Medical Billing Profession

Medical Billing Profession
In the medical field, there are many different career opportunities for a biller and coder to choose
from. Careers offered can be in Radiology, Doctor's Office, Dental Office, and working from home.
In this report, I will provide bits of information about each of these different medical billing and
coding career choices.
PHYSICIAN'S OFFICE
Medical billers and coders who work in a physician's office, deal with outpatient services. Private
physicians have their billing services sent out to insurance companies, patients, or other government
healthcare agencies. Small offices employ a small staff that comply with government guidelines.
Clinical staff work closely together to maintain a professional atmosphere on a day to day basis.
DENTAL OFFICE ... Show more content on Helpwriting.net ...
A coder looks up codes in a CDT–5 (Current Dental Terminology 5th Edition) just as a medical
coder uses a CPT (Current Procedural Terminology) guide book. Dental coders can find procedure
codes in the HCPCS Level II book as well. The guidelines are pretty much the same for billers and
coders in the dental field versus the medical field. Every examination, procedure, and surgery must
have preauthorization from a third– party payer, so the appropriate code can be submitted.
RADIOLOGY BILLING SERVICES Coders choosing the Radiology field must be knowledgeable
with CPT codes and modifiers. Here are a few services that fall under Radiology: CAT Scans, X–
Ray of different Internal Organs, and Nuclear Medicine for Limiting and Curing Internal Disorders.
It is very important to be efficient when applying the correct CPT codes. Coders and billers are
highly trained to be as accurate as possible. CONTRACT REMOTE INPATIENT CODER
In the hospital setting, there are numerous job opportunities for a biller and coder to choose from.
For instance, a contract remote inpatient coder must be able to accurately assign diagnoses and
procedure codes. To name a few, here are some of the qualifications a coder must have: one year of
inpatient coding experience, five years working in the medical field, knowledge of
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Current Procedural Terminology
CPT is the Current Procedural Terminology that consists of five–digit numeric codes used to
describe medical procedures, surgical procedures, radiology, laboratory, anesthesia and evaluation
and management (E/M) services. They are linked to diagnostic codes for reimbursement to
providers and consist of 7,800 codes ranging from 00100–99499. In order for a medical specialist to
submit a "clean claim", it is imperative they provide the correct code and know the policy for third–
party payers, guidelines and reporting requirements. Additionally, a biller and coder needs to ensure
when to a modifier. Modifiers can change the way a provider maybe reimbursed.
Category I
These codes comprise the bulk of the CPT, are five digits in length, numbered ... Show more content
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Diagnostic procedures are performed to help analyze a patient's complaint and determine the cause
of signs and symptoms. Diagnostic techniques classified in the Medicine section include an
assessment or evaluation, an examination, or the use of equipment or tools to make a recording or
measurement or conduct a function study.
Category II – the codes are used to track the performance management to collect data to measure the
quality care of a patient, they are optional. When applied the letter "F" is entered into the last field
and no reimbursement is given.
Category III – are new emerging codes for procedures, new services and technology. Include the
letter "T" in the last field. If these codes are not excepted for the placement in CPT–I after 5 years,
then they are archived.
Modifiers
These are two–digit alphanumeric suffixes that are added on to the code in order to give more
information. All modifying codes are located in Appendix A. The CPT book also has a quick access
page of the modifiers in the front of the book, for quick reference. CPT provides 37 modifiers, 3 of
which are used only by hospital outpatient and ambulatory surgery centers. In addition to these,
approximately 50 HCPCS modifiers are listed in the CPT manual for use with CPT codes. HCPCS
modifiers not listed in the CPT manual also can be used with

Evaluating Compliance Strategies in Medical Billing and...
In the medical billing and coding process there are several steps. In the medical billing process
physicians prepare and sign documentation of the patients visit. The next step is to post the medical
codes and transactions of the patients visit in the practice management program and to prepare
claims. The process used to generate claims must comply with the rules imposed by federal and state
laws as well as with payer requirements. Claims that are correct help to reduce the chance of an
investigation of the practice for fraud and also the risk of liability if an investigation does occur
(Valerius, Bayes, Newby & Seggern, 2008). Most physicians depend on their personnel to process
their medical bills without looking at the bills before ... Show more content on Helpwriting.net ...
Despite all of the errors that can occur during the medical coding and billing process there are a few
strategies that could help avoid these problems. These strategies include; avoiding unbundling
(billers and coders must be clear on what individual procedures are contained in bundled codes), be
clear on professional courtesy and discounts to uninsured or low–income patients (professional
courtesy occurs when a physician chooses to ignore the charges for service to other physicians and
their families), benchmarks the practices E/M codes with national averages, use modifiers
appropriately (CPT modifiers can eliminate any impression of duplicated billing or unbundling), and
maintaining complaint job reference aids and documentation templates. These simple steps can help
avoid billing and coding errors.
Linking procedures in the correct way and diagnoses avoids denial of payments and avoids the
possible consequences that can occur due to billing incorrectly. The consequences that could
possibly occur because of billing incorrectly are things such as; delays in processing claims

Diagnostic Coding And Procedural Coding
Medical Coding Essay Academic Essay Diagnostic coding and procedural coding lend themselves
well to the improvement of healthcare efficiency. Both have accurate recording for diagnoses and
the procedures enable the analysis of information for the patient's care, research, performance
improvement, healthcare planning and facility management. The diagnosis codes are divided into
chapters, sections, subsections, and subcategories (1). A coder should become familiar with all of the
codes before the individual moves on. It is very important to understand when an additional code or
codes are needed, what codes are secondary, and when additional information may be needed to
complete the code (1). Also, the coder should always code the reason why the patient sought
medical advice as the main diagnosis (1). There are many rules when using diagnostic and
procedural codes. By using the national diagnostic and procedural coding system correctly the coder
will have no trouble on finding the right codes to use for the case scenarios.
The information the coder needs to get from the health records is very important because this will
provide the correct information on the claim when it is billed out. If the steps are not followed
correctly then the information being submitted will not be correct. Here are the steps that need to be
taken to find the proper sequencing when diagnosing and coding are the coder needs to find the
main term or terms in the patient's medical records.

Chapter 28 Cpt Coding
Chapter 28 CPT
CPT coding is to make sure the patient is getting billed for the correct services that was rendered.
The Tabular list is a compilation of codes divided in different categories: Category I, II, III.
Category I is the basis of CPT codes. Category II is used for tracing information. Category III is
short term codes for collection of services rendered and procedures. There are 15 appendices that are
used as guides. Modifiers help report situations. Locating codes are done by finding the main term.
Assess information provided such as notes and terms. Locate the code. Guidelines are presented in
the front of the sections. Special instructions help point out rules on how to use codes. Instructional
notes are located in parentheses ... Show more content on Helpwriting.net ...
Codes are divided because of the location of sinuses. Endoscopy can be performed three different
ways; transnasal, transnoral, and transorbital. Occasionally, procedures are grouped by size, type or
differences.
Chapter 39 Cardiovascular Pacemakers can be short term or long term. Batteries for pacemakers
hold up for about 5 to 15 years. Nonselective catheter is approached through the aorta or vessel.
Selective catheter is approached through a vessel going to the aorta then proceeds to other arteries
that sector from the aorta to vessels that need fixing. Coding for selective catheter is from the greater
distal area. Second branch order is the subclavian artery.
Chapter 31Evaluation and Management Criteria: setting evaluation, contact was it direct or indirect,
is patient a child or infant, service provided, is the patient established/new. Service level consist of
three components, which is the history, exam, and decision made at the time of visit. Patient that has
seen the doctor for three year is established. One that has not seen the doctor is new. There are four
levels of making a decision. HPI factors relate to the issue the patients is dealing with. ROS factors
relates to the sign of illness. PFSH factors deals with the history of the patient and history of the

Icd 9 Research Paper
The International Statistical Institute adopted the first international classification edition, known as
the International List of Causes of Death, in 1893. WHO was entrusted with the ICD at its creation
in 1948 and published the 6th version, ICD–6, that incorporated morbidity for the first time. The
WHO Nomenclature Regulations, adopted in 1967, stipulated that Member States use the most
current ICD revision for mortality and morbidity statistics. The ICD has been revised and published
in a series of editions to reflect advances in health and medical science over time. ICD is the
foundation for the identification of health trends and statistics globally, and the international
standard for reporting diseases and health conditions. It is the ... Show more content on
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The codes use alphanumeric characters in all positions, not just the first position as in ICD–9. In
addition, there are 68,000 existing codes in the ICD–10, as opposed to the 13,000 in ICD–9.
Therefore, the codes have been greatly expanded and this expansion allows a significant increase in
the specificity of the reporting in the ICD–10, allowing more information to be conveyed in a code.
For instance if you had a burn on your right arm in did not specify which arm had the burn in the old
ICD–9, now in ICD–10 it specifies which arm has the burn. The terminology has been modernized
and has been made consistent throughout the code set. There are codes that are a combination of
diagnoses and symptoms, so that fewer codes need to be reported to fully describe a condition. The
reason they changed it is because the practice of medicine has changed considerably in the last 25
years, and the ICD needed to reflect those change. There have been many new diseases discovered,
new type of medical devices and new treatment and the

Digital Forensic Investigations
The field of digital forensics has become increasingly more important over the last few years as both
the computer and the cellular market has grown. The field of digital forensics is relatively new [16,
17]. Various methodologies have been proposed, yet there is no accepted standard procedure within
the digital forensics community. Several forensic techniques are used with success where others
have failed to prove events beyond doubt. Reasons for this failure include inadequate resources, lack
of sufficient training and shortage of funding. Experts are scarce and expensive [18], while the lack
of a professional association governing the actions of experts has been criticized [18, 17]. Within the
research community there are also inconsistencies in terminology used to describe various processes
[19,20]. The current literature reveals a number of proposed frameworks, models and procedures
that have been put in place in an attempt to formally describe an effective digital forensic
investigation process. In digital forensic investigations, various processes focus on different actions
performed, such as the data extraction, data examination, and data gathering and so on. Others tend
to be more concerned with the analysis of the data extracted from the digital media. ... Show more
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Not only is the evidence itself important in a digital forensic investigation, but the process followed
in acquiring the evidence before presentation is crucial. Numerous court decisions have given
guidelines to determine the standard required from the evidence collected and process followed in
its

Compare And Contrast Icd And Standard Internationa Medical...
According to the American College of Medical Quality, medical necessity is defined as "accepted
health care services and supplies provided by health care entities, appropriate to the evaluation and
treatment of a disease, condition, illness or injury and consistent with the applicable standard of
care." This ensures that doctors conduct the proper and necessary actions to ensure the safety and
care of a patient. Besides doing the right thing, doctors are held accountable for the welfare a proper
decisions of care for their patients. For medical necessity, a doctor must acknowledge that the care
required for any treatment is necessary for the health of the patient. Above all, medical necessity is
reason for the treatment or care. Two common medical coding classification systems are in use – the
International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). ICD
is the standard ... Show more content on Helpwriting.net ...
Proper medical coding is important, from ensuring accurate payment for physicians to creating a
valid record of patient care history. In addition to aiding the medical billing process for procedures
administered and helping expedite the payment of services for physicians, medical codes also serve
the purpose of comparing projects for research and planning for under–served health care areas,
aiding in administrative functions, as well as identifying symptoms that have medical necessity and
referenced by other physicians or specialists. As an example, for a general urinalysis, the coder must
input the code of 81000 for male or female patients. The mistake that could be made is if the coder
input 81025 for a specific urinalysis for a pregnancy test. This event could happen if the diagnosis
was reversed and a female expecting a pregnancy urinalysis gets a general urinalysis ordered. It may
seem minor, but this type of error can still be

Hospital Charge Master System
Hospital charge master – o A hospital charge master is a database. This computerized system
contains every procedure, service, supply item, and every pharmaceutical item that a hospital can
charge a patient or their insurance provider.
Coding Systems (UHB) and (http://www.medicalbillingandcoding.org/intro–to–cpt/) o Coding
systems are standardized systems used in over 100 different countries to decrypt all services,
conditions and items to be billed to a patient or their insurance provider. There are two main coding
classifications systems: International Classification of Diseases (ICD) and Current Procedural
Terminology (CPT). Currently, ICD is in its 10th edition making the current complete system name
ICD–10. ICD–10 uses up to seven ... Show more content on Helpwriting.net ...
The charge master is a convenience feature. Without registration, it is difficult to proceed. If the
registration is not completed properly put into the system, denials and delay of claims can occur.
Without the registration, you do not know if you have current/active insurance information or if the
patient's contact information is accurate. As we learned in earlier classes, especially with
government programs, patients can believe they have insurance but in actuality it has been
terminated or lapsed. If the claim goes to the A/R department for collection of payment from the
patient, if you do not have accurate contact information, the claim could be unpaid for an indefinite
amount of time. By verifying the patient's information, the entire process of service, coding, and
billing has a foundation to submit claims to the appropriate parties for

Shoul Coding In Health Care
Health care is a very complicated topic, when discussing the coding system used to reimburse
physicians for their health services to the needs of the patients, especially those who are discussed in
Rebecca's talk. In the world we live in today, not many people have full health care coverage, let
alone affording the medicine that may be needed and food or rent for their homes. "Health Leads is
a simple model where doctors and nurse can prescribes nutritious food, heat in the winter and other
basic resources for their patients the same way they would prescribe medicine."(Rebecca). With
Health Leads, the patients are able to take their prescriptions to their desk in the clinic, where the
workers work side by side with the patient to give the best services possible and to keep patients
healthy. There is a three step process in Medicare for physician reimbursement. "1). Appropriate
coding of the service provided by utilizing current procedural terminology; 2). Appropriate coding
of the diagnosis using ICD–9 code; and 3). The Centers for Medicare and Medicaid services
determination of the appropriate fee based on the resources–based relative value scale." (Ochsner).
Based on the way that Rebecca explains the Health Leads process, it does not seem as complex or as
detailed as it ... Show more content on Helpwriting.net ...
"A procedure document includes relevant information like the date of the procedure, the patient's
name, and his or her date of birth. More importantly, a procedure document includes the doctor's
diagnosis and the procedure performed."(Medical Billing and Coding). They turn the medical
coding into medical cost for that claims can process. They are also there to catch any errors such as
making sure the correct diagnosis was made as well as no inaccurate information about the

A Brief Note On The National Priorities Partnership
NPP – National Priorities Partnership
This is a group of 50 major national organizations which are directed to safe, affordable, reliable,
equitable healthcare system in US with a mission oriented to achieve such vision with the help of
coordinated and collaborative action plan. NPP focus is to ensure patients receive comprehensive,
well–coordinated level of care at all the hospital settings. [18]
OCR – Optical Character Recognition
Optical character recognition is the method or process of detection and translation of the printed or
written document into an electronic data document and is usually used in data processing systems.
Such recognitions requires definite hardware and software tools which can translate the data. [19]
PHI – ... Show more content on Helpwriting.net ...
Also, PSO activities include identification, assessment, analyzing the risks associated with the
delivery of medical health care. [21]
CLIA – Clinical Laboratory Improvements Amendments
This is a federal regulatory standards organization that apply all clinical laboratory research testing
directed on the humans in United States. [4]
EMTALA – Emergency Medical Treatment and Active Labor Act
This act enables that any emergency services directed to the facility should be performed
irrespective of payment capability or delaying treatment procedures for obtaining the insurance
information are considered unlawful and are obliged for penalizations. Emergency services should
be provided by qualified emergency surgeon with qualified personnel. [12]
CHIPS – Children 's Health Insurance Program
A federal government social program where health coverage for children are provided with the aid
of state and federal governments. [12]
HBP– Hospital–Based Physician
Hospital based physician should be a specialist in either following clinical specialties which include
anesthesiology, radiology, pathology, emergency medicine, or hospitalist and should provide 90% of
services in either inpatient, outpatient or emergency department which is stated by CMS. [22]
EMR – Electronic Medical Record
It is a patient record that the provider maintains which is in electronic format rather than the
conventional paper based format providing the detailed patient history

An Explanation Of How Billing And Coding Works For...
B. An explanation of how billing and coding works for healthcare services
Medical billing and coding are two closely related aspects of the modern health care industry. Both
practices are involved in the immensely important reimbursement cycle, which ensures that health
care providers are paid for the services they perform. For the sake of simplicity, let's divide the two
at the moment and look at them as separate pieces of a larger process. We'll begin with medical
coding.
Medical Coding– Medical coding, at its most basic, is a little like translation. It's the coder's job to
take something that's written one way (a doctor's diagnosis, for example, or a prescription for a
certain medication) and translate it as accurately as possible into a numeric or alphanumeric code.
For every injury, diagnosis, and medical procedure, there is a corresponding code. There are
thousands and thousands of codes for medical procedures, outpatient procedures, and diagnoses.
Let's start with a quick example of medical coding in action. A patient walks into a doctor's office
with a hacking cough, high production of mucus or sputum, and a fever. A nurse asks the patient
their symptoms and performs some initial tests, and then the doctor examines the patient and
diagnoses bronchitis. The doctor then prescribes medication to the patient.
Every part of this visit is recorded by the doctor or someone in the healthcare provider's office. It's
the medical coder's job to translate every bit of relevant

Procedural Terminology Essay
Research, Use and knowledge of cardiology Current Procedural Terminology (CPT) allowed me to
properly bill detailed procedures. Also, research, appeal and solve claim and billing issues using the
patient explanation of benefits and medical records.
Interfaced with insurance carrier websites and claim clearinghouses for verifying eligibility filing
electronic claims and to follow up on claims filed.
Assisted patients with eligibility and benefit coverage questions. Established and maintained
effective working relationships with employees, insurance carriers, and patients. Worked with staff
to research, identify and provide solutions to patient and insurance company inquiries.
Obtained pre–authorization for specific procedures as determined ... Show more content on
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Skilled in communicating and presenting factual information related to the work assignment.
I used multiple office automation software with varied functions to produce a wide range of
documents to provide miscellaneous clerical support. Machines and software used are standard
business computers, laptops and tablets loaded eClincal software for patient charting, electronic
claim submission and practice financial reporting. Used external faxing devices. Used Microsoft
Office Full Suite for all letter documentation and sorting financial reports from eClinical. Used
external copy machine. Used external electronic on–site deposit machine and software for daily
check deposits to Bank.
Obtained user clearance and used local hospital interfaces to obtain medical records procedural
progress and surgical notes for patient chart and claims. Hospital interfaces used were The Medical
Center of Central Georgia (Navicent Health), Perry Hospital, Houston Medical, Coliseum Hospital
and Macon Northside Hospital.
Clearinghouses I have used are Emdeon, Navicure, Dentrix, Centricity, Medicaid, Aetna, Availity,
eClaims and

Ehr Coding And Reimbursement Case Study Paper
EHR Coding and Reimbursement Case Study
One of the greatest milestones in the United States health system is the use of electronic health
records codes to ensure consistency in diagnosis and treatment procedures provided by physicians
(Romano & Stafford 2011). The purpose of the case scenario of the sixteen year old female who
visits the emergency department is to show how electronic health record coding is done and its
impact on health reimbursement. The International Classification of Diseases (ICD) and the Current
Procedural Terminology (CPT) codes are brought out well in the case study showing how they help
in ensuring physician consistency in coding diagnosis and treatment procedures for the purpose of
health reimbursement.
The International ... Show more content on Helpwriting.net ...
To determine the CPT code for the above case scenario, the first step is to identify its category 1
which in this case will be emergency department services which range from code 99281–99288. In
this category, the case scenario would also be assigned code 78000–79999 for nuclear medicine and
code 76500–76999 for diagnostic radiology. The codes would be selected based on the chest x–ray
and nuclear stress test done to the patient. Codes 99605–99607 would also be assigned based on the
medication given to the patient. In category II of CPT, the case scenario would be assigned code
0500F – 0575F for patient management based on patient evaluation and prescription changing.
In most cases, identification errors lead to ICD and CPT coding that result in dull reimbursement. If
the services submitted to the electronic health record system are not written in the patients' health
records, it could also lead to dull reimbursement. Failure to bill records before submission as well as
lack of accuracy and wrong use of codes also leads to dull reimbursement (Romano & Stafford
2011). For the claim to demonstrate medical necessity for the exam, the patient's electronic health
records submitted to the system must describe in details the procedure that the patient is to

What Competencies Are Needed For Entry Level Employment In...
1. What competencies are needed for entry level employment in healthcare/HIS?
Healthcare skills: (anatomy and physiology, medical terminology, pathophysiology, clerical and
administrative procedures, laws and ethics, communications),
Computer skills :(MS office, EHR, Internet, billing–related/PM, data mining, records management,
coding/cac,
And knowledge of healthcare reform: (privacy and security, HIPPA, HITECH, PPACA, ICD–10) for
the greatest career opportunities for advancement.
2. Describe various professions (clinical and administrative) and their roles and responsibilities in
the medical office.
Physicians, primary clinicians in the practice
Physician Assistants, formally trained to provide diagnostic, therapeutic, ... Show more content on
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Health Maintenance Organization (HMO): A type of health insurance plan that usually limits
coverage to care from doctors who work for or contract with the HMO. It generally won't cover out–
of–network care except in an emergency. An HMO may require you to live or work in its service
area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and
wellness.
Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other
health care providers that belong to the plan's network. POS plans require you to get a referral from
your primary care doctor in order to see a specialist.
Preferred Provider Organization (PPO): A type of health plan where you pay less if you use
providers in the plan's network. You can use doctors, hospitals, and providers outside of the network
without a referral for an additional cost.
Health Savings Account (HSA): A Health Savings Account allows individuals to pay for current
health expenses and save for future qualified medical expenses on a pretax basis.

7. List and briefly describe the four major government–sponsored insurance programs.
Medicare: is the federal health insurance program for people who are 65 or older, certain younger
people with disabilities, and people with End–Stage Renal Disease (permanent

Medical Coder Job Analysis Essay
The new job title could be a medical coder 1. I choose this new title because the medical coder is a
health care professional who analyzes the medical records, medical charts and assigns the
appropriate codes. Most of the job's responsibilities of a medical coder are required for the inpatient
and the outpatient coder's jobs. For example, medical coder's responsibilities are: reading and
analyzing patient records, determining the correct codes for patient records, interacting with
physicians and assistants to ensure accuracy, using codes to bill insurance providers, and
maintaining patient confidentiality and information security. In addition, the minimum required
certification of this job is CPC or CCS and RHIT with at least 4 years of experience. Those
certifications are given to a Coder who can read and assign correct diagnosis International
Classification of Diseases or ICD–10–CM, Current Procedural Terminology or CPT, supply
Healthcare Common Procedure Coding System or HCPCS code for a wide variety of clinical cases
and services, and read and assign PCS codes. The skills of this job are same as the skills of the ...
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This checklist may be distributed to all employees completing the job tasks being evaluated. PAQ is
a job analysis instrument, by using this questionnaire, we can measure job characteristics and relate
them to human characteristics as mental processing which measures analytical skills, relationship
with others that measures the required level of communication skills. In addition, PAQ questionnaire
measures job context which is the factors controlled by the organization and the individual has no
control over it. For example, work condition, policies that could affect employee's satisfaction.
Finally, this questionnaire measures work output, which measures the productivity of the employees
and the ways to increase

Healthcare : The Healthcare Industry
Healthcare Industry
The healthcare industry comprises diverse healthcare organizations, covered entities, and third
parties. In turn they provide services via health maintenance organizations (HMOs), preferred
provider organizations (PPOs), point of service (POS), and demonstrate their ability to share and
exchange data via data interoperability technologies such as Health Level 7 (HL7), Digital Imaging
and Communications in Medicine (DICOM), and Integrating the Healthcare Enterprise (IHE). This
flow of information must follow proper Health Insurance Portability and Accountability Act
(HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH)
guidelines to safeguard the patient's private and confidential information. To collaborate with
diverse entities, workflow management must flow from one entity to another while simultaneously
maintaining the CIA (confidentiality, integrity, and availability) triad (Hernandez, 2015).
Patients are billed for drugs and services rendered according to their diagnoses which follow
specific coding mechanisms such as International Classification of Diseases (ICD), Current
Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), Current
Dental Terminology (CDT), Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR),
the International Classification of Functioning, Disability, and Health (ICF), National Drug Code
(NDC), and Systematized Nomenclature of Medicine (SNOMED CT)

Medical Administrative Assistant Field
Medical Administrative Assistant Field In the field of Medical Administrative Assistant, there is a
multitude of career choices to branch off into. Of these many fields, the three that I choose to
discuss are Medical Billing, Medical Coding and Medical Assistant. All three careers are of high
demand in the medical industry and each requires the need of basic classes, with a couple of varied
courses, depending on the field. Basic requirements for all include a high school diploma or GED.
Most require an Associates degree, consisting of specific major courses and general liberal arts
courses. Additionally, these professions can continue to advance their careers by obtaining a higher
degree or attaining alternate types of specific ... Show more content on Helpwriting.net ...
Growth trends in this field are very broad. Billing specialist, patient account representative, claims
processor, analyst, auditor, collector and reviewer are only some of the many options available and
require additional specific certification and training. The average salary for medical billers ranges
mid $30,000 to lower $40,000 (Salary.com, 2011), but depending on certain factors, can excel
beyond this. Additionally, medical billers must also have solid personal skills; customer service,
patience, compassion and understanding when dealing with patients, physicians, hospital staff and
other associated personnel is a must. Medical Coding Medical coding, on the other hand, deals more
closely with patient medical records. Medical coders work in the billing office, or "back office" of
medical practices or hospitals. Alphanumeric codes are assigned to all illnesses, injuries and
treatments. Medical procedures are coded for the purpose of classifying diseases in numerical
sequences for identification and data collection purposes, similar to the Dewey Decimal System in
libraries. Coding specialists review medical records and assign numeric codes for the diagnoses
identified and procedures performed. Each medical procedure and patient encounter has a number
(CPT code) associated with it which corresponds to an ICD code. These

The Healthcare Common Procedure System (HCPCS)
The Healthcare Common Procedure System is usually known as HCPCS. This system was
developed by The Centers for Medicare and Medicaid (CMS). The advancement and practice of
HCPCS Level II codes was introduced in the 1980s. Using HPCS codes was optional up until 1996
when HIPAA was passed. The Secretary of Health and Human Services assigned authority under the
Health Insurance Portability & Accountability Act of 1996 legislation to CMS (Centers for Medicare
and Medicaid Services) to maintain and administer HCPCS Level II codes. Healthcare
professionals, along with medical billers and coders use HCPCS. HCPCS Codes are needed for
health insurance providers to produce appropriate claims. HCPCS codes are made up of five
characters and is alpha

Medical Practice Initiative
Medical Practice Initiative. One of the main drivers of the Medical Practice Initiative (MPI), aside
from patient safety, is the acquisition, maintenance, and minimization of cognitive and psychomotor
skill decay of healthcare personnel. A primary focus is maintenance of military and medical skills
throughout a caregiver's career (7). There is some crossover between the CCTI and the MPI as both
apply to healthcare providers, but the MPI is more closely tied to Role 3 through Role 5 skills and
procedures as well as common skills and procedures performed by non–military healthcare
providers during routine care delivery. Capability gaps addressed and identified as subsets of MPI
are: Fostering Clinical Excellence – Competency and Certification; Patient Variation (Anatomical)
and Pathology Scenarios; Training Measurements – Metrics and Evaluation Criteria; and Patient
Safety. Fostering Clinical Excellence – Competency and Certification There remain many questions
regarding how and why individuals learn. The optimal methods to train and educate an individual
need to be studied, as well as team training for optimal outcomes. Inserting multiple variables into
individual training further complicates the issue. The "See One, Do One, Teach One" method has
been used in the past, however, with simulation systems, the model should move toward "See Many,
Do Many, Teach Many" as it is understood that simulation systems are relevant for novices as well
as for experts providing

Reimbursement In Health Care
The Centers for Medicare and Medicaid Services is a government agency within the U.S.
Department of Health and Human Services. The CMS is in control of certain health care programs.
Reimbursement is used in the healthcare field by coding specialist in hospitals and physicians'
offices. These specialists assign appropriate diagnosis and procedure codes based on the patients'
individual medical record. Once the information from the patients' record is coded, a bill or claim is
composed and sent to a third–party payer for the reimbursement of the services that were performed
on the patient. Depending on the payer, they may request that a copy of the patients' medical record
be sent with the claim. The information extracted from the medical records

Gastroenterology Essay
Medical Coding for Gastroenterology The challenges for the field of gastroenterology are many in
the new environment of the trend toward the accountable care concept, a concept that exposes this
specialty to demands for varied and integrated care in a manner which is economically sound for the
consumer yet profitable for the physician. These challenges calls for a concerted effort to streamline
office procedures and create a more efficient working environment all while attending to the
concerns of the practice and remaining a desired, viable, vital specialty. Extensive and continual
educational and training requirements pose further demands on the time and resources of the
practice, and can cause a profound delay in the optimal outcomes of ... Show more content on
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One of the most common errors noted in coding for gastroenterology includes miscoding
colonoscopy procedures for asymptomatic patients in terms of the nature of the screening and
whether it should be coded as a surveillance or screening colonoscopy. The immense scope of
payable categories within the field requires a broad familiarity with new and updated codes in order
to deter denials and protect reimbursements. Even supply items can be cause for rejection if coders
are not current with guidelines. One of the most rejected supply claims includes a PEG–J being
claimed to the wrong jurisdiction in such cases as when used to establish a transabdominal port by
endoscopic procedure. PEG–Js must be claimed as a supply to the A/B MAC contractor. PDN
understands the many challenges of coding for gastroenterologists, especially for those employed
in–office, accustomed to working with prior CPT and ICD–9 codes. The new demands created by
ICD–10 for increased documentation and specificity require an advanced knowledge base with
regard to anatomy and terminology, and a more complete understanding and awareness of
gastroenterology diagnoses and procedures. For instance, the ICD–10 has nine different coding
options related to colon

Healthcare Common Procedure Coding System
Clinical vocabularies are defined as terminologies or coding systems that are structured list of terms
which together with their definitions are designed to describe unambiguously the care and treatment
of patients. The clinical vocabularies are used to create classification systems that are used around
the world to provide a method of distributing coded concepts in a stored meaningful manner.
(Thomson 2013) 1. What vocabularies do you have to choose from? The week 4 Neehr Perfect
Assignment gives a list of the more well known and most commonly used classification systems and
are as followed: Healthcare Common Procedure Coding System (HCPCS) Healthcare Common
Procedure Coding System (HCPCS) Level II International Classification of Diseases, ... Show more
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International Classification of Diseases, 10th revision, Procedure Coding System (ICD–10–PCS):
Coding system developed to replace Volume 3 of the ICD–9–CM manual. International
Classification of Diseases for Oncology (ICD–O): Coding system used in tumor or cancer registries
for coding the site (topography) and the histology (morphology) of neoplasms. National Drug Codes
(NDC): Universal product identifier for human drugs used to identify and report drug products.
Current Procedural Terminology (CPT): Coding system established by the American Medical
Association for coding of procedures and services. Diagnostic and statistical manual of Mental
disorders (DSM): Standard classification of mental disorders used by mental health professionals in
the US. Logical Observation Identifiers Names and Codes (LOINC): A free, universal standard for
laboratory and clinical observations, and to enable exchange of health information across different
systems. 3. Is the vocabulary appropriate for your setting and

Medical Billing And Coding And Billing
Introduction
My career that I am researching for my junior project is Medical Coding and Billing. Medical
Coding and Billing are two different jobs. Medical Coding is when a patient has any medical
procedure or exam such as going to the doctor for the stomach virus or even going to the hospital for
a broken bone. They work with the insurance companies by putting a specific number into the
computer. There's CPT Codes which stands for Current Procedural Terminology which is " Codes to
better understand the services their doctor provided, to double check their bills or negotiate lower
pricing for their healthcare services. (About Health, 2014)."
For Medical Billers they will submit and follow up on any claims in order to receive payment for
services from the patient or any health care provider. Both Medical billing and coding workers are
the health care professionals in charge of processing patient's data such as treatment records and
related insurance information. Medical billers are in charge of making sure everyone is being billed
correctly. Medical Billers interact with insurance companies just as much as Medical Coders. A
normal day for a medical biller is day to day operations; prepare all billing for Medicare, Medicate,
and all commercial insurance companies. Create electronic files, monitor payments and denials.
When creating electric files, when a new customer is sent to you Medical office you will create an
electronic folder just for them so everyone's separate

Reimbursement In Nursing
Dillon and Hoyston discuss critical steps in establishing reimbursement for a new NP, whether this
is part of an existing practice or a new practice. Initially, each NP needs to apply for a National
Provider Identification Number (NPI). "The Health Insurance Portability and Accountability Act
(HIPPA) of 1996 mandated a standard of unique identifiers for health care providers and health
plans" (Dillon & Hoyston, 2014, p.57). While the Centers for Medicare and Medicaid Services
established the National Plan and Provider Enumerator System to provide practitioners with unique
identification. This NP currently has a NPI number that would require updating for additional
practice sites. Additionally, to ensure reimbursement NPs would want to ... Show more content on
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The Oregon Health Authority lists OHP 3114; OHA 3972; OHA, 3974; OHA 3975 as the forms
required for behavior health PMHNPs to file. At the practice expands to include additional
providers, OHA lists the same required forms for family nurse or other nursing practitioners. There
are provisions for naturopaths and chiropractors to register for provider numbers to request
reimbursement for services provided, should the practice expand and include other professionals in
addition to advanced practice nurses. Rural Health Clinic Status is listed as a #14 provider type
should the additional providers choose to form a Rural Health Clinic focused on wellness, with the
joint value of an integrative health philosophy of practice, as a group rather than co–located
individual providers. Dillon and Hoyston (2014) recommend using the http://www.oagh.org/site to
credential for most managed care programs, in one place, especially if you don't have a practice
manager to assist with competing applications and filing. Consequently, understanding how to use
coding for practice is crucial. Dillon and Hoyston (2014) note that the "current Procedural
Terminology codes

Global Label Management Solution For Medical Devices...
Background The FDA introduced a new regulation that affects all FDA regulated medical device
companies. This new regulation requires that the medical devices companies become compliant with
the Unique Device Identifier (UDI) requirement within the next one to three years. Most of these
medical device companies are not yet compliant and require a suitable solution to maintain their
FDA certification. Description of the Product PRISYM ID has developed global label management
solution (PRISYM 360) that meets the FDA's UDI requirements. When a company purchases the
PRISYM 360 solution, their learners do not have the knowledge or skills necessary to perform their
job. This one–day workshop provides a condensed high level instruction covering the creation,
approval, and printing of a production label to fulfill orders for hospitals, pharmacies, and other
medical organizations. Some of the benefits of this workshop will be to provide the learners with an
introduction and overview of the new terminology, how the software functions, order of operations
related to the creation, approval, and printing of a production label, and how to create a label. The
intent is to provide the learners with a level of comfort in the application before delving into the
intense five to eight day formal instruction. Learning Objectives The application introduces a
number of new application–specific terms, essential for the learners to understand to be successful
in implementing the

Evaluating Compliance Strategies Essay
Evaluating Compliance in Coding
By: Terry Valencia
Axia College of University of Phoenix Billing and Coding compliance strategies protect physicians
from financial risk and potential loss of revenues. Physicians must document fully the service they
provide and put in force a plan that prevent or reduce coding errors. According to, "The Journal of
the National Medical Association," there are 10 top billing concerns for physicians: Medicare billing
(Part A and Part B) Mental health billing. Self–Referring to entities where the physician has a
financial interest. Billing for services provided at certain stat[–owned sites (i.e., prisons). Not
differentiating between out patient clinic and physician office visits. ... Show more content on
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Billing for non–covered services. Misused of provider identification numbers. Unbundling a
multiple component service and billing each component as a single service. Failure to properly use
coding modifiers. Upcoding the level of service provided, because of it's widespread practice.
Upcoding is a major focus of the OIG and is incorporated into the regulations initiated by the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). Upcoding is defined as, "billing for
more expensive service than the one actually performed. Most physicians do not use the lower level
Current Procedural terminology (CPT) codes because incentives fees are less.. Upcoding is
considered fraud when there is patten of selecting higher levels codes for lower level services. When
claims are filed documentation must compare to the amount of service provided. The rule is, "if
documentation of procedure is not written, it did not happen. Evaluation and Management (E &
M) guidelines are checked periodically to ensure medicare and other payers follow guidelines. The
E & M informed and update rules and regulations for coding to ensure practices maintain
compliance. Physicians has the responsibility of ensuring employees are trained to coding standards
and should periodically go over records themselves to make sure all guidelines are followed.
Physicians receive updates to ensure the practice is functioning according

Medical Coding Research Paper
The definition for Medical Billing is the process of submitting and following up on claims with
health insurance companies in order to receive payment for services rendered by a health provider.
The definition for Medical coding, is the process of converting diagnosis codes to ICD–9/10 codes
and procedure codes into CPT codes. A Medical Biller and Coder may specialize in different areas.
One area is in–patient facilities, and another area is in and out–patient facilities. An In–patient Coder
works in an in–patient facility such as a nursing home, a rehabilitation centers or a hospital. Coders
who work in hospital facility may utilize a different skill set, than those who work in a different kind
of a health facility. A Coder needs to be ... Show more content on Helpwriting.net ...
The exam was put together by a team of orthopedic coding professionals. The coder must be
knowledgeable and will be tested in these areas: ICD–9/10, CPT, HCPCS Level II and modifier
coding assignments, Evaluation and Management (E/M), both 1995 and 1997 documentation
guidelines. He or she must also be familiar with the rules and regulations of Medicare billing,
including (but not limited to) incident to , teaching situations, shared visits, consultations and global
surgery, coding of surgical procedures performed by orthopedists such as arthroscopic surgeries,
fracture repairs, and spine surgeries, etc. Coder must also know medical terminology, and anatomy
and physiology. These are the criterion that is required to take the COSC exam for

Classification Of Information For The Healthcare System
Overview of coding Coding consists of ICD–9–CM, ICD–10–CM, CPT and HCPCS codes. The
codes help classify and document the information for the healthcare system in the United States. The
ICD–9–CM stands for the International Classification of Diseases, Clinical Modifications. October
1st 2014 ICD–10–CM came out to update the class with more illnesses, conditions, and injuries of
any patient that used the medical services. The ICD–9–CM is generally classified as numerical and
alphanumerical codes with codes describing the illness and injuries. The CPT which is Current
Procedural Terminology and the HCPCS which is the Healthcare Common Procedure Coding
System are used in various medical settings. The CPT is published by the AMA yearly. CPT ... Show
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The CPT code book has nine different conventions including with symbols in the book. The
semicolon identify the main entry what is it part of all indented entries that follow with their code.
The bullets and triangles identify as the changes that were made and the current code. The facing
triangle symbol is used to identify the beginning and ending of a new or revised text within the
guidelines and instruction notes. Plus symbols are you when a procedure is carried out with another
procedure. Circled bullet symbols indicate moderate sedation is inherits part of the procedure. The
null symbol indicates codes that may not be appended with modifier 51. The pending symbol
indicates for a vaccine that is pending approval from the FDA. The resequenced symbol do not
appear in numeric sequence the reinstated code applies to codes that have been recycled. Some of
the general rules for CPT coding are analyze the note or procedural statement, determine the
procedure, locate the main term in the index, review and select the sub terms, note the code numbers
if found opposite of the selected terms, if applicable follow cross–reference never code directly from
the index, read all the notes that apply to the code, select the appropriate modifier, continue coding
all components of the procedure or services. Modifiers Modifiers may be reported with a CPT code
to identify a particular service or

Scheduling Patient Obligations
Abstract
This paper discusses potential legal issues that can occur in scheduling patient appointments.
Important healthcare legislation that impacts the scheduling of patient appointments is examined
including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Health
Information Technology for Economic and Clinical Act (HITECH), a part of the American Recovery
and Reinvestment Act of 2009 (AARA), and the Patient Protection and Affordable Care Act of 2010
(ACA) which expands HIPAA. The issue is important to a scheduler who has a responsibility to
protect the rights of patients, to protect patients protected health information (PHI), and to help
reduce the escalating number of patient death resulting from medical

Belvoir Primary Clinic Case Study
quality. As reforms continue to ensue organizations must stay abreast of these changes to guarantee
their livelihood. The Belvoir Primary clinic will obtain payment from a variety of payers. Since 45%
of the clinic's enrolled patients have commercial insurance this will be the clinic primary source of
revenue. The clinic's second largest source of revenue will come from Medicare with 35% of the
clinics population enrolled in the program. Finally, additional income will be generated from the
clinic's Medicaid beneficiaries and private payers. To maximize profitability, the clinic must
capitalize on its PCMH status by identifying new federal, state, and commercial opportunities for
revenue. The PCMH model expands current revenue streams by qualifying practices for transition
support fees, care coordination/care management fees, shared savings, and pay–for–performance
incentives (Gray & Arnovich, 2016). Types of Reimbursements ... Show more content on
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These new models aim to transform traditional fee–for–service (FFS) payments that reward episodic
care into models that reward the delivery of comprehensive primary care (Edwards et al., 2014). The
Belvoir Primary Clinic will seek to take advantage of all potential reimbursement methods such as
the Enhanced Fee–for–service (EFFS) model which will allow the clinic to receive augmented
payments due to its PCMH status (Edwards et al., 2014). The practice can also qualify for additional
payments by using PCMH specific codes to bill for non–visit related care such as care coordination
and transition support (Edwards et al., 2014; Gray & Aronvich, 2016). Furthermore, the practice can
also receive incentives through value–based and pay–for–performance (P4P) programs by meeting
performance measures and utilization goals (Edwards et al., 2014).

HL7 Electronic Health Record (EHR)
Electronic Health Record (EHR) standards refer to the agreed format that is applied to support the
definition, use and exchange of data that is related to all the aspects of Health care Information and
Technology (HIT). The standards should ensure that there is accurate, comprehensive and secure
health information of an individual patient in digital format. Being HIT building blocks, they should
provide a common framework of promoting uniformity in defining and identifying the components
of a health system. The standards should provide consistent collection and exchange of patient's
information, enhance data quality and ensure reduction of medical errors. Some of the standards
include: HL7 EHR Functional Model, CCHIT certification criteria and incentive programs
(Amatayakul & American Health ... Show more content on Helpwriting.net ...
This will help me and the team to understand how the system works. The documents will serve as
the reference point on the basic requirements. For cohesiveness, I will have the team to discuss my
findings during meetings (Trotter & Uhlman, 2011). Furthermore, I will try to understand the
terminology and the technology language that is associated with EHR information in general. In
doing so, I will seek the assistance of a professional physician, undertake research on different sites
and discuss with potential vendors to help me understand the terminologies. I will then carry out a
readiness assessment and analyze the workflow. In conducting the readiness awareness, I will put
into consideration my goals, the number of staff, current networks, the forms used and volume of
visits amongst others. Thereafter, I will carry out an analysis of office workflow by reviewing steps
of patient's encounter, data and billing collection and the quality of care. This will help me in
identifying errors and devising ways to improve on

Disadvantages Of Health Information Exchange
Health information exchange (HIE) is the electronic sharing of health information between different
healthcare organization and providers. The primary goal of HIE is to provide effective, timely, safe,
and secured healthcare information to ensure a patient is receiving the best care possible. This
concept is not new, it has been around since the early 90's and with the advancement of computer
technology, and it is becoming the way of the future. Even with all the benefits associated with HIE,
there are however still some challenges that need to be addressed. Benefits of HIE The use of HIE
helps aid provider and healthcare facilities to provide fully coordinated patient care. For all parties
involved in HIE there can be great benefits, this includes the patients, providers, and other entities
such as state, government, and public health. Patients: Improved payment coordination Improved
clinical outcomes Improved transition of care Reduction or elimination of duplicative or
unnecessary procedures or test Providers: Reduced health care cost Improved patient safety by
reducing medication and medical errors Access to valuable clinical data Improved monitoring of
patient movement and disease management State/Government/Public Health: Improved
understanding of clinical needs Access to public health and population health data in a timelier
manner Structure and types of HIE There are currently three main forms of health information
exchange: directed exchange, query

Entry Level Employment In Healthcare Case Study
1. What competencies are needed for entry level employment in healthcare/HIS/HIT?
There are several skills required for entry level employment in healthcare /HIT/HIS, for instance a
background in healthcare such a knowledge of Medical Terminology, Anatomy and Physiology,
Pathophysiology, clinical and administrative procedures along with law and ethics communication.
Although is is important to have a background in healthcare it is also important to have both
computer skills along with a knowledge of healthcare reform. skills such as Microsoft Office,
Electronic Healthcare Recording, billing related practice management, records management and
coding. having a knowledge of health care reform such as HIPPA, HITECH, PPACA, and ICD
coding system. ... Show more content on Helpwriting.net ...
What is SOAP format? Name each section and describe them.
SOAP stands for the format used for the documentation of a patient's medical encounter.
S stands for the subjective section which basically is the description of a patient's condition that is
stated in their own words and includes the pain or discomfort level, the initial time they sense there
was a problem.
O stands for objective which basically anything that can be measured such as a patient's temperature
or pulse, anything that can be seen such as the color, and lastly anything that can be heard or
touched.
A stands for assessment which basically the diagnosis of a patient made by the physician.
P stands for plan and in this section there is the physician or provider' plan of care and contains a
patient's treatment plan and includes a patients laboratory, imaging and radiological test, any further
course of treatment such as referral, follow–up appointments or care along with instructions. 4.
Define medical coding and list and describe the different code sets.
Medical coding is alphanumeric codes that is HIPPA approved for the conversion of healthcare
diagnosis, procedures, medical services, and

Nurse Practitioners: A Case Study
Introduction
The quality of care given by the advanced practice nurse (APN) is been assessed by the employers,
patients, health care auditors, government quality improvement programs, peers, and researchers
(Rhodes, Bechtle, & McNett. 2015). However, good quality is equated by different merits, for
example; to an employer, good performance could be equated with high billings and Medicare may
include a great performance in the Merit–Based Incentive payment system (MIPS) (Rhodes,
Bechtle, & McNett. 2015. There could be some discrepancy with quality performance and cost
measurement since the assessment of performance are not been evaluated equally, therefore setting a
treatment code using a fee for service practice might be helpful (Rhodes, ... Show more content on
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Stanik–Hutt, Newhouse, White, Johantgen, Bass, Wilson, Fountain, Steinwachs, Heindel, & Weiner.
(2013). Documented that "quality is the degree to which health services for individuals and
populations increase the likelihood of attaining desired health outcomes and are consistent with
current professional knowledge" (pg. 492). However, the patient outcomes become the final measure
of quality as they imitate the influence of both structures and process of care (Stanik–Hutt, et al.
2013).
Identification of Performance Measures Used for Nurse Practitioners
The housekeeping forms of performance measurement are common among APN's because of their
experience as opposed to substantive forms, because of good documentation (Buppert, 2018). In
addition, the APN use productivity incentive which was generated from the billing reports.
Eventually, the clinical productivity in the incentive plan was measured by Medical Group
Management Association (MGMA). The performance measure helps to improve overall job
satisfaction, more patient care, and less administrative tasks, increased communication, attendance
at staff meeting, increase in preceptorship, completed annual evaluation, and increase in leadership
activities (Rhodes, Bechtle, & McNett,

Current Procedural Terminology
Current Procedural Terminology (CPT) is the universal standardized language in the medical
industry. Every participant, especially doctors, epidemiologists, coders, payers–insurance
companies, government supporting programs such as Medicaid, Medicare, and other professional
accredited reporting and recording agencies, financial agencies, and analytical agencies use this
coding language to understand exactly what kinds of procedures does certain patient got and what
kind of treatment that person received as well as for accurate reimbursement purpose. Another word,
this is the universal classification of diseases and diagnosis. Each chapter of CPT starts with specific
5–digit code set being described for a specialty. There are three different

The DRG System
DRG determines the payment under Medicare Part A program for acute short–term inpatient
hospital services. DRG systems have changed over the years, it is still used for prospective payment
for the Medicare program for inpatient hospital services. Also, many states now use various forms
for Medicaid programs and commercial insurers. The DRG payment is determined by a combination
of key data elements, the hospitals location where the services are performed and demographics.
The hospital stay is determined by the patients diagnoses, ICD–10–CM codes, any surgical
procedures performed and the age of the patient and discharge status. DRG groupings refers to DRG
codes, patient classification model and key elements determines the number of codes. The
classifications are labeled using groupings referred to as DRG code and the number of codes ...
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The CPT code set is used to describe medical, surgical, and diagnostic services and is designed to
communicate information about procedures with coders, accreditation organizations, and physicians,
patients. The purpose of the codes is for financial, and administrative and analytical purposes. For
example, if a physician performs a total abdominal colectomy Cpt code (44159) should be used.
However, Cpt code (49000) exploratory laparotomy should not be used because it is included with
code (44159) it is incorrect to bill for both. Medicare and Medicaid identify CPT codes as level 1 of
the Healthcare Common Procedure Coding Systems. When using Category II codes the 5th
character is identified by an alphabetical character. The CPT section includes information about
modifiers, measures and the source, there is currently 11 CPT Category II codes. CPT Category III
codes are used for data collection services and procedures. These codes are intended to be used in
the approval process by the Food and Drug Administration

Charge Master In Healthcare: A Case Study
A charge master typically is a file utilized by a large number of providers nationwide for creating
patient charges including the outpatient services and supplies. The primary purpose of a charge
master is to ensure accuracy of the patients' records and analysis of services provided and the billing
information. The Charge Master is unique in that it can directly impact the financial performance
and efficiency of the hospital. Every healthcare facility, for the most part, has its own charge master
to make the charge capture and billing process easier and efficiently. According to Malm (2016), a
charge master consists of five essential components:
1) A unique mnemonic or number –which contains the departmental or general ledger number and

The Importance Of The HIPAA Interactions And Code Set...
The HIPAA transactions and code set standards are certain rules that regulate electronic data
interchange (EDI) of healthcare information, which include patients' identifiable and medical data,
between two or more parties. Under the Health Insurance Portability and Accountability Act of 1996
(HIPAA), if providers or healthcare organizations conduct one of the nine types of electronic
transactions of health–related information, they must adhere to the standards, which include claims
status reporting, claims submission, referral authorization and certification, and benefits
coordination. In addition, HIPAA mandates that all transactions must use standardized medical code
sets, such as CPT codes, Health Care Procedure Coding System (HCPCS), and ICD–10, to ensure
the uniform communications between providers, healthcare organizations, and payers ( American
Medical Association, 2013).
The standards affect all practices because insurance payers and health plans require all paper or
electronically submitted claims must use HIPAA transactions and code set standards to be complied
with HIPAA rules and regulations. The Code Set standards allows any insurance companies to
understand the provided services that providers send in submitted claims. Therefore, the HIPAA
standards assure that payers will promptly respond to electronic claims submission with proper
reimbursements for providers and healthcare organizations with minimal delays. With electronic
transactions, the standards have

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