For exam­ple, reduced health­care costs will result if a more spe­cific cod­ing sys­tem is employed, facil­i­tat­ing pre­ven­tion and iden­ti­fi­ca­tion of fraud and abuse or the speci­ficity needed to con­duct good qual­ity improve­ment and error reduc­tion pro­grams. The exchange of addi­tional data beyond the basic claim, and the time it takes to gather and process such detail, will sig­nif­i­cantly be reduced due to the more spe­cific detail con­tained in the ICD-10-CM and ICD-10-PCS codes.

An Invest­ment That Pays

By being the only coun­try with a mod­ern health­care sys­tem that has not adopted ICD-10 (more than 100 coun­tries already have), we are also mak­ing it more dif­fi­cult to share dis­ease and mor­tal­ity data at a time when such global shar­ing is crit­i­cal for pub­lic health. With recent pub­lic health and bioter­ror­ism events, our abil­ity to track and respond to inter­na­tional threats in real time is lim­ited by our reliance on ICD-9-CM.

For exam­ple, ICD-10-CM would have bet­ter doc­u­mented the West Nile Virus and SARS com­plexes for ear­lier detec­tion and bet­ter track­ing. Our national data sys­tems are being ren­dered use­less. The U.S. must be part of the world health data com­mu­nity. Many coun­tries rely on U.S. ana­lyt­i­cal tools based on codes and groupers. This mar­ket edge is being lost by the inex­plic­a­ble delay in com­ing inline with con­tem­po­rary code sets.

The adop­tion of SNOMED-CT as the Con­sol­i­dated Health Infor­mat­ics ini­tia­tive and license agree­ment between the National Library of Med­i­cine and SNOMED Inter­na­tional posi­tion it as the clin­i­cal lan­guage of med­i­cine in the U.S. Even­tual use of SNOMED-CT will not elim­i­nate the need for clas­si­fi­ca­tion sys­tems. Even with fully deployed ter­mi­nol­ogy sys­tems, most health infor­mat­ics pro­fes­sion­als point to the ongo­ing need for clas­si­fi­ca­tions to per­mit aggre­ga­tion of clin­i­cal data for admin­is­tra­tive pur­poses includ­ing reim­burse­ment, sta­tis­ti­cal and epi­demi­o­log­i­cal analy­ses, and health pol­icy decisions.

Con­tin­ued use of the out­dated ver­sion of ICD dimin­ishes the U.S. invest­ment in SNOMED-CT. The antic­i­pated ben­e­fits of an EHR will not be fully achieved if the ref­er­ence ter­mi­nol­ogy employed, such as SNOMED-CT, is aggre­gated into a 30-year old clas­si­fi­ca­tion sys­tem for admin­is­tra­tive use and index­ing. Valid maps are urgently needed to link from a highly spe­cific ter­mi­nol­ogy to a clas­si­fi­ca­tion sys­tem so that infor­ma­tion cap­tured in the ref­er­ence ter­mi­nol­ogy can uti­lize the power of sum­mary required for health­care report­ing and index­ing offered by the clas­si­fi­ca­tion sys­tems. The ICD-10 med­ical cod­ing sys­tem facil­i­tates more robust map­ping from SNOMED-CT in the EHR due to its gran­u­lar­ity and use of cur­rent clin­i­cal terminology.

In 2003, the National Com­mit­tee for Vital and Health Sta­tis­tics (NCVHS) rec­om­mended that the Depart­ment of Health and Human Ser­vices ini­ti­ate the rule­mak­ing process for adop­tion of ICD-10-CM and ICD-10-PCS. NCVHS spent two years care­fully lis­ten­ing to argu­ments and weigh­ing the evi­dence before pro­ceed­ing with their pos­i­tive rec­om­men­da­tion to the full committee.

ICD-10-CM and ICD-10-PCS needs to be imple­mented by Octo­ber 2008. That means imme­di­ate adop­tion through the HIPAA rule mak­ing process in 2005 is crit­i­cal to per­mit the health­care indus­try to man­age this tran­si­tion and ensure con­ti­nu­ity in its health­care data reporting.

Linda Kloss, R.H.I.A., C.A.E., is the CEO of the Amer­i­can Health Infor­ma­tion Man­age­ment Asso­ci­a­tion, head­quar­tered in Chicago.

 

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by ronick

Medical Billing Clearinghouse

October 2, 2011 in Medical Billing/Coding

What is a Med­ical Billing Clearinghouse?

An elec­tronic med­ical billing clear­ing­house acts as a mid­dle­man that takes elec­tronic med­ical claims infor­ma­tion and then sub­mits it elec­tron­i­cally to insur­ance com­pa­nies the med­ical billing clear­ing­house con­tracts with.

Why Should a Med­ical Billing Busi­ness Con­sider Using a Clearinghouse?

Look at it this way: If you don’t use a med­ical billing clear­ing­house, your client sends you a med­ical claim in super­bill for­mat, you input that infor­ma­tion into your med­ical billing soft­ware, you print out that infor­ma­tion on to a CMS1500 form, you mail that form out to the appro­pri­ate insur­ance car­rier. The insur­ance com­pany checks the claim for any errors, if every­thing is cor­rect (called a “clean claim”) the insurer sub­mits pay­ment to the physi­cian for the ser­vices ren­dered and then you bill/invoice the physi­cian for the ser­vices that you pro­vided them. Now, how long do you think that process will take and what would be your expense? Well if you were to do this for each and every claim, for each and every client that you have, then I can assure you that it would only take about a month and a few weeks before you’d be out of business.

A med­ical billing clear­ing­house cuts down on the amount of time it takes for med­ical claims to be accepted and processed by insur­ance com­pa­nies. Today, the elec­tronic med­ical billing clear­ing­house also saves the envi­ron­ment because less paper is being used to com­plete the reim­burse­ment process.

Why Is An Elec­tronic Med­ical Billing Clear­ing­house A Must?

There are sev­eral rea­sons but these impact both your busi­ness and your profits:

  • Med­ical billing clear­ing­house soft­ware catches errors that you may have made dur­ing the data entry process.
  • Once a clear­ing­house catches those errors they let you know in real time where the mis­takes were made for each and every med­ical claim so you can cor­rect them, thus reduc­ing the chances of receiv­ing rejected claims.
  • You sub­mit your claims to a clear­ing­house elec­tron­i­cally so the clear­ing­house that you pick should also trans­mit your claims to the insur­ance car­ri­ers elec­tron­i­cally, which will dra­mat­i­cally reduce your reim­burse­ment time to less than ten days. I guar­an­tee you that your clients will love you to death and pay on time each and every month.
  • Using an elec­tronic med­ical billing clear­ing­house elim­i­nates the need for you to re-key data over and over for each payer, which saves you hun­dreds of hours in data entry. Plus, because they already have the insur­ance car­ri­ers’ infor­ma­tion in their sys­tem, you can worry less about human errors being made when trans­mit­ting claim information.
  • A med­ical billing clear­ing­house allows you to sub­mit all your claims at the same time, rather than sub­mit­ting them sep­a­rately for each indi­vid­ual insurer. Again, the faster and more cleanly your claims are sub­mit­ted to the car­ri­ers, the faster pay­ments are received by your med­ical billing client.
  • A med­ical billing clear­ing­house gives you a sec­ondary loca­tion from which to man­age all your elec­tronic claims — in addi­tion to the back ups that you cre­ate of your work on a daily basis, such as those on your com­puter, on CD/DVD, tape dri­ves, etc.
  • A med­ical billing clear­ing­house saves you from spend­ing valu­able hours of your time wait­ing on hold fol­low­ing up on claim errors or rejec­tions with sev­eral dif­fer­ent insur­ance carriers.
  • Elec­tronic med­ical billing clear­ing­houses dras­ti­cally reduce or elim­i­nate the need for you to print paper forms, envelopes and spend money on postage.

Sim­ply put, when you use a good med­ical billing clear­ing­house, your clients get paid faster so you can con­tinue to ser­vice your clients needs, which, in turn, will make your clients refer more busi­ness to you with­out your hav­ing to ask. As a result, your ROI (return on invest­ment) and prof­its will sky­rocket. In short, a med­ical billing clear­ing­house, espe­cially today’s elec­tronic med­ical billing clear­ing­house, can give your med­ical billing busi­ness a com­pet­i­tive advan­tage over your com­peti­tors who do not use them.

The Med­ical Billing Clear­ing­house You Choose Should:

  • Pro­vide you with a huge payer list from which you can choose.
  • Be nation­wide, NOT regional.
  • Pro­vide sync sup­port for the type of med­ical billing soft­ware you are using to cre­ate, batch and sub­mit claims.
  • Have an easy-to-get-out-of contract.
  • Pro­vide excel­lent cus­tomer ser­vice and support.
  • Give you online access to update, track and man­age the claims you have submitted.
  • Not charge exces­sive monthly fees that are beyond the indus­try norm.

The med­ical billing clear­ing­house you select should also pro­vide you with the abil­ity to process the fol­low­ing (Note: Some of these ser­vices can be offered to your clients at an addi­tional charge thus increas­ing your prof­its per client):

    • Eli­gi­bil­ity verification
    • Sent file status
    • Claim sta­tus reports

Rejec­tion analy­sis Drop and mail paper claims if needed Sec­ondary claims processing

  • Elec­tronic Remit­tance Advice (ERA)
  • Patient state­ment services
  • Pay­ment pro­cess­ing reporting
  • Trans­ac­tion sum­maries and reports of all your clear­ing­house activity

A home-based med­ical billing and cod­ing busi­ness is one that pro­vides physi­cians with sev­eral lev­els of ser­vices and a med­ical billing clear­ing­house does the same for the med­ical billing busi­ness owner. Be absolutely cer­tain that you shop around for med­ical billing clear­ing­houses that best fit your needs and bud­get — but DO NOT choose one strictly based on cost.

Elec­tronic med­ical billing clear­ing­houses must pro­vide at least the ser­vices I’ve men­tioned ear­lier. If you have to wait due to cus­tomer ser­vice issues at your clear­ing­house you will lose money, your per­sonal and busi­ness cred­i­bil­ity, and finally your valu­able clients.

Last, pay spe­cial atten­tion to the med­ical billing clearinghouse’s startup and enroll­ment fees that you may have to pay for each prac­ti­tioner or prac­tice you will be sub­mit­ting claims for. Those charges can eat into your prof­its. There are med­ical billing clear­ing­houses in the mar­ket­place that charge flat fees regard­less of how many physi­cians you bill for now or in the future, so proper research is the best way to keep your clear­ing­house expenses to a bare minimum.

Writ­ten BY: P.G. Hackett

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by ronick

Coder shortage goes straight to the Bottom Line

September 30, 2011 in Medical Billing/Coding

 

The prob­lems asso­ci­ated with nurse and phar­ma­cist short­ages are becom­ing an old and sad story. Now you can add a new chap­ter: The lack of med­ical coders has risen to crit­i­cal lev­els in some areas, and those who do noth­ing about it stand to lose mil­lions of dol­lars in unbilled charges.

Cod­ing is a key com­po­nent in the rev­enue cycle,” says Phil Incar­nati, president/CEO of McLaren Health Care Corp., Flint, Mich. “If you get bogged down in cod­ing, you stop the rev­enue. With the dif­fi­cul­ties health care sys­tems and indi­vid­ual hos­pi­tals are deal­ing with to make a mar­gin to sup­port their mis­sions, you cer­tainly don’t want to short­change your­self on the rev­enue side.”

McLaren board Chair­man Charles Weeks agrees: “Hos­pi­tals can’t afford to wait until the sit­u­a­tion becomes dire. They need to be dili­gent about keep­ing up with the sit­u­a­tion or they stand to lose a lot of cash flow.”

William Cronin, pres­i­dent of PHNS HIM Inc. (Provider Health­Net Ser­vices Health Infor­ma­tion Man­age­ment Inc.), Mon­u­ment, Colo., esti­mates the short­age to be as great as 30 per­cent nation­wide. A study by the Amer­i­can Health Infor­ma­tion Man­age­ment Asso­ci­a­tion, Chicago, finds that the short­age is most crit­i­cal in the north­east­ern and west­ern parts of the country.

The Bureau of Labor Sta­tis­tics esti­mates that U.S. hos­pi­tals will need 97,000 new med­ical record and med­ical health tech­ni­cians by the year 2010 to replace those who are leav­ing the field now.

The sit­u­a­tion is going to get worse before it gets bet­ter,” says Incar­nati, who has helped imple­ment a num­ber of mea­sures to min­i­mize the short­age among the health care system’s six hos­pi­tals. “Hos­pi­tal board mem­bers have a fidu­ciary respon­si­bil­ity to facil­i­tate the preser­va­tion of assets for a hos­pi­tal. Cod­ing is so crit­i­cal that it needs to be high on the radar screen for board mem­bers and hos­pi­tal admin­is­tra­tion. You don’t want to be in the posi­tion where you are mak­ing a lot of mis­takes in this area because the penal­ties are extreme.”

Fewer peo­ple are choos­ing cod­ing as a pro­fes­sion, in part because of the com­plex­ity and chang­ing nature of the job due to fre­quent revi­sions of gov­ern­ment reg­u­la­tions. Greater work­load result­ing from expanded prospec­tive pay­ment reg­u­la­tions are also to blame. These include out­pa­tient, skilled nurs­ing, reha­bil­i­ta­tion, home health and long-term acute care. Addi­tion­ally, because there are no degree pro­grams in cod­ing, hos­pi­tals have no direct source or pipeline from which they can recruit.

On top of that, learn­ing how to do clin­i­cal cod­ing is no easy task. The coder is respon­si­ble for review­ing all tests, diag­noses, results and med­ica­tions and giv­ing them a numeric value. This requires sub­stan­tial clin­i­cal under­stand­ing as well as med­ical record and com­puter tech­nol­ogy knowl­edge. Many coders come from the clin­i­cal field look­ing to begin a sec­ond career. Oth­ers pur­sue a degree in health infor­ma­tion man­age­ment to help pre­pare them for the job. To become cer­ti­fied, they must undergo an 18-month AHIMA pro­gram and pass an exam offered by that orga­ni­za­tion or take a cer­ti­fi­ca­tion pro­gram offered by the Amer­i­can Acad­emy of Pro­fes­sional Coders.

To really become com­pe­tent at the pro­fes­sion, on-the-job expe­ri­ence is a neces­sity, says Nelly Leon-Chisen, direc­tor of cod­ing and clas­si­fi­ca­tion with the Amer­i­can Hos­pi­tal Asso­ci­a­tion. While they are often hard to find, there are cer­tifi­cate pro­grams that spe­cial­ize in cod­ing, Leon-Chisen notes. Some asso­ciate degree pro­grams in health infor­ma­tion tech­nol­ogy teach cod­ing and there are sev­eral bachelor’s pro­grams in health infor­ma­tion man­age­ment that cover cod­ing as well. “The prob­lem is that there aren’t a lot of edu­ca­tional pro­grams that offer these degrees, and when they do, they are in larger cities,” she says.

Typ­i­cally, those enter­ing the pro­fes­sion have a med­ical records back­ground and are forced into on-the-job train­ing, accord­ing to Incarnati.

That leads to another part of the puz­zle. Because hos­pi­tals are so short-staffed with cod­ing per­son­nel, many lack the man­power to pro­vide essen­tial train­ing for new coders. Even those peo­ple with an edu­ca­tion in med­ical infor­ma­tion man­age­ment need direct over­sight and train­ing for six months to a year to get up to speed on the com­plex­i­ties of the job, Leon-Chisen says.

In the rush to fill med­ical cod­ing vacan­cies, hos­pi­tals need to be scrupu­lous about hir­ing qual­i­fied peo­ple. After all, a hospital’s rep­u­ta­tion is on the line, says Bill Robert­son, pres­i­dent and trustee of Adven­tist Health­Care Inc., Rockville, Md. “Hos­pi­tals have a lot to lose if they don’t use qual­i­fied peo­ple,” he says. “Cod­ing essen­tially cre­ates the win­dow [through] which oth­ers judge the com­plex­ity of care you’re pro­vid­ing. Out­comes are adjusted by sever­ity. If your cod­ing is not com­plete and up-to-date, it will affect how out­side com­pa­nies judge your level of care.”

Rita Sci­chilone, AHIMA’s direc­tor of cod­ing prod­ucts and ser­vices, agrees: “Coders are an inte­gral part of a health care sys­tem. Not only are they key in reim­burse­ment and pro­cess­ing claims but they are crit­i­cal in deci­sion sup­port, index­ing of dis­ease and over­all clin­i­cal man­age­ment. They are respon­si­ble for mak­ing sure the hos­pi­tal fol­lows the appro­pri­ate gov­ern­ment rules and reg­u­la­tions. Inac­cu­rate and inap­pro­pri­ate codes are what get a hos­pi­tal into com­pli­ance prob­lems with fraud and abuse.”

Con­tract cod­ing com­pa­nies pick up the slack for many hos­pi­tals, and have become a $5 bil­lion busi­ness, says Cronin.

It is not uncom­mon to see more than $1 mil­lion to $2 mil­lion worth of charts that have been untouched for weeks or months, accord­ing to Cronin. He’s even seen the num­ber rise above $20 mil­lion because of missed dead­lines. The result is a sig­nif­i­cant loss of revenues.

A tell­tale sign that your hos­pi­tal may be short of coders is an increase in accounts receiv­able or out­stand­ing days to col­lect pay­ment, Incar­nati says. Adven­tist strives for a three– to four-day turnover, Robert­son says.

For McLaren Health Care Corp., which has annual rev­enues of approx­i­mately $2 bil­lion, a day lost in accounts receiv­able trans­lates into approx­i­mately $5.5 mil­lion in lost reim­burse­ment, Incar­nati says.

INCENTIVES

Many hos­pi­tals, such as Adven­tist, are begin­ning to imple­ment inter­nal mea­sures to ease the short­age: upgraded pay scales, sign­ing bonuses, flex-time and over­time oppor­tu­ni­ties, schol­ar­ship pro­grams for cod­ing edu­ca­tion, online train­ing pro­grams, in-house train­ing for inter­nal employ­ees and increased use of free­lance coders.

Hos­pi­tals also should con­cen­trate on employee reten­tion. “Coders need to know that they are respected and rec­og­nized for the impor­tant con­tri­bu­tions they make,” Sci­chilone says. “Cur­rent coders need to be sup­ported by oppor­tu­ni­ties for con­tin­u­ing edu­ca­tion and pro­fes­sional development.”

Adds Incar­nati: “Our indus­try receives a lot of crit­i­cism that we are not proac­tive enough [with] rev­enue. There are some good lessons to learn from the pain of oth­ers. This is one issue that hos­pi­tals can’t afford to sit on.”

Writ­ten By: Susan Meyers

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by ronick

10 Things You Should Do Before You Start Your Medical Billing Business

September 30, 2011 in Medical Billing/Coding

One time, I saw a news­pa­per ad say­ing they are hir­ing work-at-home med­ical billers. I called the num­ber (just to find out what it is!), I found out that for you to be able to work as a Med­ical Biller, you have to pur­chase their soft­ware at a range of $800–1,500 (I thought, it is actu­ally a packaged-medical billing busi­ness). They will then train you how to use their soft­ware, after (I think) 10 days of train­ing, you will have an access to their so-called doc­tors’ data­base. They promised you can get your 1st client through their database.

Due to my curios­ity, I started read­ing and research­ing pack­aged home­based med­ical billing busi­ness. But take note: the train­ing you will get is NOT actu­ally a med­ical billing train­ing. The bot­tom line here? – you sim­ply pur­chase the busi­ness, pay for their soft­ware and start your busi­ness! But how real­is­tic is this? I know some peo­ple who ended up with no clients at all after pur­chas­ing the soft­ware! And then later on, I’ve read that the Fed­eral Trade Com­mis­sion warned us about these com­pa­nies offer­ing home­based med­ical billing busi­ness with their false claims on how you make a lot of money on this business.

Med­ical Billing is a legit­i­mate busi­ness (either home-based or office-based) and you can make good money as long as you know how to do it, the right way. But before that, con­sider the 10 Things You Need To Do:

1. Try to gain actual work expe­ri­ence. Work as a Med­ical Biller in a doctor’s office (or even as a vol­un­teer at your near­est hos­pi­tal). Do this for at least a year.

2. You should be highly knowl­edge­able on HIPAA (Health Insur­ance Porta­bil­ity and Account­abil­ity) and how does your cur­rent work/practice place complies/follows its rules and reg­u­la­tions. I always empha­size this because it is very impor­tant in any health provider businesses

3. Learn the actual “know-how” on claims sub­mis­sion (paper billing & elec­tronic billing)

4. Learn how you can deal with insur­ances, can you han­dle col­lec­tions? denied/rejected claims? Learn how to file appeals for denied claims

5. Learn how to ana­lyze and opti­mize proper cod­ing (pro­ce­dure and diag­no­sis codes) to avoid rejec­tion & denials

6. Learn how to review and ana­lyze the rea­sons for unbilled and or aged med­ical claims

7. Beside learn­ing the med­ical ter­mi­nolo­gies, you should also know many “med­ical billing” terms and its mean­ing: (PCP, copay, co-insurance, deductibles, allowed amounts, pre­de­ter­mi­na­tion, med­ical neces­sity, progress notes, prog­no­sis, treat­ment plan, preau­tho­riza­tion, appeals, refer­rals, scripts, ben­e­fits and eli­gi­bil­ity, cap­i­ta­tions, HMOs, PPOs, POS, EPOHIPAA)

8. Learn how to prop­erly post: – pay­ments, deductibles, co-insurance, adjust­ments and write-offs (it is dif­fer­ent when you are actu­ally at work doing the post­ings than what you learned dur­ing your training)

9. Feel the med­ical billing sce­nario (how is the cash flow? what about the turn-around time of payments?)

10. And the last but not the least, feel the work— do you like what you do? Do you have the abil­ity and the man­age­r­ial skill to run your business?

Writ­ten By: Pinky Mcbanon

Avatar of ronick

by ronick

The Coder Codes

September 30, 2011 in Medical Billing/Coding

 

CPT man­ual

I was sit­ting com­fort­ably on the couch, watch­ing the foot­ball game in the liv­ing room on a cold, win­ter Sun­day after­noon. the New York Giants were play­ing the New York Jets in a game for big apple brag­ging rights. the game was close and time was run­ning out. I gave it my undi­vided attention.Suddenly, my wife runs down the stairs and heads towards me car­ry­ing my two year old son. Fran­ti­cally, she states, “I think he’s sick. Look at him, plus he hasn’t eaten all day.” This was unusual for my son. He usu­ally eats any and every­thing avail­able. I see sweat drip­ping from his fore­head. I check for a fever by putting my hand on his fore­head and i’m sur­prised by how cold it is. “He is freez­ing,” I state.“Do some­thing,” she screams at me. I look at my son who is lay­ing in her arms, limp as can be with his eyes barely open. This is a far cry from the two year old who is nor­mally keep­ing busy by ter­ror­iz­ing every­thing and every one in the house. “You’ve got to do some­thing,” she con­tin­ues. “Isn’t this what you do for a liv­ing?” She had turned to sar­casm so I knew that she was really upset and unrav­el­ing. Our son had never been sick in the two plus years that he’d been alive.I began to take him from her. At that moment, when we were both hold­ing him, mak­ing the exchange, he began to cough. He unleashed a cough that’s only heard from vet­eran drinkers who chase the smell of alco­hol from their breath by smok­ing half a pack of cig­a­rettes a day. He con­tin­ued to cough, an uncon­trol­lable cough that led to him vom­it­ing. the pro­jec­tion was mostly in my direc­tion, but my wife caught some of the after effects. She grabbed a nearby towel and began to wipe his face. I stood him up and aimed his head away from us in case he had more to offer.

My wife looked at me once again. “What are you going to do for him? Don’t you do this for a liv­ing?” She was vis­i­bly upset and the sar­casm was at its fullest. “Don’t you take care of patients? This is a patient.” I knew that see­ing some­one ill or hurt or help­less, espe­cially if that some­one was your child, was a hard pill to swal­low, but geez…I hurt too. Finally I yelled, “I AM NOT A DOCTOR. I AM JUST A coder.” I had never referred to this posi­tion as ‘just’ a coder. I know that coders play a very impor­tant role in med­i­cine, but let’s face it, I’m no doc­tor. She looked at me and seemed to calm down. She jumped on the phone and began speak­ing with his pediatrician’s office. While she did that, I did what comes naturally…I began to code.

I put my hands on my son’s neck then on his fore­head. This time he was burn­ing up. He had a fever. I sat down and cra­dled him in my arms. He was shak­ing. Although he was hot, he was expe­ri­enc­ing chills.

I leafed through the alpha­betic pages of my men­tal ICD-9-CM man­ual and found the codes for chills with fever, cough and vom­it­ing. I was sure to con­firm them in the numeric index. My wife hung up the phone and explained that we were going to take him to the pediatrician’s office. they had told her to bring him in right away.

We quickly changed clothes, grabbed our coats and headed for the front door. I attempted to use my periph­eral vision to steal a glance at the tele­vi­sion in hopes of catch­ing an update on the score of the game, but my wife pressed the power but­ton on the remote before I could.

We arrived at the office and were called in imme­di­ately. My son’s doc­tor asked, “what’s wrong with him?” My wife’s voice echoed loudly in my head, ‘DO SOMETHING.’ So I did. I handed my son to the doc­tor and con­fi­dently stated, “he is expe­ri­enc­ing a 780.6, has a 786.2 and 787.03 all over my wife and I. He is all your now.” the doc­tor laughed, my wife smiled and I was back on her good side. 

ICD 9 CM

ICDCM

After an estab­lished, office visit E&M code, my son turned out to have 382.9, Oti­tis media. Doc gave him antibi­otics and a cough sup­pres­sant and sent us on our way.

R. Rus­sell, CPC

 

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