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Select a provider or health care facility coder/biller to interview and review the process they go through to satisfy reimbursement requirements for billing purposes. Write a paper of 750-1,000 words that describes the processes that are utilized in producing a final bill. Include in the paper:
- How health care charging and pricing processes are different from those in other industries.
- How private and government insurers and payers impact actual reimbursement.
- Cite a minimum of three references to support your rationale. Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center. Jessie
- How does charging and pricing process work?
- How does each type of payer (self, third and government) differ?
- How does each type of payer (self, third and government) impact the actual reimbursement?
- How health care charging and pricing processes are different from those in other industries o Other industries have automated processes o Health care requires technology be applied in a patient by patient basis
- How does charging and pricing process work? o Each charge code is associated with a revenue code linking to revenue categories used in the hospitals accounting and billing systems (Pilato, 2014) o Every chargeable item in the hospital must be part of the charge description master (CDM) in order for a hospital to track and bill a patient, payer, or another healthcare provider (Pilato, 2014)
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o For each chargeable procedure, item, or service, the CDM includes a unique item number, technical description, CPT/HCPCS and revenue codes, the assigned price, and several other elements. Multiple subsystems interface with the CDM including radiology, laboratory, respiratory, pharmacy, central supply, and billing (Pilato, 2014) o The CDM’s primary functions are to (Pilato, 2014): ▪ Produce an itemized statement ▪ Assign charges on the inpatient claim
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o Reimbursement from Medicare is a three-step process (Beck & Margolin, 2007): ▪ Appropriate billing coding of the service provided by utilizing current procedural terminology ▪ Appropriate coding of the diagnosis using ICD-9 code
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▪ Centers for Medicare and Medicaid Services (CMS) determination of the appropriate fee based on the resources-based relative value scale (RBRVS) o Prior to 1992, physicians were reimbursed based on “usual, customary, and reasonable charges” (UCR). UCRs were based on the physician's most frequent charge for the service (usual), the average charge for that service in the area (customary), and the actual charge for the service (reasonable) (Beck & Margolin,
▪ Individuals within the federal government, private insurers, and non- procedure-based medical specialties felt that this system perpetuated rising health care costs and inequities in medical care ▪ In response to this, the federal government instituted the Medicare fee schedule, and Medicare implemented the RBRVS in 1992 o Final physician reimbursement by CMS is then multiplied by a geographic practice cost index (GPCI), which is intended to adjust payments for differences in physician practice costs across geographic areas (Beck & Margolin, 2007) o private payers do not have to follow the rules set forth by the federal government (for instance, they often do not recognize surgical modifiers), they find that CPT® is a well-established and familiar system allowing for correct physician coding (Beck & Margolin, 2007) o Private payers in non-capitated contracts often set reimbursement based on a percentage of the Medicare fee schedule (Beck & Margolin, 2007) ▪ Percentage varies by region
- Do the billing rules change for the state or federal agencies? o Billers must ensure that the bill meets the standards of billing compliance o Typically follow guidelines laid out by the Health Insurance Portability and Accountability Act (HIPPA) and the Office of the Inspector General (OIG) (Medical Billing & Coding Certification, 2017)
- Reimbursement involves more than just what you get paid; it is a long, and often convoluted, process that starts when a patient first contacts your office (Beck & Margolin, 2007)
- Current procedural terminology (CPT) was first published by the American Medical Association (AMA) in 1966 with the purpose of helping to standardize terminology among physicians and service as a shorthand that would simplify medical records for physicians and record clerks (Beck & Margolin, 2007)
- Errors in charge and billing o The implications for having inappropriate charges and mismatches affect a hospital’s earnings before interest, depreciation and amortization (EBIDA), cost-to-charge ratios, and outlier payments. For example, assume the organization reports to Medicare 1,000 colonoscopies in one year-500 with biopsy and 500 without. Also assume that within the organization’s chargemaster, the charge for “with biopsy” is $800. However, the charge for colonoscopy “without biopsy” is only $500 (Pilato, 2014) o Three areas of disconnect (Pilato, 2014):
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- Auditing for inaccurate charges is a complex process. This step is usually the responsibility of the clinical department. However, clinical departments only perform half of the review; they do not match charges to coded procedures
- May not understand codes, but simply review a list of daily charges to ensure that all services were charged ▪ CPT procedure descriptions in the chargemaster can be very different from ICD code descriptions
- Auditing inpatient charges is a difficult and labor- intensive process
- Ann M (2016) o Education background: 2 years in HIT o Why did you choose career? Many different directions I could go in and knew I would find a career path in the field that I would ultimately want to follow o Have you ever worked in coding? If so, was it a difficult learning curve when you first started? Yes, it was a pretty difficult learning curve for me, I feel like everything I learned in school didn’t matter, and that’s when I realized I would have been better off going to a practicum at a facility with an HER, that way my first job would not have been my first time using it o Has ICD-10 changed your work any? Actually no. I did not have to use ICD-9 for long, and 3M makes it pretty simple now that I am a pro at using it o To what extent does your workplace use EMR's? I work remotely so everything comes to me in an EHR. There are still some documents that have to be scanned in the HIM department at the
facilities
o What was the most important subject area of health information
that you studied in school? Since I knew I wanted to start off coding, I would say my coding classes. Second would be RCM o How physically demanding is your job? Not physically demanding at all o What are some of the changes that you have seen within the profession since you started? I have not been working in this field long enough to see real changes. I entered right when ICD-10 was getting ready to be used in the US o Where do you see this profession headed? Even more automation on the coding side. Not saying that there won't be a need for coders. I just see the EHRs and coding applications becoming even more integrated at some point o What advice would you give a student wanting to get into this profession? study hard...Find out where you want to start and make yourself as marketable as possible. Be flexible o Best advice I received during my practicum from the HIM
director: work as a coder at some point if you can. Even if you do
not like it and want to move on to something else, the coding experience will be looked upon favorably if you apply for a different HIM/RCM position in the future
- Catherine (2008) o Traveler coder position opened up a whole new range of experiences besides getting to travel and getting paid for it, I
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have also been able to gather experience a lot of different types of coding in big hospitals over 1000 patients and also using different types of encoders and different billing systems which each hospital have different information they want entered o Coding rules and hospital rules differ, need to be flexible at times
- Corrie Alvaraz (2011) o Tell us about your job and the most challenging aspects of the work? ▪ I perform random chart audits; conduct workshops on coding; train new coders; participate in process improvements: evaluate a process to determine if it can be improved upon. We would look at the time a
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▪ Well, I arrive to work at 8:00, as the office opens at this time. I will generally put my coding system in order, and then review the billing statements prepared the day before. I am both a medical biller and a medical coder. Many larger offices will have a separate person for each function, but I work in a smaller office. There are only 4 physicians, so I am able to complete the tasks of both a medical biller and coder
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▪ Next I will check in with each nurse to find out what type of patients we will have this day. This will allow me to get a head start on any research I may need to do regarding coding for specific tasks the doctors or nurses may have performed. Next, I will review all billing before it goes out to the parties responsible for payment to insure they are all correct. By the afternoon, I will have received a number of new physician reports to code.
