00:00
Depending on what type of health care
provider you are, you may have a different
level of expertise in interaction with
coding and billing for services that are
delivered between the health care
organization and the patient or client
served. Now, no matter what your interaction
is, precision and accuracy
of data reporting is paramount.
00:20
Now coding serves as the language.
00:23
Now, it's the language of health care
services rendered.
00:25
It's a standardized system that assigns
alphanumeric codes to medical
procedures, diagnoses and services.
00:33
Now, these codes ensure clear communication,
accurate documentation
and proper billing for health care services
rendered.
00:41
Coding is also the language that insurance
companies use to organize what gets
paid for and what doesn't.
00:49
Prescribing providers such as physicians,
advanced practice nurses and
physician assistants may be expected to
assign initial codes for services
and then ancillary coding staff will check
and adjust these to maximize reimbursement.
01:04
A solid understanding of medical terminology
is essential
for accurate coding.
01:10
Knowing common prefixes, suffixes and root
words that form the
foundation of medical terms, this knowledge
will help you accurately decipher
documentation and assign appropriate codes
using the various code sets
for different areas of health care, which
typically include these three.
01:30
Current procedural terminology or CPT.
01:35
International Classification of Diseases,
ICD
Codes and Healthcare Common Procedure
Coding System
or the HCPCS.
01:47
Now, CPT codes are used to describe medical
procedures and services.
01:52
ICD codes represent diagnoses, and HCPCS
codes,
cover supplies, equipment and additional
services.
02:01
Each code set has its own guidelines and
updates, so staying up to date is
crucial. Most providers stay current through
participation in continuing education
courses or they work with coding and
billing specialists in their various
settings. Avoiding billing and coding errors
is crucial to prevent
reimbursement violations from insurance
companies and the health care facility in
which you work and the federal government.
02:26
The basics of this process begin when a
provider assigns a code for a service such as
an assessment, treatment or a procedure.
02:33
Now, this code serves as the foundation for
billing.
02:37
Once all the codes are assigned for a
particular patient interaction, they're then
consolidated into a bill which is submitted
to the insurance agency in the form of a
claim. Providers and personnel managing the
coding and billing processes
are held to a very high level of ethical
obligation to be as
accurate and appropriate as possible.
02:58
Even as a beginner, it is important to
familiarize yourself with coding and billing
regulations such as those set by the Centers
for Medicare and Medicaid Services,
CMS and other regulatory bodies.
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Here's an example.
03:13
Advanced care providers like nurse
practitioners and physician assistants may
work alongside a physician provider.
03:20
These interdisciplinary relationships make
coding and billing a bit more
complicated. An NP or PA can perform a
service on their
own as an advanced provider, and sometimes
they perform services incidental to
the care being provided by the physician.
03:37
Depending on which reimbursement codes and
bills are different, an important
technological aspect of this situation is
when the advanced provider holds their own
provider identification number or pin.
03:51
When patient visits are coded and submitted.
03:54
Using this pin number, the provider or
practice is reimbursed at a percentage
of the billable physician rate.
04:00
However, there are nuances to the
reimbursement structure.
04:05
This can depend on whether the advanced
provider performs the care within the same
office or incidental to the care provided by
the physician.
04:13
So, knowing the specific codes and billing
procedures means the office or
providers can ensure maximum reimbursement
for services rendered.
04:22
You may be asking yourself who the big
players are in this world of coding,
billing and reimbursement for services.
04:29
One of the biggest influences on this system
is the Quality Payment program or the
QPP. The Centers for Medicare and Medicaid
Services CMS
sets regulations that promote value-based
care and reimburse healthcare providers
based on the quality of care they deliver.
04:46
The QPP consists of two tracks the
merit-based incentive payment system,
the MIPS and the Advanced Alternative
Payment models or the
APMS. MIPS is a performance-based payment
system that
adjusts Medicare reimbursements based on
four performance categories
quality promoting interoperability,
improvement
activities and cost.
05:11
Now, through this program, healthcare
professionals have the opportunity to earn
incentives for delivering high-quality care,
improving health outcomes
and achieving cost efficiency.
05:23
Advanced alternative payment models.
05:25
APMS are alternative payment models designed
to reward healthcare providers
who take on financial and performance
accountability for patient care.
05:34
In APMS, healthcare providers are
incentivized for delivering
coordinated, high-quality care while
assuming financial risks and meeting
certain performance standards.
05:45
As technology advances, coding, and billing
processes are also
evolving. Digital platforms and electronic
health records.
05:54
Streamline the coding and billing workflow,
which should improve accuracy and
efficiency. The world of coding and billing
in health care may seem
complex, but with a solid understanding of
the fundamentals and
adherence to the evolving regulations,
healthcare professionals can accurately
document services, ensure proper
reimbursement and contribute to the
delivery of high-quality care.