Healthcare Reimbursement
ABSTRACT
My paper will be discussing medical coding systems: past, present, and future. I will be comparing the International Classification of Diseases 9th Revision Clinical Modification and the International Classification of Diseases 10th Revision Clinical Modification, why the International Classification of Diseases 9th Revision Modification is being changed to the International Classification of Diseases 10th Revision Modification, history and background of medical coding systems, how fraud impacts coding systems in physician’s offices and talking about the effect of coding errors. ICD-10-CM should be easier to find the codes because of all the new codes and distinguishing of different body parts.
CODING FRAUD To understand how fraud impacts coding systems one must understand how medical professionals and health care facilities are reimbursed for their services. In most cases a patient does not pay for a service directly. Most payments to medical professionals and health care facilities are made by a third party payer, whether it is private insurance or a government program like Medicare. “The ICD-9-CM is used by physician’s offices to code and classify morbidity data from medical records, physician offices, and surveys conducted by the National Center for Health Statistics” (Valerius, Bayes, Newby, Seggern, 2012, p. 128). This is the coding process. They billing or coding specialist fills out the coding form to send to the third-party payer (insurance company) so the hospital or physician’s office can be reimbursed for the services rendered.
Coding can be very complicated and can lead to fraud by upcoding, assumption coding, billing invalid/outdated codes, downcoding and various other problems. “Upcoding is the use of a procedure code that provides higher payment” (Valerius, Bayes, Newby, Seggern, 2012, p. 243). Upcoding is very easy to accomplish, and difficult to detect. All a physician has to do is embellish a patient’s diagnosis to justify
My paper will be discussing medical coding systems: past, present, and future. I will be comparing the International Classification of Diseases 9th Revision Clinical Modification and the International Classification of Diseases 10th Revision Clinical Modification, why the International Classification of Diseases 9th Revision Modification is being changed to the International Classification of Diseases 10th Revision Modification, history and background of medical coding systems, how fraud impacts coding systems in physician’s offices and talking about the effect of coding errors. ICD-10-CM should be easier to find the codes because of all the new codes and distinguishing of different body parts.
CODING FRAUD To understand how fraud impacts coding systems one must understand how medical professionals and health care facilities are reimbursed for their services. In most cases a patient does not pay for a service directly. Most payments to medical professionals and health care facilities are made by a third party payer, whether it is private insurance or a government program like Medicare. “The ICD-9-CM is used by physician’s offices to code and classify morbidity data from medical records, physician offices, and surveys conducted by the National Center for Health Statistics” (Valerius, Bayes, Newby, Seggern, 2012, p. 128). This is the coding process. They billing or coding specialist fills out the coding form to send to the third-party payer (insurance company) so the hospital or physician’s office can be reimbursed for the services rendered.
Coding can be very complicated and can lead to fraud by upcoding, assumption coding, billing invalid/outdated codes, downcoding and various other problems. “Upcoding is the use of a procedure code that provides higher payment” (Valerius, Bayes, Newby, Seggern, 2012, p. 243). Upcoding is very easy to accomplish, and difficult to detect. All a physician has to do is embellish a patient’s diagnosis to justify
References: Hazlewood, A. (2003). ICD-9-CM to ICD-10-CM: implementation issues and challenges. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_ 005426.hcsp?dDocName=bok3_005426 History of the development of the ICD, n.d., Retrieved from www.who.int/classifications/icd/en/ history/en/hisotryoficd.pdf Landers, J. (n.d.) The history of medical coding. Retrieved from http://www.ehow.com/print/ about_5581364_history-medical-coding.html Mills, R. E., Butler, R. R., McCullough, E. C., Bao, M. Z., & Averill, R. F. (2011). Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments. Medicare & Medicaid Research Review, 1(2), E1-E13. doi:10.5600/mmrr.001.02.a02 The differences between ICD-9 and ICD-10. (2012, September 25). Retrieved from http://ama-assn.org/amal/pub/upload/mm/399/icd10-icd9-differences-fact-sheet.pdf Valerius, J.D., Bayes, N.L., Newby, C., Seggern, J.B., (2012). Medical insurance an integrated claims process approach. New York, NY: McGraw-Hill