Medical billing codes are used to communicate the diagnosis and treatment of a patient from the healthcare provider to the patient's payer (private insurance, Medicare or Medicaid). Those codes help the payer determine how much to pay the provider for services rendered to the patient. These codes allow for modifiers which describe procedures and services in greater detail. Modifier 22 When a procedure takes longer than it should, the medical coder can use Modifier 22 to indicate the extra work involved. Billers set a standard time interval for each procedure or patient visit. An annual physical might take 90 minutes, while a standard follow-up visit might take 20 minutes. The biller pays according to the standard time interval, unless Modifier 22 is used. When used, it can trigger the payer to increase payment by up to 30 percent over the standard rate. This could be due to the particular patient's situation or to the type of medical procedure being done. If the surgeon uses a local anesthetic, no modifier is required. If the surgeon uses a general or regional anesthetic, Modifier 47 is used to distinguish this difference. Modifier 51 Some patients get multiple medical procedures done during the same visit with a healthcare provider. If the same provider performed multiple procedures, the first procedures is billed as normal. The subsequent procedures are billed, using Modifier 51. Modifier 53 If a patient experiences a life-threatening situation, while undergoing a medical procedure, the surgeon or physician will likely terminate the procedure early. If this happens, the medical coder can use Modifier 53 to indicate the situation to the payer. This code cannot be used if the doctor cancels the procedure before it starts. To use Modifier 53, the doctor must provide documentation and appropriate medical codes of why he or she terminated the procedure. Modifier
Dr. Tagge, the lead surgeon, finally updated the family over two and a half hours later stating that Lewis did well even though he had to reposition the metal bar four times for correct placement (Kumar, 2008; Monk, 2002). Helen reported wondering if Dr. Tagge had realized how much Lewis’ chest depression had deepened since he last saw him a year ago in the office, especially considering he did not lay eyes on Lewis until he was under anesthesia the day of surgery (Kumar, 2008). In the recovery room, Lewis was conscious and alert with good vital signs, listing his pain as a three out of ten (Monk, 2002). Nurses and doctors in the recovery area charted that he had not produced any urine in his catheter despite intravenous hydration (Kumar, 2008; Monk, 2002). Epidural opioid analgesia was administered post-operatively for pain control, but was supplemented every six hours by intravenous Toradol (Ketorolac) (Kumar, 2008; Solidline Media,
Case 1 -- You work in a busy multi-specialty clinic with a high patient volume. The physicians enter the type of code that will yield the greatest reimbursement. You suspect the codes are not accurate.
As a certified medical coder (CCA 11/2012), I have contributed to the HIMS department by helping code inpatient encounters from patients in the Residential Rehab Unit as well as outpatient encounters from the other clinics at this VA applying the official coding conventions outlined in the International Classification of Diseases 9th revision handbook as well as in the VHA’s Official Coding Guidelines, V11.0 dated August 10, 2011. Having coded many encounters over the past 3 years, I can easily determine the main condition after study that is chiefly responsible for a patient’s admission to the hospital. ICD-9-CM defines this as the primary diagnosis code and I find that it is most important to list this code first in your documentation
The chargemaster or charge description master (CDM) is a basically a financial tool or an electronic system that housed detailed description/information about service charges to patients. The chargemaster can be a manual list or a file that is located in the organization’s account receivable billing system that contains hospital’s services, item, and their charges. Furthermore, the chargemaster is a very crucial aspect of the reimbursement cycle and must contain vital information necessary to produce an itemized statement and claim form. Key components of the chargemaster include, chargemaster line-item numbers, line-item descriptions, revenue codes, CPT codes or healthcare common procedure coding system (HCPCS) codes,
Medical billers often communicate with physicians and other health care professionals to explain diagnoses or to attain further information by means of phones, email, fax, etc. The biller must know how to read a medical record and be familiar with CPT®, HCPCS Level II and ICD-9-CM codes.
Langenbrunner, J., Cashin, C. & Dougherty, S. (2009). Designing and implementing health care provider payment systems how-to manuals. Washington, D.C: World Bank.
Rockwell, P.E.,M.D. Director of Anesthesiology, Leonard Hospital, Troy, NY, U.S. Supreme Court, Markle vs. Abele, 72-56, 72-730, 1972. P.11
...health of a patient and a follow up check at the GP’s may be required.
The private insurers are patients with other insurances. Under Medicare and Medicaid, services that are provided by the hospitals are paid by a prospective reimbursement. Prospective reimbursement is established before the services are provided. They have a defined dollar amount per day and per diagnosis. They also use a fee scheduled by CPT code or procedure code which is usually used for physicians. Since these types of insured patients only are billed a certain amount, most procedures are not fully reimbursed. Retrospective reimbursement is determined after the services have been delivered. This is one of the reasons organizations are struggling. Along with less reimbursement, the CPT codes or procedure codes have to be correct according to the procedure ordered. “If an organization wants to get paid, its better off taking the time to make sure all its codes are accurate, timely , and meet all payers’ requirements ”(Kapsambelis, 2004, p. 3).
...dical emergency where there is not time to wait for court overruling, the staff is not legally obligated to obtain parental permission; in this case two consultants should make an entry in the patient’s chart that procedure or transfusion was necessary to save the patient’s life. As a consequence and overruling from the court system, the state withdraws parental decision in order to protect and promote health of the child (Effa-Heap, 2009).
There are several factors that contribute to the complexity of the revenue cycle. Frequent changes in contracts with payers, legislative mandates, and managed care are just a few examples of reasons why revenue cycle in the healthcare industry is so complex. Furthermore, the problems that arise in the steps of the revenue cycle further complicate the whole process. For example, going through the steps of the revenue cycle efficiently is extremely difficult when it is managed by poorly trained personnel. Furthermore, if a healthcare provider does not have the proper information system to track patient records and billing, receiving reimbursement can become difficult. In addition, one of the main factors that delay payments is denial from the insurance companies. The reason for Denial includes incorrect coding, the certain sequence of care and medical necessity or even delay in submitting claims. Lastly, inefficient patient correspondence can not only hinder the process of revenue cycle but also result in many patient complaints (Wolper, 2004).
Properly implemented and medication-use technology has the potential to moderate these costs. Bar-code-assisted medication administration (BCMA) has been shown to reduce medication administration errors by as much as 54-86%. BCMA, along with computerized electronic prescriber order entry and an electronic medication administration record, closes a technological loop that extends from the transmission of the order to the administration of the medication at bedside (Strykowski, Hadsall, Sawchyn, VanSickle, Niznick,
reimbursement determinations. As a result, the camaraderie among physicians has developed into a more aggressive approach to impede competition (Shi & Singh, 2012). Little information is shared with patients in regards to procedures or disease control. The subjects are forced to rely on the internet for enlightenment on the scope of their illnesses (Shi & Singh, 2012). Furthermore, the U.S. health care system fails to provide adequate knowledge on billing strategies for operations and other medical practices. The cost in a free system is based on supply and demand and is known in advance of hospital admission (Shi & Singh, 2012). The need for new technology is another characteristic that is of interest when considering the health care system. Technology is often v...
E&M codes range from level 1 (associated with the lowest payment) to 5 (highest payment). The payments for different E&M code levels vary between different insurance companies and between different localities and providers. The difference between the payments for the highest vs. lowest E&M code levels can be as high as 10-fold (Zhang, Shubina, Morrison, & Turchin,
The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care.