Basics of Billing and Coding

by Rhonda Lawes, PhD, RN

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    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.

    03:11 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.

    About the Lecture

    The lecture Basics of Billing and Coding by Rhonda Lawes, PhD, RN is from the course Healthcare Informatics.

    Included Quiz Questions

    1. Merit-based Incentive Payment System
    2. Advanced Alternative Payment Models
    3. Quality Care Payment Procedure
    4. Quantitative client payment system
    5. Client milestone payment procedure
    1. A code for the service or procedure performed.
    2. The consolidation of fees from a client encounter.
    3. An insurance claim number.
    4. The health care provider’s identification number.
    1. International Classification of Diseases
    2. Current procedural terminology
    3. Healthcare common procedure coding system
    4. National healthcare diagnosis classification

    Author of lecture Basics of Billing and Coding

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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