Medical coding for reimbursement

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Medical Coding and Billing:

Medical coding is the assigning the codes to the diagnosis, procedures and for supplies. Medical billing is submission of codes to the insurance for payment.

Proper medical coding is must for accurate payment.

Medical Coder has to follow these guidelines

1) NCCI: National Correct Coding Initiative
2) LCD: Local Coverage Determination
3) CPT guidelines
4) AMA guidelines

Guidelines must to be followed. If the guidelines are not followed the claims will not be paid and also leads to the decreased cashflow.

Most of the Medical Billers will do the charge posting and also claim processing with focusing much on the Medical Coding Guidelines. Follow the guidelines is must.

Another important aspect is the Medical Record Documentation. Physician documentation is should be legible and document all the findings. Every page of Medical record should have the patient name. Physician has to sign the document.

Claims are processed either by the electronic submission and paper submission.

For Physician services 837 P is used for the E submission of the clams ( ANSI) and CMS 1500 is for the paper claims submission.

For the services in the hopsital, 837I for E Submission and UB 04 for the paper claims.

Clean claim submission is must. One need to check all the demographics before submission of the claims. Medical necessity need to be established.

Using the lcearing house like Gate way EDI will help a lot for checking the claims errors. Remember, clearing house will checks but not FIX the errors. You need check the errors and resubmit the claims for the payment.

Typically insurance takes 20 days for e submission payments and 30 days for the paper claim submission payments. Payer pays by paper check and/or ERAs.

If the claim is not paid, call the insurance and do the collections. Appeals are many levels.

Instead of working on denials and working with appeals the best way is to do the proper coding and billing so that you can prevent denials.
Following the CMS guidelines is very important. CMS NCCI Guidelines is must to follow. This way of coding and billing will increases the cashflow.

ICD-10 codes implementation brings more opportunities, the number of codes are increasing.

One need to pay more attention to the following for appropriate reimbursement

1. Insurance Verification
2. Authorization
3. Checking the coverage decision
4. Checking the codes compatibility
5. Avoiding the Unbundling
6. Take care of the up-coding and down-coding
7. Follow the guidelines
8. Follow the ICD coding conventions
9. CMS coding guidelines
10. Update your knowledge

Appropriate coding is not only for the reimbursement, but also for the compliance.

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