Essay, medical coding, and payers assignment
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Liberty University *
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Dec 6, 2023
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Uploaded by MajorCrownMole19
1
Medical Coding and Medical Coding and Payor’s
Introduction
In a medical office, ensuring accurate billing notes for Medicare is crucial to avoid claim
rejections and denials. This essay will discuss three examples of wrong billing that can affect
claims and provide strategies to prevent future problems. By addressing these issues, healthcare
providers can enhance their billing practices and maintain a smooth reimbursement process.
Examples of Wrong Billing and Strategies for Prevention
1.
Unbundling of Services
One common error in medical billing is the unbundling of services, which
involves separately billing for individual components of a bundled procedure. This
practice can lead to claim denials and potential fraud allegations. To avoid this
problem, coders should closely follow the National Correct Coding Initiative (NCCI)
edits, which provide guidance on bundling rules for Medicare claims (Centers for
Medicare & Medicaid Services, 2020). Additionally, regular training sessions and
audits can help coders stay updated on billing guidelines and identify any instances of
unbundling. (Green, 2021) "Do not pervert justice by siding with the crowd, and do
not show favoritism to a poor person in a lawsuit." - Exodus 23:2 (NIV)
2. Lack of Specificity in Diagnosis Coding
Inaccurate or insufficiently specific diagnosis coding can result in claim denials or
downcoding, leading to reduced reimbursement. To avoid this issue, coders should adhere to the
guidelines provided by the International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM). They should accurately document the patient's condition, including
any relevant details and associated complications, to ensure appropriate coding. Regular
2
education and training on coding updates and documentation requirements are essential for
coders to maintain accurate and specific coding practices. (Stowell et al., 2018)
"Whatever you
do, work at it with all your heart, as working for the Lord, not for human masters." - Colossians
3:23 (NIV)
3. Failure to Meet Medical Necessity Criteria
Claims can be denied if the services rendered are deemed not medically necessary. To
prevent this, healthcare providers should ensure that documentation clearly supports the medical
necessity of the services provided. Coders should review the patient's medical record thoroughly,
ensuring that it includes relevant clinical findings, treatment plans, and any supporting
documentation for the services billed. (Green, 2021) Regular communication and collaboration
between physicians and coders can help ensure accurate coding and proper documentation to
meet medical necessity requirements.
(Stowell et al., 2018) : "He has shown you, O mortal, what
is good. And what does the Lord require of you? To act justly and to love mercy and to walk
humbly with your God." - Micah 6:8 (NIV)
Conclusion
Avoiding incorrect billing in medical coding for Medicare claims is essential to prevent
claim denials and ensure proper reimbursement. By addressing issues such as unbundling of
services, lack of specificity in diagnosis coding, and failure to meet medical necessity criteria,
healthcare providers can enhance their billing practices. Regular training, adherence to coding
guidelines, and effective communication between coders and physicians are key strategies to
prevent future billing problems and maintain compliance with Medicare regulations.
3
References
Centers for Medicare & Medicaid Services. (2020). National Correct Coding Initiative
Edits. Retrieved from
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index
Liberman, A. L., & Newman-Toker, D. E. (2018). Symptom-Disease Pair Analysis of Diagnostic
Error (SPADE): a conceptual framework and methodological approach for unearthing
misdiagnosis-related harms using big data.
BMJ Quality & Safety
,
27
(7), 557–
566.
https://doi.org/10.1136/bmjqs-2017-007032
Stowell, N. F., Schmidt, M. K., & Wadlinger, N. (2018). Healthcare fraud under the microscope:
improving its prevention.
Journal of Financial Crime
,
25
(4), 1039–
1061.
https://doi.org/10.1108/jfc-05-2017-0041
Green, M. (2021).
Understanding Health Insurance: A Guide to Billing and Reimbursement -
2021 edition
. Cengage Learning.
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