Thursday, January 25, 2024

7 Hot Topics of Medical Coding and Billing

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Popular Paths of Medical Coding and Billing 

Medical coding and billing are a signficant part of the healthcare industry. However, medical coding and billing are also some other popular topics in the medical field. In this article, we are going to talk about many popular subjects of medical coding and billing.

medical coding and billing

Medical Coding

Medical coding transforms medical procedures and medical services into regular medical codes. The diagnoses and procedure codes are taken from health records, like a transcription of doctor’s notes, lab, and radiologic results. Medical coding specialists help ensure the principles are applied accurately throughout the medical billing process, including extracting the data from documentation, drafting the relevant codes, and generating a claim paid by insurance agencies.

The medical care provider studies the patient’s complaint and medical history, make an expert evaluation of what’s wrong and how to treat them, and documents the patient’s visit. That document is not only the patient’s ongoing record; it’s how the medical care provider gets paid.

Medical codes translate that documentation into standardized codes that represent payers the following:

  • patient’s diagnosis
  • Medical requirement for treatments, services, or supplies the patient suffered
  • Treatments, services, and supplies provided to the patient
  • Any particular concerns or medical conditions that influenced those treatments and services

Medical coding needs the ability to understand anatomy, physiology, and details of the services and the rules and regulations of the payers to succeed.

The primary responsibility of a Medical Coder is to evaluate medical records and assign standard codes using CPT®, ICD-10-CM, and HCPCS Level II classification systems. In addition, to help develop a steady coding and billing process, the coder checks the patient’s medical record to verify the work done. Finally, both billers and coders work together to avoid insurance payment rejections.

Medical Billing

Medical billing is submitting and following up on claims with medical insurance firms to receive payment for services provided by a medical care provider. Medical billing translates a healthcare service into a billing claim. The responsibility of the medical biller in a medical care office is to follow the claim to ensure the practice receives reimbursement for the work the providers perform. An expert biller can manage revenue performance for the clinic.

Is Medical Coding the Same as Medical Billing?

No. The primary duty of a medical coder is to evaluate medical records and select standard codes using CPT®, ICD-10-CM, and HCPCS Level II classification systems. On the other hand, medical billers process and follow up on claims sent to medical insurance firms for reimbursement of services provided by a healthcare provider. The medical coder and biller may be the same person or work to ensure that invoices are paid correctly. 

Skills of a Medical Biller

  • Navigate through different insurance rules and guidelines to overcome A/R days
  • Understand the differences of insurance carriers types along with their claim requirements
  • Provide successful follow-up efforts for A/R, including the claims process for denied claims
  • Execute best practices for insurance and patient collections while maintaining excellent public relations
  • Reduce risk by understanding Fair Debt collection practices, professional service regulations, clean claims and timely filing guidelines, refund requirements, and other regulations
  • Use data and reports as signs for possible improvement areas

Medical Auditing

Medical auditing is a systematic evaluation of performance within a healthcare company. Most audits look at elements of payer reimbursement processes to evaluate agreement with payer guidelines and national and state regulations. The medical audit follows an essential role in a healthcare organization’s compliance plan by identifying errors and working out corrective actions to reduce them.

Medical audits provide a mechanism to:

  • Review quality of care provided to patients
  • Educate providers on documentation guidelines
  • Determine if organizational policies are current and effective
  • Optimize revenue cycle management
  • Ensure appropriate revenue is captured
  • Defend against federal and payer audits, malpractice litigation, and health plan denials

The Importance of Medical Auditing

Medical auditing performed by the provider organization, or on its side, is essential because it keeps coding and billing errors in check. Audits recognize not only incorrect coding but also stop incorrect coding from being repeated. Formal claim errors require a total effect on an organization and, worse, invite governmental objection.

By revealing areas of the objection, medical auditing resolves ignorance. 

The laws governing healthcare fraud, principally the False Claims Act (FCA), account for the uncertainty of purpose in habitual over-coding and overbilling. Accordingly, the intended objective to deceive is not required for government and punishment under the FCA.


What Does a Healthcare Auditor Do?

A medical auditor handles internal or external coding efficiency, policies, and methods to ensure an organization works efficiently and has a straightforward operation. The auditor must maintain medical coding, medical terminology, clinical documentation, compliance, and regulatory guidelines. Additionally, the auditor must be able to determine the scope of an audit. Use approved tools to perform the audit, compile the data, report the findings, and provide corrective recommendations and staff training.

Most medical auditors are experienced medical coders with high-level training. Auditors may work with an insurer, government agency or contractor, or medical provider. In the workplace, auditors play a crucial role in the organization’s financial success by:

  • Reducing claim denials caused by inappropriate coding or insufficient documentation
  • Determining outliers before payers ask the practice to conduct an internal audit
  • Revealing variation from national averages due to inappropriate coding
  • Avoiding a RAC audit or requests for medical record documentation from federal contractors
  • Ensuring proper documentation that supports reported services and procedures
  • Discovering overpayments and protecting against false claims liability
  • Identifying reimbursement deficiencies

Having conducted a successful medical coding audit, the auditor can impart knowledge to resolve non-compliant billing activity. Thus, auditing enables the provider and staff to protect patients and achieve optimal reimbursement without the risk of disciplinary actions.

Healthcare Compliance

Healthcare compliance is the formal name for proactive tasks to prevent fraud, waste, or abuse within a medical care entity. A compliance program is the active, ongoing process to guarantee that legal, ethical, and professional standards are met and communicated throughout healthcare.

Compliance promotes a culture where participants within the healthcare organization try to prevent, detect, and resolve activity that could lead to fraud, waste, or abuse. 

Advantages of Healthcare Compliance Programs

Organizations also benefit from having a healthcare compliance plan and program. An effective compliance program helps the organization detect issues early to fix them, like medical coding and billing problems. The compliance program also positively impacts the organization, indicating that its leadership and employees care about compliance and act ethically.

Healthcare organizations cannot get the benefits of their compliance programs except they use them. 

Many healthcare entities can benefit from an effective healthcare compliance program. These entities include:

  • Hospitals
  • Nursing facilities
  • Physicians and physician groups
  • Durable medical equipment (DME) suppliers
  • Laboratories
  • Home health providers
  • Hospice providers
  • Third-party billing companies
  • Medicare Choice organizations 
  • Ambulance suppliers
  • Pharmaceutical manufacturers
  • Public Health Service research awards

Practice Management

A practice manager is responsible for managing all business features of medical practice, including financials, human resources, information technology, compliance, marketing, and operations. Professionals in practice management hold positions like Practice Manager, Administrator, CEO, COO, and Executive Director. Practice managers work for small independent practices, large multispecialty clinics, hospital-employed systems, and other management and consulting companies.

The general responsibilities and detailed practice management requirements include managing the revenue cycle, compliance regulations, human resources, health information, and available business processes. As a result, modern practices are looking for certified practice managers who can effectively manage the business side of medicine.

Managing a medical practice is complex because of requirements of cost reduction, greater compliance, and technology implementation headlines in health care today. However, it is also an exciting, rewarding profession and has a high growth rate in the industry. Practice managers are always learning new things, have the opportunity to work with and lead a variety of bright people, and coordinate efforts that provide for the health and well-being of their customers, the patient.

Risk Adjustment

Risk adjustment is a methodology that compares a person’s health status to a risk score to predict healthcare costs. For example, the “risk” to a health plan insuring members with expected high healthcare use is “balanced” by insuring members with assumed lower healthcare costs.

However, risk adjustment is how insurance firms participating in specific programs get paid for managing members’ medical needs based on their diagnoses.

Risk adjustment is vital to ensure sufficient consideration for health insurance plans to maintain coverage and access to care for recipients who are likely to acquire higher than average costs. Risk adjustment programs are developed and managed by government companies created to assist all acceptable public members.

So, a medical insurance company cannot distinguish or purposely ensure only a unique demographic of members with a limited range of expected healthcare costs. The case mix of healthy and sicker patients, and the cost-sharing of expenses spread across all members, is designed to provide access to quality healthcare regardless of health status and history.

Providers have a vital role to play in risk adjustment, too. A committed partnership between the provider and the health plan is essential to bringing valuable benefits to enrollees.

For example, insurers may use premiums and risk adjustment payments to offer their members enrollment in exercise programs, case or disease management, transportation to medical appointments, and other services. The health plan uses diagnosis codes that providers submit on claims to identify what programs are needed and who needs them more precisely.

Telemedicine and Telehealth

What Is Telehealth?

Telehealth is the use of electronic information and distance communication technologies for medical-related services. Patient visits using videoconferencing devices, store-and-forward imaging, and text messages that provide patient education are some examples of telehealth.

What Is Telemedicine?

Telemedicine is a part of telehealth, mainly focused on online clinical services. In a small service, the healthcare provider is not physically present with the patient. 

Those who perform telehealth and telemedicine services and claim reimbursement need to know the variations in definitions to ensure compliance with the various rules surrounding this area of healthcare.

What Are the Types of Telehealth?

Follow are some categories used by many stakeholders across the U.S.

Live video telehealth is an audiovisual interaction between a provider and another individual (patient or provider). The telecommunications system used allows for an actual remote encounter in place of an in-person visit. In addition, live video telehealth is an example of synchronous telehealth, meaning it happens simultaneously rather than the provider evaluating transmitted data later.

Mobile health, or mHealth, uses mobile devices, often through application software (apps), to provide information and services to patients. Text messages that promote healthy behavior are an example of mobile health.

Remote patient monitoring collects health data, such as blood sugar or heart rate, from a patient and digital transmission of the information to healthcare providers in another location for evaluation. This kind of telehealth may have benefits like reducing hospitalizations and improving the quality of life for the patient.

Store-and-forward telehealth is also known as asynchronous because it is not a real-time method. Instead, recorded health information is transmitted to a practitioner for evaluation or another service.

What Are Telecare and Related Health?

Telehealth and telemedicine aren’t the only terms used for areas that join telecommunications technology and healthcare. Telecare and connected health are among the many other possibilities. As a result, telehealth and telemedicine terms can differ widely, but the definitions offer some insight into using the words.

According to the Federal Communications Commission (FCC), Telecare uses technology that helps people stay free in their own homes, like fitness apps, digital medication reminders, and tools that connect individuals with their instructors.

Related health is an all-encompassing term for similar concepts that bring together health and telecommunications. Technology-enabled care (TEC) is another term for related health.

Medicare and Telehealth

Third-party payer coverage and reimbursement of telehealth and telemedicine influence whether healthcare providers offer the services and whether patients choose to participate. Medicare’s rules regarding telehealth services are an excellent place to start for understanding the relationship between insurers and telehealth services because there are tens of millions of Medicare beneficiaries across the U.S.

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