tag:blogger.com,1999:blog-57048088487522236202024-02-18T23:29:22.839-05:00Medical Coding And BillingOnline Resource for Medical Coding, Billing Requirements, offers online specialty content for CPT, ICD-9, ICD-10, and HCPCS codes and cross reference guides.Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.comBlogger25125tag:blogger.com,1999:blog-5704808848752223620.post-37091303508156865102012-07-24T11:19:00.002-04:002012-07-24T11:22:16.608-04:00Coding Neoplasms<div style="text-align: center;">
<span style="font-family: Calibri, sans-serif;"><span style="font-size: large;"><b>Neoplasms - The first step in choosing the
correct code.</b></span></span></div>
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<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">The word "neoplasm" is often used interchangeably with the word "cancer" despite this inaccuracy. Neoplasm, which literally means "new growth," is an abnormal mass of tissue, and can be benign (not cancer) or malignant (cancer).</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">Understanding the differences in primary, secondary, in-situ, benign and undetermined behavior neoplasms is the first step in choosing the correct neoplasm code. A primary neoplasm is cancer (malignant), and designates the location (its origin) of where the cancer started. A secondary neoplasm (metastases) is cancer (malignant) that designates where the cancer spread. In-situ is cancer (malignant); however, it is confined to a specific area of origin, such as in the cervix or breast. A benign neoplasm is not cancer and is a localized tumor that has well-differentiated cells that do not metastasize or invade surrounding tissues. Some examples of benign neoplasms include lipoma, adeoma and hemangioma. A neoplasm of undetermined behavior is a diagnosis that can only be utilized if the pathologist notes in his pathology report that the behavior of the tumor is undetermined.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">The general guidelines for neoplasms include first determining if a neoplasm is benign, in-situ, malignant or of uncertain histological behavior. In addition, if the neoplasm is malignant, determination needs to be made if there are any secondary (metastatic) sites involved. </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">The guidelines for neoplasm are divided into nine separate categories to help with assigning the appropriate neoplasm code(s).</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">1. <b>Treatment directed at the malignancy</b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">If the treatment is directed at the malignancy, assign the malignancy code as the principal diagnosis. (An exception to this rule is when the patient is admitted for chemotherapy, radiation therapy or immunotherapy for the malignancy. In this situation, utilize the V58.x code as the principal diagnosis followed by the code for the malignancy.) An example of this would be a patient with sigmoid colon cancer admitted for a colectomy. The principal diagnosis would be the sigmoid colon cancer (primary site), as opposed to the patient being admitted for chemotherapy for the sigmoid colon cancer. In this situation, the chemotherapy code would be used as the principal diagnosis (V58.11), with an additional code for the sigmoid colon cancer.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">2. <b>Treatment directed at the secondary site</b> </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">If a patient is admitted with metastatic cancer, and the treatment is directed toward the secondary (metastatic) site, utilize the metastatic cancer code as the principal diagnosis followed by the primary cancer site (if still present) or a V code for a history of the primary neoplasm. An example of this would be a patient with prostate cancer who is currently undergoing chemotherapy admitted for a severe headache. After an MRI of the brain, it is determined that the patient has metastatic cancer of the brain from his prostate cancer. The principal diagnosis would be the metastatic (secondary) brain cancer and an additional code would be added for the prostate cancer.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">3. <b>Coding and sequencing of complications</b> </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">Anemia is often a result of neoplasms, as well as, therapy directed toward the neoplasm. When a patient is admitted for anemia due to a neoplasm and the treatment is directed toward the anemia, utilize the code 285.22, Anemia due to neoplasm as the principal diagnosis followed by the code for the neoplasm. Anemia due to a neoplasm, 285.22, can also be utilized as a secondary diagnosis if the patient suffers from anemia and is being treated for the malignancy.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted for anemia due to chemotherapy, immunotherapy or radiation therapy, and the treatment is directed at the anemia, the anemia code should be the principal diagnosis. An additional code should be used to capture the neoplasm.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When anemia due to a neoplasm (285.22) and anemia due to chemotherapy (285.3) are both documented on the same encounter, both 285.22 and 285.3 can be coded. If both are documented as the reason for admission, based upon coding guidelines, either can be chosen as the principal diagnosis.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted due to dehydration due to a malignancy or therapy directed at the malignancy, and only the dehydration is being treated, the dehydration is sequenced as the principal diagnosis followed by a code for the malignancy.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted due to complications that resulted from a surgical procedure, code the complication as the principal or first-diagnosis if the treatment is directed toward the complication.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">4. <b>Primary malignancy previously excised</b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a primary neoplasm has been excised and no further treatment (i.e., chemotherapy, immunotherapy, radiation therapy) is being directed toward that neoplasm, and there is no evidence of any existing primary neoplasm, utilize a code from V10.x for a personal history of a malignant neoplasm. Should an extension, metastases or invasion to another site be documented, code a secondary malignancy to that site. The secondary malignancy can be utilized as the principal or first-listed diagnosis followed by a V10.x code for the personal history of a malignancy.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">5. <b>Admission/encounter involving chemotherapy, immunotherapy and radiation therapy</b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted for the administration of chemotherapy, immunotherapy or radiation therapy, the appropriate V58.x code is used as the first-listed or principal diagnosis followed by the code for the neoplasm(s) that is being treated.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted for chemotherapy, immunotherapy or radiation therapy, and develops complications, such as dehydration or uncontrolled nausea and vomiting, code the appropriate V58.x code as the principal diagnosis followed by codes for the complications.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted for the surgical removal of a neoplasm and receives chemotherapy, immunotherapy or radiation therapy after the surgery, the appropriate neoplasm code should be listed as the principal diagnosis.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">6. <b>Admission/encounter to determine extent of malignancy</b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted to determine the extent of a primary or secondary malignancy, the malignancy is coded as the principal diagnosis. </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">7. <b>Symptoms, signs and ill-defined conditions listed in Chapter 16 associated with neoplasms</b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">Should any signs, symptoms or ill-defined conditions listed in Chapter 16 be related with a primary or secondary neoplasm, the neoplasm is listed as the principal diagnosis. </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">8. <b>Admission/encounter for pain control/management</b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted for pain control due to pain related to a neoplasm, utilize the code 338.3 as the principal diagnosis followed by a code for the neoplasm. In addition, 338.3, pain related to neoplasm can be utilized as the principal or a secondary diagnosis dependent on the reason for admission, and is used if the pain is acute or chronic. </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">9. <b>Malignant neoplasm associated with transplanted organ</b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">When a patient is admitted for a malignant neoplasm in a transplanted organ, the principal diagnosis will be a complication of a transplant (996.8x) followed by the code 199.2, malignant neoplasm associated with transplanted organ. Also, utilize a code for the specific neoplasm.</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">To obtain the correct neoplasm code, the coder should carefully read over the documentation, determine the type(s) of neoplasm(s), assess the reason for admission, and then review the coding guidelines. </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">This month's column has been prepared by Meredith McCollum, MBA, RHIA, CCS, ICD-10-CM/PCS AHIMA Certified Trainer, a coding educator with Precyse (www.precyse.com), which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance. Meredith's position is dedicated to providing ICD-9 and ICD-10 education to both internal colleagues, as well as clients based across the United States. She also is an adjunct professor for DeVry University where she not only teaches ICD-9 and ICD-10, but also develops classes for their nationwide Health Information Technology Program. </span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif; font-size: large;"><b>Want to test your knowledge?</b></span><br />
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<span style="font-family: Calibri, sans-serif;"><u><b>Quiz</b> </u></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">1. A patient with small cell carcinoma of the right lower lobe of the lung is admitted for a 7-day treatment of chemotherapy. The chemotherapy is administered, and the patient is discharged. How would this case be coded?</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">2. A 63-year-old male is admitted with a severe headache and backache. The patient has a history of malignant melanoma 6 years prior with no reoccurrence. An MRI is performed of the brain, spinal cord and vertebrae. The scan notes metastatic disease of the brain, spinal cord and the vertebrae. Radiation therapy is administered prior to his discharge. How would this be coded?</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">3. A 7-year-old female with acute lymphocytic leukemia (ALL) is admitted with severe anemia due to her ALL. The patient is transfused two units of packed red blood cells and discharged. What would the codes be for this encounter?</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">4. A 55-year-old male is admitted for pain control due to severe pain related to metastatic bone cancer from a primary lung carcinoma. How is this encounter coded?</span><br />
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<span style="font-family: Calibri, sans-serif;"><b><u>Answers</u></b></span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">1. The chemotherapy code will be listed as the principal diagnosis (V58.11), followed by a code for the neoplasm of the lower lobe of the lung (162.5). In addition, a procedure code for the administration of chemotherapy can be added (99.25).</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">2. The secondary neoplasm code for the brain and spinal cord (198.3) will be the principal diagnosis with additional diagnoses for secondary neoplasm to the vertebra (198.5), and V10.82 for personal history of melanoma of the skin. A procedure for the radiation therapy can also be added (92.29).</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">3. The anemia due to a neoplasm is assigned as the principal diagnosis (285.22) with an additional code for ALL (204.00). In addition, the procedure code for the transfusion of the packed cells can be added (99.04).</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />
<span style="font-family: Calibri, sans-serif;">4. The code for the pain due to a neoplasm (338.3) is used as the principal diagnosis followed by a code for the metastatic bone cancer (198.5) and primary lung cancer (162.9).</span><br />
<span style="font-family: Calibri, sans-serif;"><br /></span><br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com9tag:blogger.com,1999:blog-5704808848752223620.post-81841229401935424842012-07-11T11:43:00.000-04:002012-07-11T11:50:23.855-04:00Glossary Of Medical Billing Terms<br />
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<span style="font-size: x-large;">Medical Billing <span style="background-color: white;">Terms</span></span></div>
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<b>AMA</b> - American Medical Association. The AMA is the largest association of doctors in the United States. They publish the Journal of American Medical <span style="background-color: white;">Association which is one of the most widely circulated medical journals in the world.</span><br />
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<b>Aging</b> - One of the medical billing terms referring to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing <span style="background-color: white;">software's have the ability to generate a separate report for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.</span><br />
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<b>Ancillary Services</b> - These are typically services a patient requires in a hospital setting that are in addition to room and board accommodations - such as surgery, tests, counseling, therapy, etc.<br />
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<b>Appeal</b> - When an insurance plan does not pay for treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurer may require documentation when processing an appeal and typically has a formal policy or process established for submitting an appeal. Many times the<br />
process and associated forms can be found on the insurance providers web site.<br />
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<b>Applied to Deductible</b> - You typically see these medical billing terms on the patient statement. This is the amount of the charges, determined by the patients <span style="background-color: white;">insurance plan, the patient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the insurance provider.</span><br />
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<b>Assignment of Benefits</b> - Insurance payments that are paid to the doctor or hospital for a patients treatment.<br />
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<b>ASP</b> - Application Service Provider. This is a computer based services over a network for a particular application. Sometimes referred to as SaaS (Software <span style="background-color: white;">as a Service). There application service providers that offer Medical Billing. The appeal of an ASP is it frees a business of the the need to purchase, maintain, and backup software and servers.</span><br />
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<b>Beneficiary</b> - Person or persons covered by the health insurance plan.<br />
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<b>Blue Cross Blue Shield (BCBS)</b> - An organization of affiliated insurance companies (approximately 450), independent of the association (and each other), that offer insurance plans within local regions under one or both of the association's brands (Blue Cross or Blue Shield). Many local BCBS associations are non-profit BCBS sometimes acts as administrators of Medicare in many states or regions.<br />
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<b>Capitation</b> - A fixed payment paid per patient enrolled over a defined period of <span style="background-color: white;">time, paid to a health plan or provider. This covers the costs associated with the patients health care services. This payment is not affected by the type or number of services provided.</span><br />
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<b>CHAMPUS</b> - Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. This is federal health insurance for active duty <span style="background-color: white;">military, National Guard and Reserve, retirees, their families, and survivors.</span><br />
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<b>Charity Care</b> - When medical care is provided at no cost or at reduced cost to a patient that cannot afford to pay.<br />
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<b>Clean Claim</b> - Medical billing term for a complete submitted insurance claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.<br />
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<b>Clearinghouse</b> - This is a service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for <span style="background-color: white;">errors. This minimizes the amount of rejected claims as most errors can be easily corrected. Clearinghouses electronically transmit claim information that is </span><span style="background-color: white;">compliant with the strict HIPPA standards (this is one of the medical billing terms we see a lot more of lately).</span><br />
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<b>CMS</b> - Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, HIPPA, and other health programs. Formerly <span style="background-color: white;">known as the HCFA (Health Care Financing Administration). You'll notice that CMS it the source of a lot of medical billing terms.</span><br />
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<b>CMS 1500</b> - Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper <span style="background-color: white;">claims be submitted on CMS-1500's. The form is distinguished by it's red ink.</span><br />
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<b>Coding</b> - Medical Billing Coding involves taking the doctors notes from a patient visit and translating them into the proper ICD-9 code for diagnosis and CPT <span style="background-color: white;">codes for treatment.</span><br />
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<b>COBRA Insurance</b> - This is health insurance coverage available to an individual and their dependents after becoming unemployed - either voluntary or <span style="background-color: white;">involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, It's typically more </span><span style="background-color: white;">expensive than insurance the cost when employed but does benefit from the savings of being part of a group plan. Employers must extend COBRA coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget Reconciliation Act which was passed by Congress in 1986. </span><br />
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COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain conditions extend up to 36 months.<br />
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<b>Co-Insurance</b> - Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%.<br />
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<b>Collection Ratio</b> - This is in reference to the providers accounts receivable. It's the ratio of the payments received to the total amount of money owed on the providers accounts.<br />
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<b>Contractual Adjustment</b> - The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company.<br />
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<b>Coordination of Benefits</b> - When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and <span style="background-color: white;">the other as secondary.</span><br />
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<b>Co-Pay</b> - Amount paid by patient at each visit as defined by the insured plan.<br />
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<b>CPT Code</b> - Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding <span style="background-color: white;">ICD-9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot.</span><br />
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<b>Credentialing</b> - This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. <span style="background-color: white;">CAQH credentialing process is a universal system now accepted by insurance company networks.</span><br />
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<b>Credit Balance</b> - The balance thats shown in the "Balance" or "Amount Due" column of your account statement with a minus sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund.<br />
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<b>Crossover claim</b> - When claim information is automatically sent from Medicare the secondary insurance such as Medicaid.<br />
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<b>Date of Service (DOS)</b> - Date that health care services were provided.<br />
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<b>Day Sheet</b> - Summary of daily patient treatments, charges, and payments received.<br />
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<b>Deductible</b> - amount patient must pay before insurance coverage begins. For example, a patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor's visits or prescriptions to reach the deductible.<br />
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<b>Demographics </b>- Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.<br />
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<b>DME </b>- Durable Medical Equipment - Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.<br />
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<b>DOB </b>- Abbreviation for Date of Birth<br />
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<b>Downcoding </b>- When the insurance company reduces the code (and corresponding amount) of a claim when there is no documentation to support the level of service submitted by the provider. The insurers computer processing system converts the code submitted down to the closest code in use which usually reduces the payment.<br />
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<b>Duplicate Coverage Inquiry (DCI) </b>- Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other <span style="background-color: white;">coverage exists.</span><br />
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<b>Dx</b> - Abbreviation for diagnosis code (ICD-9 or ICD-10 code).<br />
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<b>Electronic Claim</b> - Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format as defined by the receiver.<br />
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<b>Electronic Funds Transfer (EFT)</b> - An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a <span style="background-color: white;">bank account and eliminates the need for paper checks.</span><br />
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<b>E/M</b> - Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a <span style="background-color: white;">patients treatment needs.</span><br />
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<b>EMR</b> - Electronic Medical Records. This is a medical record in digital format of a patients hospital or provider treatment.<br />
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<b>Enrollee</b> - Individual covered by health insurance.<br />
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<b>EOB</b> - Explanation of Benefits. One of the medical billing terms for the statement that comes with the insurance company payment to the provider explaining <span style="background-color: white;">payment details, covered charges, write offs, and patient responsibilities and deductibles.</span><br />
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<b>ERA</b> - Electronic Remittance Advice. This is an electronic version of an insurance EOB that provides details of insurance claim payments. These are formatted in according to the HIPAA X12N 835 standard.<br />
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<b>ERISA</b> - Employee Retirement Income Security Act of 1974. This law established the reporting, disclosure of grievances, and appeals requirements and financial <span style="background-color: white;">standards for group life and health. Self-insured plans are regulated by this law.</span><br />
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<b>Fee For Service</b> - Insurance where the provider is paid for each service or procedure provided. Typically allows patient to choose provider and hospital. <span style="background-color: white;">Some policies require the patient to pay provider directly for services and submit a claim to the carrier for reimbursement. The trade-off for this flexibility is usually higher deductibles and co-pays.</span><br />
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<b>Fee Schedule</b> - Cost associated with each treatment CPT medical billing codes.<br />
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<b>Financial Responsibility</b> - The portion of the charges that are the responsibility of the patient or insured.<br />
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<b>Fiscal Intermediary (FI)</b> - A Medicare representative who processes Medicare claims.<br />
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<b>Formulary</b> - A list of prescription drug costs which an insurance company will provide reimbursement for.<br />
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<b>Fraud</b> - When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.<br />
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<b>GPH</b> - Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees (or former employees).<br />
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<b>Group Name</b> - Name of the group or insurance plan that insures the patient.<br />
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<b>Group Number</b> - Number assigned by insurance company to identify the group under which a patient is insured.<br />
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<b>Guarantor</b> - A responsible party and/or insured party who is not a patient.<br />
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<b>HCFA</b> - Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).<br />
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<b>HCPCS</b> - Health Care Financing Administration Common Procedure Coding System. (pronounced "hick-picks"). Three level system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided when delivering health services. May also be referred to as a<br />
procedure code in the medical billing glossary.<br />
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The three HCPCS levels are:<br />
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<ul>
<li><span style="background-color: white;">Level I - American Medical Associations Current Procedural Terminology </span><span style="background-color: white;">(CPT) codes.</span></li>
<li><span style="background-color: white;">Level II - The alphanumeric codes which include mostly non-physician </span><span style="background-color: white;">items or services such as medical supplies, ambulatory services, </span><span style="background-color: white;">prosthesis, etc. These are items and services not covered by CPT (Level </span><span style="background-color: white;">I) procedures.</span></li>
<li><span style="background-color: white;">Level III - Local codes used by state Medicaid organizations, Medicare </span><span style="background-color: white;">contractors, and private insurers for specific areas or programs.</span></li>
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<b>Healthcare Insurance</b> - Insurance coverage to cover the cost of medical care necessary as a result of illness or injury. May be an individual policy or family <span style="background-color: white;">policy which covers the beneficiary's family members. May include coverage for disability or accidental death or dismemberment.</span></div>
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<b>Heathcare Provider</b> - Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to be confused with insurance <span style="background-color: white;">providers or the organization that provides insurance coverage.</span></div>
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<b>Health Care Reform Act</b> - Health care legislation championed by President Obama in 2010 to provide improved individual health care insurance or national <span style="background-color: white;">health care insurance for Americans. Also referred to as the Health Care Reform Bill or the Obama Health Care Plan.</span></div>
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<b>HIC</b> - Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them as a Medicare beneficiary. <span style="background-color: white;">This unique number is used when processing Medicare claims.</span></div>
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<b>HIPAA</b> - Health Insurance Portability and Accountability Act. Several federal regulations intended to improve the efficiency and effectiveness of health care. <span style="background-color: white;">HIPAA has introduced a lot of new medical billing terms into our vocabulary lately.</span></div>
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<b>HMO</b> - Health Maintenance Organization. A type of health care plan that places restrictions on treatments.</div>
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<b>Hospice</b> - Inpatient, outpatient, or home healthcare for terminally ill patients.</div>
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<b>ICD-9 Code</b> - Also know as ICD-9-CM. International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number.</div>
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<b>ICD 10 Code</b> - 10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October, 2013 for ICD-10.</div>
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<b>Incremental Nursing Charge</b> - Charges for hospital nursing services in addition to basic room and board.</div>
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<b>Indemnity</b> - Also referred to as fee-for-service. This is a type of commercial insurance were the patient can use any provider or hospital.</div>
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<b>In-Network (or Participating)</b> - An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for <span style="background-color: white;">procedures.</span></div>
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<b>Inpatient</b> - Hospital stay of more than one day (24 hours).</div>
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<b>IPA</b> - Independent Practice Association. An organization of physicians that are contracted with a HMO plan.</div>
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<b>Intensive Care</b> - Hospital care unit providing care for patients who need more than the typical general medical or surgical area of the hospital can provide. <span style="background-color: white;">May be extremely ill or seriously injured and require closer observation and/or frequent medical attention.</span></div>
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<b>MAC</b> - Medicare Administrative Contractor. Contractors who process Medicare claims.</div>
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<b>Managed Care Plan</b> - Insurance plan requiring patient to see doctors and hospitals that are contracted with the managed care insurance company. Medical <span style="background-color: white;">emergencies or urgent care are exceptions when out of the managed care plan service area.</span></div>
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<b>Maximum Out of Pocket</b> - The maximum amount the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, <span style="background-color: white;">the insurance typically then pays 100% of eligible expenses.</span></div>
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<b>Medical Assistant</b> - A health care worker who performs administrative and clinical duties in support of a licensed health care provider such as a physician, <span style="background-color: white;">physicians assistant, nurse, nurse practitioner, etc.</span></div>
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<b>Medical Coder</b> - Analyzes patient charts and assigns the appropriate code. These codes are derived from ICD-9 codes (soon to be ICD-10) and corresponding CPT treatment codes and any related CPT modifiers.</div>
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<b>Medical Billing Specialist</b> - Processes insurance claims for payment of services performed by a physician or other health care provider. Ensures patient medical billing codes, diagnosis, and insurance information are entered correctly and submitted to insurance payer. Enters insurance payment information and</div>
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processes patient statements and payments. Performs tasks vital to the financial operation of a practice. Knowledgeable in medical billing terminology.</div>
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<b>Medical Necessity</b> - Medical service or procedure that is performed on for treatment of an illness or injury that is not considered investigational, cosmetic, or experimental.</div>
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<b>Medical Record Number</b> - A unique number assigned by the provider or health care facility to identify the patient medical record.</div>
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<b>MSP</b> - Medicare Secondary Payer.</div>
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<b>Medical Savings Account</b> - Tax exempt account for paying medical expenses administered by a third party to reimburse a patient for eligible health care expenses. Typically provided by employer where the employee contributes regularly to the account before taxes and submits claims or receipts for reimbursement. Sometimes also referred to in medical billing terminology as a Medical Spending Account.</div>
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<b>Medical Transcription</b> - The conversion of voice recorded or hand written medical information dictated by health care professionals (such as physicians) <span style="background-color: white;">into text format records. These records can be either electronic or paper.</span></div>
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<b>Medicare</b> - Insurance provided by federal government for people over 65 or people under 65 with certain restrictions. </div>
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There are 2 parts:</div>
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<ul>
<li><span style="background-color: white;">Medicare Part A - Hospital coverage</span></li>
<li><span style="background-color: white;">Medicare Part B - Physicians visits and outpatient procedures</span></li>
<li><span style="background-color: white;">Medicare Part D - Medicare insurance for prescription drug costs for anyone enrolled in Medicare Part A or B.</span></li>
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<b>Medicare Coinsurance Days</b> - Medical billing terminology for inpatient hospital coverage from day 61 to day 90 of a continuous hospitalization. The patient is <span style="background-color: white;">responsible for paying for part of the costs during those days. After the 90th day, the patient enters "Lifetime Reserve Days."</span></div>
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<b>Medicare Donut Hole</b> - The gap or difference between the initial limits of insurance and the catastrophic Medicare Part D coverage limits for prescription <span style="background-color: white;">drugs.</span></div>
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<b>Medicaid</b> - Insurance coverage for low income patients. Funded by Federal and state government and administered by states.</div>
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<b>Medigap</b> - Medicare supplemental health insurance for Medicare beneficiaries which may include payment of Medicare deductibles, co-insurance and balance <span style="background-color: white;">bills, or other services not covered by Medicare.</span></div>
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<b>Modifier</b> - Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or "modified" in some way. Modifiers are important to explain additional procedures and obtain <span style="background-color: white;">reimbursement for them.</span></div>
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<b>N/C</b> - Non-Covered Charge. A procedure not covered by the patients health insurance plan.</div>
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<b>NEC</b> - Not Elsewhere Classifiable. Medical billing terminology used in ICD when information needed to code the term in a more specific category is not available.</div>
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<b>Network Provider</b> - Health care provider who is contracted with an insurance provider to provide care at a negotiated cost.</div>
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<b>Nonparticipation</b> - When a healthcare provider chooses not to accept Medicareapproved payment amounts as payment in full.</div>
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<b>NOS</b> - Not Otherwise Specified. Used in ICD for unspecified diagnosis.</div>
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<b>NPI Number</b> - National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through theNational Plan and Provider <span style="background-color: white;">Enumeration System (NPPES).</span></div>
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<b>OIG</b> - Office of Inspector General - Part of department of Health and Human Services. Establish compliance requirements to combat healthcare fraud <span style="background-color: white;">and abuse. Has guidelines for billing services and individual and small group physician practices.</span></div>
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<b>Out-of Network (or Non-Participating)</b> - A provider that does not have a contract with the insurance carrier. Patients usually responsible for a greater <span style="background-color: white;">portion of the charges or may have to pay all the charges for using an out-of network provider.</span></div>
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<b>Out-Of-Pocket Maximum</b> - The maximum amount the patient has to pay under their insurance policy. Anything above this limit is the insurers obligation. These <span style="background-color: white;">Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions.</span></div>
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<b>Outpatient</b> - Typically treatment in a physicians office, clinic, or day surgery facility lasting less than one day.</div>
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<b>Palmetto GBA</b> - An administrator of Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) in the US and its territories. A wholly <span style="background-color: white;">owned subsidiary of BlueCross BlueShield of South Carolina based in Columbia, South Carolina.</span></div>
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<b>Patient Responsibility</b> - The amount a patient is responsible for paying that is not covered by the insurance plan.</div>
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<b>PCP </b>- Primary Care Physician - Usually the physician who provides initial care and coordinates additional care if necessary.</div>
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<b>POS </b>- Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom <span style="background-color: white;">to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance.</span></div>
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<b>POS (Used on Claims)</b> - Place of Service. Medical billing terminology used on medical insurance claims - such as the CMS 1500 block 24B. A two digit code <span style="background-color: white;">which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.</span></div>
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<b>PPO </b>- Preferred Provider Organization. Commercial insurance plan where the patient can use any doctor or hospital within the network. Similar to an HMO.</div>
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<b>Practice Management Software</b> - software used for the daily operations of a providers office. Typically used for appointment scheduling and billing.</div>
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<b>Preauthorization </b>- Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as <span style="background-color: white;">outpatient surgery) for those procedures to be considered a covered expense.</span></div>
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<b>Pre-Certification</b> - Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn't <span style="background-color: white;">guarantee the benefits will be paid.</span></div>
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<b>Predetermination </b>- Maximum payment insurance will pay towards surgery, consultation, or other medical care - determined before treatment.</div>
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<b>Pre-existing Condition (PEC)</b> - A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months).</div>
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<b>Pre-existing Condition Exclusion</b> - When insurance coverage is denied for the insured when a pre-existing medical condition existed when the health plan <span style="background-color: white;">coverage became effective.</span></div>
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<b>Premium </b>- The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage.</div>
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<b>Privacy Rule</b> - The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). <span style="background-color: white;">PHI is any information on a patient about the status of their health, treatment, or payments.</span></div>
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<b>Provider </b>- Physician or medical care facility (hospital) who provides health care services.</div>
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<b>PTAN </b>- Provider Transaction Access Number. Also known as the legacy Medicare number.</div>
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<b>Referral </b>- When one provider (usually a family doctor) refers a patient to another provider (typically a specialist).</div>
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<b>Remittance Advice (R/A)</b> - A document supplied by the insurance payer with information on claims submitted for payment. Contains explanations for rejected <span style="background-color: white;">or denied claims. Also referred to as an EOB (Explanation of Benefits).</span></div>
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<b>Responsible Party</b> - The person responsible for paying a patients medical bill. Also referred to as the guarantor.</div>
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<b>Scrubbing </b>- Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer.</div>
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<b>Self-Referral</b> - When a patient sees a specialist without a primary physician referral.</div>
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<b>Self Pay </b>- Payment made at the time of service by the patient.</div>
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<b>Secondary Insurance Claim</b> - claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.</div>
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<b>Secondary Procedure</b> - When a second CPT procedure is performed during the same physician visit as the primary procedure.</div>
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<b>Security Standard</b> - Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a sub-set or compliment to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI.</div>
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<b>Skilled Nursing Facility</b> - A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care.</div>
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<b>SOF </b>- Signature on File.</div>
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<b>Software As A Service (SAAS)</b> - One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS <span style="background-color: white;">relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS.</span></div>
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<b>Specialist </b>- Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some heathcare plans require <span style="background-color: white;">beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist.</span></div>
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<b>Subscriber </b>- Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder.</div>
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<b>Superbill </b>- One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes <span style="background-color: white;">several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.</span></div>
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<b>Supplemental Insurance</b> - Additional insurance policy that covers claims fro deductibles and coinsurance. Frequently used to cover these expenses not <span style="background-color: white;">covered by Medicare.</span></div>
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<b>TAR </b>- Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services <span style="background-color: white;">rendered.</span></div>
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<b>Taxonomy Code</b> - Specialty standard codes used to indicate a providers specialty sometimes required to process a claim. </div>
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<b>Term Date</b> - Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible.</div>
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<b>Tertiary Insurance Claim</b> - Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage <span style="background-color: white;">the primary and secondary insurance may not cover.</span></div>
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<b>Third Party Administrator (TPA)</b> - An independent corporate entity or person (third party) who administers group benefits, claims and administration for a selfinsured company or group.</div>
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<b>TIN </b>- Tax Identification Number. Also known as Employer Identification Number (EIN).</div>
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<b>TOP </b>- Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan.</div>
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<b>TOS </b>- Type of Service. Description of the category of service performed.</div>
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<b>TRICARE </b>- This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as <span style="background-color: white;">CHAMPUS.</span></div>
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<b>UB04 </b>- Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.</div>
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<b>Unbundling </b>- Submitting several CPT treatment codes when only one code is necessary.</div>
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<b>Untimely Submission</b> - Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied.</div>
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<b>Upcoding </b>- An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the <span style="background-color: white;">reimbursement from the insurance payor. </span></div>
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<b>UPIN </b>- Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number.</div>
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<b>Usual Customary & Reasonable(UCR)</b> - The allowable coverage limits (fee schedule) determined by the patients insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient.</div>
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<b>Utilization Limit</b> - The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim can be denied if the <span style="background-color: white;">services exceed this limit.</span></div>
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<b>Utilization Review (UR)</b> - Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures.</div>
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<b>V-Codes</b> - ICD-9-CM coding classification to identify health care for reasons other than injury or illness.</div>
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<b>Workers Comp</b> - Insurance claim that results from a work related injury or illness.</div>
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<b>Write-off</b> - Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as "not covered" in some glossary of billing terms.</div>
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<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-45694955267531918492012-07-06T09:23:00.004-04:002012-07-06T09:51:50.885-04:00Continuing Education Unit Guidelines and Information<div style="text-align: center;">
<span style="background-color: white; font-size: x-large;">Continuing Education Unit (CEU) <br />Guidelines and Information</span></div>
<div style="text-align: left;">
<span style="background-color: white;"><div>
<b><u>Definition of CEU</u></b></div>
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One CEU = ten contact hours of participation in organized continuing education/training experience under responsible, qualified direction and instruction.</div>
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<b><u>Definition of Contact Hour</u></b></div>
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One contact hour = one 60 minute clock hour of interaction between learner and instructor or between learner and materials which have been prepared to bring about learning.</div>
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<b>Please Note:</b> Contact implies a connection between a learner and a learning source. For the purpose of the CEU, that connection is two-way. The instructor or learning source must monitor the learner’s progress and provide some form of feedback to the learner. This definition and requirement apply to face-to-face interaction as well as distance learning programs.</div>
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<b><u>Minimum Hours</u></b></div>
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NSGC does not grant CEUs for learning programs that are less than a total of one hour in length. Sessions within a learning program may be of any length.</div>
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<u><b>Calculation of Contact Hours for Distance Education/Training and Other Alternative Delivery Methods</b></u></div>
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<span style="background-color: white;">Self-paced programs include learning programs in which learners progress at their own pace. Program developers should establish a standard number of contact hours based on an average number of hours required by several representative learners to complete the program. Program developers desiring to introduce a new self-paced learning program might select a representative sample from the intended audience – the larger the audience, the better – to complete the </span><span style="background-color: white;">learning program. Each member of the sample records the actual amount of time spent completing the learning program. The number of hours spent by all members of the sample is totaled, averaged, and divided by the number of representatives in the sample. Please note that NSGC requires a minimum of 3 learners to be considered a representative sample. Program developers should continue to monitor the amount of time it takes learners to complete the learning program. The standard should be adjusted, if necessary. This continuing validation provides credibility to the NSGC’s established standards.</span></div>
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<span style="background-color: white;"><br /></span></div>
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<span style="background-color: white;"><div>
<b><u>What CAN be Counted</u></b></div>
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The following learning activities are examples of types of activities to include when calculating</div>
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contact hours for CEUs:</div>
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<ul>
<li><span style="background-color: white;">classroom or meeting session time led by instructor and/or discussion leader;</span></li>
<li><span style="background-color: white;">activities in which a learner is engaged in a planned learning program in which the </span><span style="background-color: white;">learner’s progress is monitored and the learner receives feedback. (Examples include, </span><span style="background-color: white;">but are not limited to, independent study, computer-assisted instruction, interactive video, </span><span style="background-color: white;">web site learning, and planned projects.)</span></li>
<li><span style="background-color: white;">projects and assignments which are an integral part of a learning program; and/or</span></li>
<li><span style="background-color: white;">learner assessment and learning program evaluations</span></li>
</ul>
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</span></div>
</span></div>
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<b><u>What CANNOT be Counted</u></b><br />
While unplanned and unsupervised activities may produce worthy learning and are occasionally <span style="background-color: white;">recognized by other the professions and licensing boards, they do not meet NSGC’s </span><span style="background-color: white;">requirements for CEUs.</span><br />
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The following activities do not qualify for CEUs:<br />
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<ul>
<li><span style="background-color: white;">Academic credit courses</span></li>
<li><span style="background-color: white;">Association membership and leadership activities</span></li>
<li><span style="background-color: white;">Committee meetings.</span></li>
<li><span style="background-color: white;">Entertainment and recreation</span></li>
<li><span style="background-color: white;">Individual scholarships</span></li>
<li><span style="background-color: white;">Mass media learning programs (i.e., through television, radio, newspaper)</span></li>
</ul>
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Specific activities that promote professional development may meet the requirements for <span style="background-color: white;">Professional Activity Credits (PACs) as defined by the American Board of Genetic Counseling </span><span style="background-color: white;">(ABGC).</span></div>
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<span style="background-color: white;"><br /></span></div>
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<span style="background-color: white;"><div>
<b><u>Guidelines</u></b></div>
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NSGC requires that learning source/sponsoring organizations adhere to the following guidelines <span style="background-color: white;">when planning activities that will be submitted for CEU approval.</span></div>
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<span style="background-color: white;"><br /></span></div>
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<b><i><span style="background-color: white;">System for Awarding CEUs: The provider must have a system in place to identify learners </span><span style="background-color: white;">who meet requirements for satisfactory completion.</span></i></b></div>
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<ul>
<li><span style="background-color: white;">Satisfactory completion requirements are established prior to the beginning of the </span><span style="background-color: white;">learning program.</span></li>
<li><span style="background-color: white;">Requirements for performance levels are based on the intended learning outcomes.</span></li>
<li><span style="background-color: white;">For conferences and live events, NSGC requires that attendance within a given session </span><span style="background-color: white;">be part of the satisfactory completion requirements.</span></li>
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<li><span style="background-color: white;">Attendance requirements should be set high and documented on rosters, sign-in </span><span style="background-color: white;">sheets, self-report forms, or other methods for tracking attendance.</span></li>
</ul>
<li><span style="background-color: white;">Learners are informed of satisfactory completion requirements prior to their participation </span><span style="background-color: white;">in the learning program and are informed that only those who meet the requirements will </span><span style="background-color: white;">earn CEUs.</span></li>
<li><span style="background-color: white;">Whether each learner has (or has not) met the specified requirements for satisfactory </span><span style="background-color: white;">completion and is (or is not) awarded CEUs Is verified.</span></li>
<li><span style="background-color: white;">The criteria for successful completion are compatible with the learning outcomes of each </span><span style="background-color: white;">learning program.</span></li>
<li><span style="background-color: white;">When partial credit is awarded to learners who do not attend the entire learning program, </span><span style="background-color: white;">the provider has a system to track, calculate, and award variable credit.</span></li>
</ul>
</div>
<div>
<b style="background-color: white;"><i>Learning Environment and Support Systems:</i></b><span style="background-color: white;"> </span><b style="background-color: white;">Learning environment and support services,</b></div>
<div>
<b>appropriate to the continuing education or training goals and learning outcomes, are </b><b style="background-color: white;">provided</b><span style="background-color: white;">.</span></div>
<div>
<ul>
<li><span style="background-color: white;">The design and use of facilities should facilitate teaching and learning. For example, </span><span style="background-color: white;">lighting, sound, seating, visuals, reference materials, and other needed resources should </span><span style="background-color: white;">be appropriate and available to enhance learning.</span></li>
<li><span style="background-color: white;">In distance learning formats, such as correspondence study and computer-assisted </span><span style="background-color: white;">instruction, the instructor or learning source may not be able to control the learning </span><span style="background-color: white;">environment. In such cases, the instructor or learning source should include ways to </span><span style="background-color: white;">support learners and facilitate learning in the planning process.</span></li>
<li><span style="background-color: white;">The instructor or learning source makes available convenient, efficient, and responsive </span><span style="background-color: white;">learner support services (e.g., scheduling, registration, technical support, advising, and </span><span style="background-color: white;">counseling, etc.) appropriate and sufficient for the ongoing success of the learning </span><span style="background-color: white;">program</span></li>
</ul>
<div>
<div>
<b><i>Planning and Instructional Personnel: Qualified personnel are involved in planning and conducting each learning program.</i></b></div>
<div>
<ul>
<li><span style="background-color: white;">Qualified individuals must be directly involved in determining the learning program purpose, and planning, designing, developing, conducting, and evaluating each learning experience.</span></li>
<li><span style="background-color: white;">The quality of a continuing education program and its value to the learner rests heavily on the competence of the planners and the instructor(s) in the subject matter, and their ability to communicate and facilitate learning. It is the joint responsibility of the learning source, the planner(s), and the instructor(s) to ensure that the learning experience results in the learners achieving the learning outcomes.</span></li>
<li><span style="background-color: white;">NSGC defines “qualified personnel” as those who:</span></li>
<ul>
<li><span style="background-color: white;">Are competent in the subject matter;</span></li>
<li><span style="background-color: white;">Understand the learning program’s purpose and learning outcomes; and</span></li>
<li><span style="background-color: white;">Have knowledge and skill in instructional methods and learning processes</span></li>
</ul>
<li><span style="background-color: white;">NSGC requires that short biographical sketches and/or CVs for instructors and planning personnel be provided at the time an application is submitted for CEU approval.</span></li>
<li><span style="background-color: white;">Instructors should demonstrate high standards of professional conduct and should not discriminate against learners on the basis of gender, age, socioeconomic or ethnic background, sexual orientation, or disability.</span></li>
<li><span style="background-color: white;">Individuals who participate in a continuing education/training program have the right to </span><span style="background-color: white;">know of any commercial interest an instructor may have in a product or service mentioned during a program. Therefore, NSGC requires that the learning source </span><span style="background-color: white;">disclose each instructor's proprietary interest in any product instrument, device, service, or materials discussed in the program, as well as the source of any compensation related to the presentation.</span></li>
<ul>
<li><span style="background-color: white;">NSGC recommends that learning sources and planning personnel require instructors to complete a Conflict of Interest agreement at the time they are </span><span style="background-color: white;">selected/contracted to present.</span></li>
<li><span style="background-color: white;">This information must be made available to the learners prior to the program and may be conveyed through promotional materials, a written handout, or an </span><span style="background-color: white;">announcement prior to the commencement of the training. Disclosure statements are not necessary if there is no commercial interest.</span></li>
</ul>
<li><span style="background-color: white;">The learning source/sponsoring organization must provide completed Conflict of Interest agreements to NSGC at the time an application is submitted for CEU approval.</span></li>
<li><span style="background-color: white;">Instructors should be provided feedback on their performance.</span></li>
</ul>
<div>
<div>
<b>Learning Outcomes: <i>The instructor or learning source has clear and concise written <span style="background-color: white;">statements of intended learning outcomes, commonly referred to as participant behavioral </span><span style="background-color: white;">or performance objectives, based on identified needs for each continuing education and </span><span style="background-color: white;">training learning program.</span></i></b></div>
<div>
<ul>
<li><span style="background-color: white;">The learning outcomes (performance objectives):</span></li>
<ul>
<li><span style="background-color: white;">Provide a framework for learning program planning;</span></li>
<li><span style="background-color: white;">Are the basis for selection of content and instructional strategies;</span></li>
<li><span style="background-color: white;">Describe to learners exactly what knowledge, skills, and/or attitudes they are </span><span style="background-color: white;">expected to accomplish/demonstrate as a result of the learning program;</span></li>
<li><span style="background-color: white;">Are the basis for providing periodic feedback, measuring progress, and final </span><span style="background-color: white;">assessment of learning.</span></li>
</ul>
<li><span style="background-color: white;">The learning outcomes (performance objectives) must be clear, concise, and </span><span style="background-color: white;">measurable.</span></li>
<ul>
<li><span style="background-color: white;">NSGC recommends using the suggested list of behavioral verbs when </span><span style="background-color: white;">developing learning outcomes (performance objectives).</span></li>
<li><span style="background-color: white;">Each learning outcome (performance objective) should contain no more than one </span><span style="background-color: white;">behavioral verb.</span></li>
</ul>
<li><span style="background-color: white;">For large events such as conferences or conventions:</span></li>
<ul>
<li><span style="background-color: white;">Overall learning outcomes must be established</span></li>
<li><span style="background-color: white;">Each session within the event must have its own learning outcomes </span><span style="background-color: white;">(performance objectives) or be keyed to one or more of the overall program </span><span style="background-color: white;">outcomes.</span></li>
</ul>
<li><span style="background-color: white;">The number of planned outcomes is appropriate for the learning program.</span></li>
<ul>
<li><span style="background-color: white;">For conferences or conventions, NSGC requires a minimum of three overall </span><span style="background-color: white;">learning outcomes</span></li>
<li><span style="background-color: white;">For individual sessions or smaller activities NSGC recommends a minimum of </span><span style="background-color: white;">two learning outcomes (performance objectives) be established per sixty minutes </span><span style="background-color: white;">of educational content</span></li>
</ul>
<li><span style="background-color: white;">Learners should be informed of these intended learning outcomes (performance </span><span style="background-color: white;">objectives) prior to and during the learning program.</span></li>
</ul>
<div>
<div>
<b><i>Content and Instructional Methods: Content and instructional methods are appropriate for <span style="background-color: white;">the learning outcomes of each learning program and provide opportunities for learners to </span><span style="background-color: white;">participate and receive feedback.</span></i></b></div>
<div>
<ul>
<li><span style="background-color: white;">Subject matter and content are directly related to learning outcomes. NSGC requires that </span><span style="background-color: white;">learning sources/sponsoring organizations track this relation by completing an </span><span style="background-color: white;">Educational Activity Overview form.</span></li>
<li><span style="background-color: white;">Content should be organized in a logical manner, proceeding from basic to advanced </span><span style="background-color: white;">levels.</span></li>
<li><span style="background-color: white;">Instructional methods are consistent with learning outcomes regardless of delivery </span><span style="background-color: white;">method.</span></li>
<li><span style="background-color: white;">Instructional methods accommodate various learning styles.</span></li>
<li><span style="background-color: white;">Learning experiences should be designed to promote relevant interaction between </span><span style="background-color: white;">learner and learning resources to achieve the stated learning outcomes</span></li>
</ul>
<div>
<div>
<b><i>Assessment of Learning Outcomes: Formal processes or procedures established during </i></b><span style="background-color: white;"><b><i>program planning are used to assess achievement of the learning outcomes.</i></b> </span></div>
<div>
<ul>
<li><span style="background-color: white;">In every learning program for which CEUs are awarded, the learning source/sponsoring </span><span style="background-color: white;">organization must require learners to demonstrate that they have attained the learning </span><span style="background-color: white;">outcomes</span></li>
<li><span style="background-color: white;">Assessments may take diverse forms, such as performance demonstrations under real or </span><span style="background-color: white;">simulated conditions, written or oral examinations, written reports, completion of a </span><span style="background-color: white;">project, self-assessment, or locally or externally developed standardized examinations.</span></li>
<ul>
<li><span style="background-color: white;">NSGC recommends utilizing self-assessment tools for conferences or live </span><span style="background-color: white;">programs and the sessions contained within the conference. Please click here to </span><span style="background-color: white;">see a sample self-assessment form.</span></li>
<li><span style="background-color: white;">NSGC recommends using multiple choice examinations for distance learning </span><span style="background-color: white;">programs.</span></li>
<ul>
<li><span style="background-color: white;">A passing score of 80% or higher should be required.</span></li>
<li><span style="background-color: white;">NSGC recommends including approximately 5-7 questions per sixty </span><span style="background-color: white;">minutes of educational content.</span></li>
</ul>
<li><span style="background-color: white;">The way that learners will demonstrate their attainment of the outcomes should </span><span style="background-color: white;">be an integral part of the program planning</span></li>
<li><span style="background-color: white;">Assessments may be made at the conclusion of the learning program, or after </span><span style="background-color: white;">some elapsed time following the learning experience.</span></li>
</ul>
<li><span style="background-color: white;">Learners must be informed in advance that learning outcomes will be assessed.</span></li>
</ul>
<div>
<div>
Post-Program Evaluation: Each learning program is evaluated.</div>
<div>
Program evaluation is a measurement of the quality, or determination of the worth, of the <span style="background-color: white;">learning program as a whole, examining all parts of the planning and delivery process.</span></div>
<div>
<ul>
<li><span style="background-color: white;">The evaluation process should examine the needs assessment, logistical and </span><span style="background-color: white;">instructional planning and execution, selection and preparation of instructors, operations, </span><span style="background-color: white;">and the extent to which learning outcomes were achieved.</span></li>
<li><span style="background-color: white;">The evaluation process should ask the following questions (amongst others determined </span><span style="background-color: white;">by the learning source/sponsoring organization):</span></li>
<ul>
<li><span style="background-color: white;">Did the learning experience and the instructional methods used accomplish the </span><span style="background-color: white;">learning outcomes?</span></li>
<li><span style="background-color: white;">Did the learners indicate that the learning outcomes were appropriate for the </span><span style="background-color: white;">stated program purpose and for the learners involved?</span></li>
<li><span style="background-color: white;">Was learning program execution effective and efficient?</span></li>
<li><span style="background-color: white;">Distance learning programs should be evaluated periodically by comparing the </span><span style="background-color: white;">degree of learner achievement to the intended learning outcomes, by assessing </span><span style="background-color: white;">the appropriateness and effectiveness of the technology used, and by </span><span style="background-color: white;">determining the cost effectiveness of the program</span></li>
</ul>
<li><span style="background-color: white;">Evaluation results are incorporated into learning program improvements.</span></li>
</ul>
<div>
<div>
<b><u>Submitting Your Program for CEU Approval</u></b></div>
<div>
For consideration of Continuing Education Units (CEUs) for genetic counselors, please complete <span style="background-color: white;">the CEU application and submit it with the required supporting material. Applications and </span><span style="background-color: white;">supporting material must be received in the NSGC Executive Office no later than 6 weeks in </span><span style="background-color: white;">advance of the printing of your general information brochure in order to be considered. Programs </span><span style="background-color: white;">using only online announcements may submit the application up to 4 weeks in advance of the </span><span style="background-color: white;">online posting of the announcement.</span></div>
<div>
<br /></div>
<div>
<b><u>Once Your Program has been Approved</u></b></div>
<div>
Organizations whose applications are approved will receive notification of the number of CEUs <span style="background-color: white;">approved, as well as the exact verbiage that much appear in the program announcement or </span><span style="background-color: white;">brochure. </span></div>
<div>
<span style="background-color: white;"><br /></span></div>
<div>
<span style="background-color: white;"><b><u>Issuing of CEUs</u></b></span></div>
<div>
NSGC requires learning sources/sponsoring organizations to collect, track and provide various <span style="background-color: white;">information of an approved learning program or activity in order to issue CEUs to genetic </span><span style="background-color: white;">counselors:</span></div>
<div>
<ul>
<li><span style="background-color: white;">Payment of $25.00 per individual claiming CEUs will be required at the time the learning </span><span style="background-color: white;">source/sponsoring organization files for CEUs on behalf of its participants.</span></li>
<li><span style="background-color: white;">The learning source/sponsoring organization must provide NSGC with a spreadsheet </span><span style="background-color: white;">containing the following information for each individual claiming CEUs:</span></li>
<ul>
<li><span style="background-color: white;">Full Name (first, middle, last)</span></li>
<li><span style="background-color: white;">Company</span></li>
<li><span style="background-color: white;">Street Address</span></li>
<li><span style="background-color: white;">City, State and Zip</span></li>
<li><span style="background-color: white;">Email Address</span></li>
<li><span style="background-color: white;">Number of CEUs & Contact Hours to be issued</span></li>
</ul>
<li><span style="background-color: white;">For live events, copies of sign-in sheets and/or self-report forms (tracking learner </span><span style="background-color: white;">attendance)</span></li>
<li><span style="background-color: white;">For live events distance learning activities, summaries of learner assessments</span></li>
</ul>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</span></div>
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com2tag:blogger.com,1999:blog-5704808848752223620.post-34634291741622071732012-07-06T08:12:00.000-04:002012-07-06T08:13:43.915-04:00At Home Medical Billing Jobs<div style="text-align: center;">
<span style="font-size: x-large;">Working From Home</span></div>
<div style="text-align: left;">
</div>
You’ve probably seen the ads for at home medical billing jobs. Can you really sit at <span style="background-color: white;">home and make a good living as a medical biller or coder? The short answer is yes </span><span style="background-color: white;">you can but it’s not as simple as some of those ads make it sound. The only way this </span><span style="background-color: white;">is possible is if you have a very flexible and accommodating employer or have your </span><span style="background-color: white;">own billing or coding business. If you are really good at what you do and have proven</span><br />
yourself trustworthy, your boss may not care where you work – as long as you can be as <span style="background-color: white;">productive at home as you are in the office.</span><br />
<span style="background-color: white;"><br /></span><br />
In order to succeed at medical coding jobs from home, you should be result oriented <span style="background-color: white;">and self-disciplined, able to work independently, and manage your time. You also should </span><span style="background-color: white;">have the required work space or office at home, be OK with little or no social interaction, </span><span style="background-color: white;">and be able to separate family and work.</span><br />
<span style="background-color: white;"><br /></span><br />
Due to the nature of the work, medical billing and coding jobs from home are more <span style="background-color: white;">feasible now than ever. Most practices billing systems are server based and accessible </span><span style="background-color: white;">remotely from any PC – either via web or remote desktop. You do have to be in touch </span><span style="background-color: white;">with insurance companies, patients, and healthcare providers.</span><br />
<span style="background-color: white;">However most of this can </span><span style="background-color: white;">be done by phone, fax, and email. </span><br />
<span style="background-color: white;"><br /></span><br />
<span style="background-color: white;">A lot of the medical coding and billing work I do at home can be done on any schedule </span><span style="background-color: white;">as long as it's done promptly. A medical biller bears a lot of responsibility as the financial </span><span style="background-color: white;">health of a practice is dependent on our performance.</span><br />
<span style="background-color: white;"><br /></span><br />
<span style="background-color: white;"></span><br />
<span style="font-size: large;">Benefits</span><br />
The benefits of medical billing from home and medical coding from home are the <span style="background-color: white;">flexibility to set your own hours and the tax advantages of having a home office (consult </span><span style="background-color: white;">with your accountant). It’s also nice not to have to deal with the daily commute. When </span><span style="background-color: white;">working from home it’s very important to make sure your office complies with HIPAA </span><span style="background-color: white;">privacy practices and all patient information is handled as such.</span><br />
<span style="background-color: white;"><br /></span><br />
<span style="font-size: large;">Disadvantages</span><br />
The drawbacks are that you have to be disciplined not to let it interfere with your home <span style="background-color: white;">life. If you don't set boundaries, work can really interfere with your home life. </span><br />
<span style="background-color: white;"><br /></span><br />
<span style="background-color: white;">If you have employees they need to have access to your home. Depending on how your </span><span style="background-color: white;">home is laid out this can be intrusive to your privacy. I employ other stay at home moms </span><span style="background-color: white;">who work from their home part time as contractors. I just give them an assignment and </span><span style="background-color: white;">they can perform on their own schedule. Our medical billing software allows access to </span><span style="background-color: white;">our server via Remote Desktop from any other PC.</span><br />
<span style="background-color: white;"><br /></span><br />
<span style="font-size: large;">Demand may Create Flexible Work Options</span><br />
According to the U. S. Department of Labor’s latest Occupational Outlook, the prospects <span style="background-color: white;">for medical records and health information technicians (under which medical coders fall), </span><span style="background-color: white;">employment is expected to increase by 18% through 2016. This means there will be a </span><span style="background-color: white;">strong demand for medical coders.</span><br />
<span style="background-color: white;"><br /></span><br />
For employers having difficulty attracting qualified coders, they are more likely to <span style="background-color: white;">offer more flexibility to accommodate productive employees. One of the best benefits </span><span style="background-color: white;">is remote medical coding. Larger more progressive employers typically have the </span><span style="background-color: white;">information technology systems and HIPAA procedures in place to allow remote medical </span><span style="background-color: white;">coding jobs.</span><br />
<span style="background-color: white;"><br /></span><br />
For motivated employees, working from home results in improved morale and <span style="background-color: white;">productivity. Offering such a benefit makes it easier to attract and retain good </span><span style="background-color: white;">employees. Especially in large cities, municipalities may offer incentives for </span><span style="background-color: white;">telecommuting to business to ease traffic congestion.</span><br />
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com1tag:blogger.com,1999:blog-5704808848752223620.post-33176930715338704582012-07-06T07:22:00.002-04:002012-07-06T07:51:08.510-04:00Medical Coding and Billing Jobs<div style="text-align: center;">
<span style="font-size: x-large;">Finding Medical Coding and Billing Jobs</span></div>
<div style="text-align: left;">
</div>
<br />
A good place to start is the local classified listings - online classified is probably the <span style="background-color: white;">easiest. Although local newspapers aren't the only source in searching for medical billing </span><span style="background-color: white;">and coding jobs like there used to be, they are a good starting point when looking locally. </span><span style="background-color: white;">Don't forget CraigsList - many employers are discovering this is a great way to advertise </span><span style="background-color: white;">medical coding and billing jobs because it's free, quick, and easy.</span><br />
<span style="background-color: white;"><br /></span><br />
According to a recent CNNMoney article, most people looking for a job look in a variety <span style="background-color: white;">of different sites. The average web sites used in most job searches is 5. For larger </span><span style="background-color: white;">employers such as hospitals, large practices, and medical research facilities, you'll do </span><span style="background-color: white;">better going directly to the web site for job listings. But it really helps to have someone </span><span style="background-color: white;">you know on the inside pulling for you (and looking out for your resume) at these larger </span><span style="background-color: white;">employers.</span><br />
<span style="background-color: white;"><br /></span><br />
<span style="background-color: white;"><span style="font-size: large;">Most Popular Web Sites</span></span><br />
<span style="background-color: white;"></span><br />
There's two types of online job sites - general purpose job boards catering to a wide <span style="background-color: white;">variety of professions, industries and locations. General purpose sites are CareerBuilder, </span><span style="background-color: white;">Monster, or Yahoo! HotJobs. In the latest survey by Weddle's which prints a guide to </span><span style="background-color: white;">internet job hunting, the most popular job sites are:</span><br />
<span style="background-color: white;"></span><br />
<br />
<ul>
<li><span style="background-color: white;">CareerBuilder</span></li>
<li><span style="background-color: white;">CareerJournal</span></li>
<li><span style="background-color: white;">Indeed.com</span></li>
<li><span style="background-color: white;">Job.com</span></li>
<li><span style="background-color: white;">Monster</span></li>
<li><span style="background-color: white;">SimplyHired</span></li>
<li><span style="background-color: white;">HotJobs (Yahoo!)</span></li>
<li><span style="background-color: white;">SnagAJob</span></li>
</ul>
<div>
<div>
After trying several of these sites to search for a medical billing and coding job, I really <span style="background-color: white;">liked the Indeed Jobs site the best. It's one of the best sites to search for online medical </span><span style="background-color: white;">billing jobs. Indeed compiles job listings from thousands of different job website sources </span><span style="background-color: white;">from large and small local companies. The job results are relevant, unlike other job </span><span style="background-color: white;">sites who send you jobs in a completely different field when you sign up for email alerts. </span><span style="background-color: white;">Indeed allows you to save your searches and sign up for email alerts.</span></div>
<div>
<span style="background-color: white;"><br /></span></div>
<div>
Online sites also have a lot of tools to help in the job search like advice, example <span style="background-color: white;">resume's, and preparing for the interview. They allow you to set up a profile and receive </span><span style="background-color: white;">email notification when there's there's an opening that matches your criteria. Monster </span><span style="background-color: white;">even offers resume writing and interview coaching services for a fee.</span></div>
<div>
<br /></div>
<div>
I notice there's a lot of jobs listed in both the local and online boards for temp and hiring <span style="background-color: white;">agencies. What an employer will do sometimes is have the employment agency screen </span><span style="background-color: white;">potential applicants and present the most qualified candidates as they don’t want to </span><span style="background-color: white;">dedicate the time for this.</span></div>
<div>
<span style="background-color: white;"><br /></span></div>
<div>
<span style="font-size: large;">Network</span></div>
<div>
A lot of job openings don't even get posted online. That's why its so important to network <span style="background-color: white;">and speak with as many people as possible. Every year, a number of job openings are </span><span style="background-color: white;">filled even before they can be advertised. Your friends, relatives, ex-coworkers, and </span><span style="background-color: white;">neighbors may have inside information about a vacancy for the right job. If there is a </span><span style="background-color: white;">certain hospital or physicians office you want to work for, try to get to know someone </span><span style="background-color: white;">who works there.</span></div>
<div>
<span style="background-color: white;"><br /></span></div>
<div>
Most of the people that I have hired for my Medical Billing business have not been <span style="background-color: white;">through ads or postings, but from friends and referrals. Knowing that an employee is </span><span style="background-color: white;">trustworthy counts for a lot even if they don’t have a lot of experience.</span></div>
</div>
<br />
<br />
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-61623158769840333882012-07-06T06:39:00.001-04:002012-07-06T06:40:04.723-04:00Medical Billing and Coding Employment<br />
<div style="text-align: center;">
<span style="font-size: x-large;">Outlook for Medical Billing and Coding</span></div>
<div style="text-align: center;">
<span style="font-size: x-large;">Employment</span></div>
<div style="text-align: left;">
<span style="font-size: large;"><br /></span></div>
<div style="text-align: left;">
<span style="font-size: large;">Medical Billing Employment</span></div>
<div style="text-align: left;">
</div>
The U. S. Department of Labor - Bureau of Labor Statistics projects an annual increase <span style="background-color: white;">of 14.4% in health care office and administrative support occupations. Although the </span><span style="background-color: white;">Department of Labor does not specifically categorize the medical billing specialist, they </span><span style="background-color: white;">do project a 20.9% increase in those performing bookkeeping and accounting functions </span><span style="background-color: white;">and a 21.5% increase in general office clerical functions - which is where the medical </span><span style="background-color: white;">billing employment functions best fit.</span><br />
<span style="background-color: white;"><br /></span><br />
This corresponds to a projected increase of 21.3% for professional and related <span style="background-color: white;">occupations - or health care providers which will need billing services. Especially </span><span style="background-color: white;">considering the increasing complexity of the billing process brought on by changes in </span><span style="background-color: white;">health care reimbursement (like HIPAA).</span><br />
<span style="background-color: white;"><br /></span><br />
In summary the outlook is very good for medical billing employment. And this is based <span style="background-color: white;">on the most credible source available - the U.S. Department of Labor. Reference the </span><span style="background-color: white;">Bureau of Labor Statistics Career Guide to Industries - Health Care.</span><br />
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<span style="background-color: white;"><span style="font-size: large;">Medical Coding Job Opportunities</span></span><br />
<span style="background-color: white;"></span><br />
The DOL projects a faster than average growth for medical coding jobs with those <span style="background-color: white;">having a good background being in especially high demand. Through the year 2016, </span><span style="background-color: white;">medical coding positions are estimated to increase by 18%. </span><br />
<span style="background-color: white;"><br /></span><br />
<span style="background-color: white;">This higher than average demand is due to the increased need for medical treatments, </span><span style="background-color: white;">procedures, and tests due to an aging population. Also driving the demand is greater </span><span style="background-color: white;">scrutiny placed on health care services by insurance companies, consumers and their </span><span style="background-color: white;">employers, and regulatory agencies.</span><br />
<span style="background-color: white;"><br /></span><br />
Medical coding jobs will also be abundant for those with good computer skills. There is <span style="background-color: white;">an increasing movement by the health care industry to electronic medical records. DOL </span><span style="background-color: white;">projects opportunities in physician offices, outpatient and home health services, and </span><span style="background-color: white;">nursing facilities. Not only will new positions be created but many opportunities will be </span><span style="background-color: white;">created by retirements.</span><br />
<span style="background-color: white;"><br /></span><br />
Experienced medical coders with credentials will be in particularly high demand. Health <span style="background-color: white;">care providers and facilities are challenged to attract and retain good coders. The </span><span style="background-color: white;">Occupational Outlook anticipates job prospects to be especially good for medical coders </span><span style="background-color: white;">through temporary job agencies and professional services firms.</span><br />
<span style="background-color: white;"><br /></span><br />
<span style="background-color: white;">The U. S. Department of Labor (DOL) creates the Occupational Information Handbook </span><span style="background-color: white;">which gives the outlook for various professions in the United States. The medical coder </span><span style="background-color: white;">job falls under the classification of Medical Records and Health Information Technicians. </span><span style="background-color: white;">According to their latest report, approximately 2 out of 5 jobs (or 40%) of jobs are </span><span style="background-color: white;">in hospitals. The remaining 60% are in provider offices, nursing facilities, outpatient </span><span style="background-color: white;">centers, and home health services.</span><br />
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<span style="background-color: white;"><span style="font-size: large;">Work Schedule</span></span><br />
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Most medical coding positions work a typical 40 hour work week with occasional <span style="background-color: white;">overtime. Hospitals which are open 24/7 may require coverage during evening, night, </span><span style="background-color: white;">and weekend times. Because of the increased demand of medical billing coding jobs, </span><span style="background-color: white;">employers may be more accommodating of flexible work schedules. In their attempts to </span><span style="background-color: white;">attract good employees, employers will probably be more accommodating by offering</span><br />
more flexible work hours and work-at-home options.<br />
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<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com1tag:blogger.com,1999:blog-5704808848752223620.post-83536124959336208072012-06-20T05:37:00.000-04:002012-06-20T05:48:13.302-04:00Finding the Best Medical Billing and Coding Schools<h2 style="text-align: center;">
Tips</h2>
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<div>
Are you looking to launch your career in the medical field? Both the medical biller and medical coder play a crucial role in the successful operation of a medical practice or facility. In order to make yourself a valuable part of the team, you should ensure that you receive training and certification from an accredited educational institute. There are many medical billing and coding schools that can help you well on your way to educational and career success.</div>
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How do you pick the right school for you, however? How do you ensure that the schools you are selecting will best serve your needs for training and best prepare you to pass the certification exams? Let’s take a look at just a few of the steps you should take prior to enrolling in any medical billing and coding schools.</div>
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<span style="font-size: large;">Are They Accredited?</span></div>
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The reality is that anyone can set up shop or a website that will allow them to appear to be a legitimate educational institute. However, if they are not accredited, you will not only be spending your money on a course that might not fully prepare you to take the exams, but your coursework and your certifications may not even be recognized once you set out to find a job.</div>
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A simple check to verify their accreditation can potentially save you a significant amount of money and a lot of unnecessary frustrations and delays in getting your career started off on the right foot.</div>
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<span style="font-size: large;">The Right School For You</span></div>
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Picking the right medical billing and coding schools is an important part of ensuring that you will be successful in both passing the exams and landing a great job. There are a few factors that you should consider when you are picking your school.</div>
<div>
<ul>
<li><span style="background-color: white;">Are you currently working?</span></li>
<li><span style="background-color: white;">Do you have reliable transportation?</span></li>
<li><span style="background-color: white;">Do you have access to a computer and reliable internet connection?</span></li>
<li><span style="background-color: white;">These questions are very important because they can mean the difference between attending a traditional brick and mortar school, and taking your classes online.</span></li>
</ul>
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<div>
Both forms of school can help you to successfully pass your certification exams; however, your current lifestyle and other commitments will have an impact on the type of school that you select. Do a bit of careful consideration and ensure that you pick the right school and the right type of classes for you. If you are currently working, you may find that online classes are the best choice for you. However, if you are not working, you may find that attending class is the best choice. Only you know what will work out best for you and your current situation.</div>
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<span style="font-size: large;">Costs To Consider</span></div>
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Costs are always going to be a factor for most of us when it comes to considering medical billing and coding schools. Fortunately, the majority of schools are sure to have financial aid programs that can help you to still attain your dreams, even while you may be on a strict budget. With the combination of grants, loans, and other financial services, you will be able to get the training that you need. This investment in your future is something that you shouldn’t hesitate over.</div>
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Be sure that you pay attention to the fees that your selected schools charge. A reputable educational institute will ensure that you have a detailed plan of your fees upfront so that there are no unpleasant surprises when you are trying to get proof of course completion.</div>
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A bit of cost comparison shopping will also help you to narrow down the educational institute that offers the best class costs. Keep in mind that cheaper doesn’t always mean that a school is inferior. The most important thing is that they have a stellar reputation with former students and that they are accredited.</div>
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<span style="font-size: large;">An Investment Of Time, An Investment In You</span></div>
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It can take anywhere from three to twelve months to complete a course at medical billing and coding schools. If you are currently working, or have other commitments, then it might take up to a year to finish your training and pass your exams. The important thing for you to remember is that getting your certifications is an investment in you and in your future.</div>
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Qualified professionals are always going to be in high demand in the medical field. Make yourself the best potential candidate, attend well-rated medical billing and coding skills, and launch yourself into a stable and well-paying career that you can be proud of.</div>
</div>Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com2tag:blogger.com,1999:blog-5704808848752223620.post-21258722799284546382012-06-20T05:33:00.000-04:002012-06-20T05:34:34.290-04:00Types of Medical Coding Jobs<br />
Within healthcare, multiple job opportunities exist with the majority in great need for qualified workers. Because there is an increasing number of people needing quality medical care, this particular sector is growing faster than expected. Some of the jobs in highest demand are those involving actual medical professionals who provide patient care while others are workers behind the scenes handling patient accounts, running diagnostics, and so on. For this group of people, skilled employees are needed most for medical coding jobs.<br />
<br />
As far as medical coding jobs, there are actually several different career opportunities, each being slightly unique and offering a somewhat different pay scale. Because of the huge need in this area, we wanted to provide information specific to options for medical coding jobs that a person might consider. Keep in mind, all of these jobs offer stability, good pay, and opportunity for advancement within the healthcare sector.<br />
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<span style="font-size: large;">Job Information</span><br />
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To start with, it is important to know that while there are many different medical coding jobs from which a person could choose, they do not all fall under this category or have titles that would reflect as being associated with medical billing. Therefore, it would be more beneficial to look at jobs that involve the same type of work opposed to jobs being titled as “medical coding”. Overall, work for jobs such as these includes billing for services provided to patients, as well as medical supplies and procedures.<br />
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These jobs entail using a numeric coding system which would be applied to diseases, conditions, treatments, diagnosis, medications, treatment plans, and continued care among other things for each patient seen. With the information for a patient file being properly coded, the process of filing insurance forms for payment or reimbursement would be possible. Therefore, while coding is a large part of these jobs, billing is also involved which is why jobs are sometimes referred to as medical billing and coding.<br />
<br />
Although some medical coding jobs are entry level positions, the work requires a skilled professional. Qualifications to work in the various jobs would vary to some degree but they would all require something specific to include the following:<br />
<br />
<ul>
<li><span style="background-color: white;">Experience in billing and coding</span></li>
<li><span style="background-color: white;">Experience working in a healthcare environment</span></li>
<li><span style="background-color: white;">Specialized knowledge</span></li>
<li><span style="background-color: white;">Experience with insurance or medical billing and coding procedures</span></li>
</ul>
<span style="background-color: white;">Now, there are some companies that will hire a person for medical coding jobs who has not worked in a healthcare environment but for the most part, this would be a huge benefit for the facility and doctor but also the individual hired to do the work. </span><br />
<br />
<span style="font-size: large;">Medical Coding Arenas</span><br />
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As mentioned, several different options exist for medical coding to include actual jobs and duties, as well as areas of expertise as shown below. Depending on the individual’s experience, training, and education, as well as the hiring doctor or facility, the area in which a person works could be just one or several.<br />
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<b><u>Medical</u></b> – The areas that commonly need medical coding experts includes dentistry, cancer care, and pediatrics<br />
<b><u>Coding System</u></b> – In this case, areas would include a doctor’s office, nursing home or assisted living facility, or surgical center<br />
<b><u>Insurance</u></b> – Along with private and public insurance companies, the individual would likely handle insurance claims with Medicaid and Medicare<br />
<b><u>Patient</u></b> – This would include patients on an inpatient or outpatient basis, as well as those receiving emergency care<br />
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<span style="font-size: large;">Job Options</span><br />
<br />
Regarding actual medical coding jobs, the following are a few examples where dedicated and skilled workers are always needed.<br />
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<b><u>Medical Billing Clerk</u></b> – Primary responsibilities for this job involves maintaining patient records specific to services, goods, and procedures provided for a specific healthcare facility. Invoices would be generated and bills printed for payment from patients, as well as insurance providers, merchants, and various service providers. Because the person in this role would have direct contact with patients and professionals, great communication and customer service would be mandated along with billing and medical coding ability.<br />
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<b><u>Medical Coding Specialist</u></b> – For this job, medical documents would be reviews and key information about a patient’s condition extracted. That information would then be translated using numerical codes into a diagnostic and procedural system that allows insurance claims to be filed while following regulations set by the federal government.<br />
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<b><u>Clinical Data Specialist</u></b> – This is the last of the medical coding jobs we wanted to mention, which includes duties of reviewing, editing, and making corrections to data that the internal computer systems generated. With this, accuracy and compliance of information for medical billing purposes could be validated specifically for Medicaid and Medicare.<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-75097289412906442242012-06-18T03:32:00.003-04:002012-06-18T03:34:14.253-04:00GEMs FAQs<br />
The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) created the national version of the General Equivalence Mappings (GEM) to ensure that consistency in national data is maintained. They have made a commitment to update the GEMs annually along with the updates to International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) and Procedure Coding System (PCS) during the transition period prior to ICD-10 implementation. CMS and CDC will maintain the GEMs for at least three years beyond October 1, 2013, which is the compliance date for implementation of ICD-10 for all covered entities.<br />
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<span style="background-color: white;"><span style="font-size: large;">1. Are the General Equivalence Mappings a Substitute for Learning to Use the ICD-10-CM and ICD-10-PCS?</span></span><br />
The GEMs are not a substitute for learning how to use the ICD-10-CM and ICD-10-PCS. Providers’ coding staff will assign codes describing the patients’ encounters from the ICD-10-CM and ICD-10-PCS code books or encoder systems. In coding individual claims, it will be more efficient and accurate to work from the medical record documentation and then select the appropriate code(s) from the coding book or encoder system. The GEMs are a tool to assist with converting larger International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) databases to ICD-10-CM and ICD-10-PCS.<br />
<br />
<span style="font-size: large;">2. Who Can Use the General Equivalence Mappings?</span><br />
The GEMs can be used by anyone who wants to convert coded data. Possible users of the GEMs include the following:<br />
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<ul>
<li><span style="background-color: white;">All payers;</span></li>
<li><span style="background-color: white;">All providers;</span></li>
<li><span style="background-color: white;">Medical researchers;</span></li>
<li><span style="background-color: white;">Informatics professionals; </span></li>
<li><span style="background-color: white;">Coding professionals—to convert large data sets;</span></li>
<li><span style="background-color: white;">Software vendors—to use within their own products;</span></li>
<li><span style="background-color: white;">Organizations—to make mappings that suit their internal purposes or that are based on their own historical data; and </span></li>
<li><span style="background-color: white;">Others who use coded data.</span></li>
</ul>
<br />
<span style="background-color: white;"><span style="font-size: large;">3. What are the General Equivalence Mappings?</span></span><br />
The GEMs are a tool that can be used to convert data from ICD-9-CM to ICD-10-CM and PCS and vice versa. Mapping from ICD-10-CM and PCS codes back to ICD-9-CM codes is referred to as backward mapping. Mapping from ICD-9-CM codes to ICD-10-CM and PCS codes is referred to as forward mapping. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, including data for:<br />
<br />
<ul>
<li><span style="background-color: white;">Tracking quality; </span></li>
<li><span style="background-color: white;">Recording morbidity/mortality;</span></li>
<li><span style="background-color: white;">Calculating reimbursement; or</span></li>
<li><span style="background-color: white;">Converting any ICD-9-CM-based application to ICD-10-CM/PCS.</span></li>
</ul>
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<span style="background-color: white;">The GEMs are complete in their description of all the mapping possibilities as well as when there are new concepts in ICD-10 that are not found in ICD-9-CM. All ICD-9-CM codes and all ICD-10-CM/PCS codes are included in the collective GEMs:</span><br />
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<ul>
<li><span style="background-color: white;">All ICD-10-CM codes are in the ICD-10-CM to ICD-9-CM GEM; </span></li>
<li><span style="background-color: white;">All ICD-9-CM Diagnosis Codes are in the ICD-9-CM to ICD-10-CM GEM;</span></li>
<li><span style="background-color: white;">All ICD-10-PCS codes are in the ICD-10-PCS to ICD-9-CM GEM; and</span></li>
<li><span style="background-color: white;">All ICD-9-CM Procedure Codes are in the ICD-9-CM to ICD-10-PCS GEM.</span></li>
</ul>
<br />
<span style="background-color: white;"><span style="font-size: large;">4. How Have the General Equivalence Mappings Been Used to Date?</span></span><br />
To date, the GEMs have been used to:<br />
<br />
<ul>
<li><span style="background-color: white;">Translate ICD-9-CM codes in the Official ICD-9-CM Coding Guidelines to aid in producing the Official ICD-10-CM Coding Guidelines; </span></li>
<li><span style="background-color: white;">Convert version 26.0 of Medicare Severity Diagnosis Related Groups from an ICD-9-CM-based application to an ICD-10-CM/PCS-based application;</span></li>
<li><span style="background-color: white;">Convert the Medicare Code Editor to a native ICD-10-CM/PCS-based application; and</span></li>
<li><span style="background-color: white;">Produce a purpose-built ICD-10-CM/PCS to ICD-9-CM crosswalk for reimbursement called the ICD-10 Reimbursement Mappings.</span></li>
</ul>
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<span style="background-color: white;"><span style="font-size: large;">5. What are the Reimbursement Mappings?</span></span><br />
The Reimbursement Mappings were developed by CMS in response to non-Medicare industry requests for a “standard one-to-one reimbursement crosswalk,” which is a temporary mechanism for mapping ICD-10-CM/PCS codes submitted on or after October 1, 2013 back to “reimbursement equivalent” ICD-9-CM codes. In order to develop the Reimbursement Mappings, CMS used the GEMs as a starting point by selecting the best ICD-9-CM code that maps to each ICD-10 code based on Medicare data. The Reimbursement Mappings identify the best matching ICD-9-CM code that can be used for reimbursement purposes for each ICD-10 code. All ICD-10-CM/PCS codes are in the Reimbursement Mappings; however, all ICD-9-CM codes are not in the Reimbursement Mappings. Where an ICD-10-CM/PCS code translates to more than one ICD-9-CM code, a single choice is required to create a functioning crosswalk. Inpatient hospital frequency data was used to aid in choosing a final ICD-9-CM translation in the crosswalk. If needed, the Reimbursement Mappings may be used to process ICD-10-CM/PCS-based claims received on or after October 1, 2013, with a legacy ICD-9-CM-based system as part of a planned transition period, until systems and processes are developed to process ICD-10-CM/PCS-based claims directly. The Reimbursement Mappings consist of two crosswalks:<br />
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<ul>
<li><span style="background-color: white;">ICD-10-CM to ICD-9-CM for Diagnosis Codes; and</span></li>
<li><span style="background-color: white;">ICD-10-PCS to ICD-9-CM for Procedure Codes.</span></li>
</ul>
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<span style="background-color: white;">CMS is not using the ICD-10 Reimbursement Mappings for any purpose. We are converting our systems and applications to accept ICD-10-CM/PCS codes directly.</span><br />
<span style="background-color: white;"><br /></span><br />
<span style="font-size: large;"><span style="background-color: white;">6. </span><span style="background-color: white;">Is There a One-to-One Match Between ICD-9-CM and ICD-10?</span></span><br />
No, there is not a one-to-one match between ICD-9-CM and ICD-10, for which there are a<br />
variety of reasons including:<br />
<br />
<ul>
<li><span style="background-color: white;">There are new concepts in ICD-10 that are not present in ICD-9-CM;</span></li>
<li><span style="background-color: white;">For a small number of codes, there is no matching code in the GEMs;</span></li>
<li><span style="background-color: white;">There may be multiple ICD-9-CM codes for a single ICD-10 code; and </span></li>
<li><span style="background-color: white;">There may be multiple ICD-10 codes for a single ICD-9-CM code.</span></li>
</ul>
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-90233506859010454762012-06-18T02:49:00.001-04:002012-06-18T02:52:39.156-04:00General Equivalence Mappings<br />
In healthcare, diagnosis and procedure codes and their attached descriptions are the currency for many critical data transactions. Healthcare organizations rely heavily on coded data to govern reimbursement, monitor the health of the population, track trends in disease and treatment, and optimize the delivery of healthcare in the US.<br />
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The possible implementation of the ICD-10 code set is a historic opportunity to upgrade the quality of healthcare data, but like everything worth having, it comes at a cost. One cost is mapping between the old and new code sets.<br />
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A recurring theme in the ongoing ICD-10 implementation debate has been the need for a crosswalk between the old and new code sets to help the industry make the transition. The lack of an “official” mapping between ICD-9-CM and ICD-10-CM/-PCS has long been seen as a major challenge to ICD-10 implementation. The <a href="http://generalequivalencemappings.blogspot.com/" target="_blank">General Equivalence Mappings (GEMs)</a> are an attempt to meet that challenge.<br />
<h2 style="text-align: center;">
What Are GEMs?</h2>
<span style="background-color: white;">The GEMs are the product of a coordinated effort spanning several years and involving the National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS), AHIMA, the American Hospital Association, and 3M Health Information Systems. The GEM files are a public domain reference mapping designed to give all sectors of the healthcare industry that use coded data a tool to convert and test systems, link data in long-term clinical studies, develop application-specific mappings, and analyze data collected during the transition period and beyond.</span><br />
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It would be impossible to produce a “one size fits all” set of mappings because a mapping is heavily dependent on its purpose. A map for reimbursement uses different rules and contains different entries than a map for research.<br />
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The GEMs are more than simple crosswalks. They cannot be used in a legacy system in unaltered form to get from a code in one set to a code in the other. A clear one-to-one correspondence between an I-9 or I-10 code is the exception rather than the rule.<br />
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It is useful to think of GEMs as two-way translation dictionaries for diagnosis and procedure codes from which crosswalks can be made for specific purposes. They elucidate the differences between the code sets and assist users in making informed decisions about how to link the codes in a way that meets their needs.<br />
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While ICD-9-CM diagnosis codes and ICD-9-CM procedure codes are maintained by two different government entities, the GEMs were developed separately but collaboratively to maintain consistency insofar as possible. The resulting files can be merged seamlessly as needed—subsets extracted, analyzed, and applied—without taking extra steps to make them compatible.<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-38406282751605043982012-06-13T06:14:00.001-04:002012-06-13T06:17:04.566-04:00Medical Billing and Coding Certification<br />
Professional medical billing and coding certification is a designation earned by an individual as proof that a minimum level of competency. Certification typically follows graduation from a formal training program and requires passing a certification exam. The certification is usually earned from a professional society and valid for a defined time, such as 1 year. These certifications must be renewed on a periodic basis and require evidence of completion of continuing education units (CEU’s) and maintaining membership in the granting professional society.<br />
<br />
Certification is different from being licensed. Licensing is typically required by state government agencies to demonstrate a minimum level of knowledge or ability as required by law.<br />
<br />
<b>Benefits of Certification:</b><br />
<br />
<ul>
<li>Distinguishes you from others - gives you an advantage when applying for job over those not certified.</li>
<li>Shows your commitment to the profession - Shows management that you are improving.</li>
<li>Improves income potential.</li>
<li>Demonstrates a basic level of knowledge about the profession.</li>
<li>Commitment to ethical responsibilities of the profession.</li>
<li>Improved opportunities for advancement.</li>
</ul>
<br />
There's not a combined medical billing and coding certification, but there are separate certifications for medical billing and medical coding. Medical coding certifications are more diverse and involved due to the complexity of coding. Independent home based medical coders and billers benefit from certification for marketing your credentials to potential clients.<br />
<br />
<span style="font-size: x-large;">Medical Billing Certification</span><br />
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The American Medical Billing Association (AMBA) is probably one of the most recognized organizations offering a medical billing certificate through examination and education. The Certified Medical Reimbursement Specialist (CMRS) is an exam based certification that demonstrates a knowledge in insurance reimbursement, medical terms, coding (ICD9, CPT4 and HCPCS), claim appeals, and compliance (HIPAA and OIG). The CMRS exam has 16 sections with 700 questions. A score of 85% is required to pass and recieve the CMRS credential designation.<br />
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<b>The CMRS Exam is divided into 16 Sections:</b><br />
<br />
<ul>
<li>Medical Terminology</li>
<li>Anatomy and Physiology</li>
<li>Information Technology</li>
<li>Web and Information Technology</li>
<li>ICD-9-CM Coding</li>
<li>CPT-4 Coding</li>
<li>Clearinghouses</li>
<li>CMS 1500</li>
<li>Insurance</li>
<li>Insurance Carriers</li>
<li>Acronyms</li>
<li>Compliance</li>
<li>Fraud and Abuse</li>
<li>Managed Care</li>
<li>General</li>
<li>Case Study</li>
</ul>
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Maintaining certification requires obtaining 15 continuing education units (CEU’s) from an approved listing every year. Cost is $325 plus membership in AMBA. AMBA recognizes the CEU’s from courses offered by the AAPC (American Academy of Professional Coders) and many other reputable organizations.<br />
<br />
<span style="font-size: x-large;">Healthcare Billing and Management Association</span><br />
<br />
The Healthcare Billing and Management Association offers the Certified Healthcare Billing & Management Executive (CHBME) and Certified Medical Billing Associate (CMBA). However these tend to be designed more for executives, managers, and supervisors. Probably the highest level of credentialing offered for medical billing andreimbursement is the RHIA and RHIT certifications offered by the AHIMA (American Health Information Management Association).<br />
<br />
RHIA is Registered Health Information Administrator. They are mostly involved with the management of patient health information, medical records, and computer information systems.RHIT is Registered Health Information Technician. They are health information technicians associated with medical records and computer applications and systems.<br />
<br />
<span style="font-size: x-large;">Medical Coding Certification</span><br />
<br />
Coding credentials are administered by two different organizations - AAPC (American Academy of Professional Coders) and the AHIMA (American Health Information Management Association). Employers may have differing preferences when hiring. If you are considering becoming credentialed talk with an experienced professional already in the coding field and get their opinion.<br />
<br />
<b>Here's a summary of their certifications:</b><br />
<br />
<b><i><u>AAPC Certifications:</u></i></b><br />
<br />
<ul>
<li>CPC - <i>Certified Professional Coder</i></li>
<li>CPC-H - <i>Certified Coding Specialist - Hospital</i></li>
<li>CPC-P - <i>Certified Coding Specialist - Payer</i></li>
<li>AAPC <i>also offers several other specialty credentials</i></li>
</ul>
<br />
<b><i><u>AHIMA Certifications:</u></i></b><br />
<br />
<ul>
<li>CCA - <i>Certified Coding Associate. This is an entry-level certification.</i></li>
<li>CCS - <i>Certified Coding Specialist. More proficient coders.</i></li>
<li>CCS-P - <i>Certified Coding Specialist - More proficient Physician Based coder.</i></li>
<li>CHDA - <i>Certified Health Data Analyst</i></li>
</ul>
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com3tag:blogger.com,1999:blog-5704808848752223620.post-3217165035632908062012-06-13T06:06:00.000-04:002012-06-13T06:08:00.840-04:00Medical Billing and Coding Training<br />
Medical billing training is typically not as involved as the training needs for medical coding. If you’re goal is a corporate job, generally the more training and credentials the better. Even if you’re planning to stay strictly in medical billing, having some coding knowledge is very useful in understanding coding errors. A good knowledge of coding also makes you more valuable to an employer and justifies asking for a higher salary.<br />
<br />
The amount of training you need depends on your goals – getting a good job at a hospital, large practice, or insurance company - or starting a medical billing business. Smaller practices will usually not be as stringent for certification or training. The downside is they probably aren’t going to pay as well or have the benefits of a larger employer. One of the nice things about a smaller practice is they tend to be more informal.<br />
<br />
<br />
<span style="font-size: x-large;">Medical Billing Training</span><br />
<br />
Training for medical billing can be obtained from a variety of sources such as local vocational schools, community colleges, or distance learning (or online). A good medical billing training program establishes a basic foundation in medical billing necessary for an entry level job. A good certificate program can can take anywhere from 6 to 9 months to complete.<br />
<br />
<b>Topics typically covered:</b><br />
<br />
<ul>
<li>Keyboarding skills</li>
<li>Medical terminology</li>
<li>Medical office procedures</li>
<li>Billing and insurance reimbursement</li>
<li>Basic coding</li>
<li>Medical law (HIPAA) and ethics</li>
</ul>
<br />
There are also reasonably priced (less than $1000) reputable medical billing courses online which can be completed at your own pace. If you are considering an online medical billing school, the material should be written by someone with extensive experience in the field. You should also receive a certificate upon successfully completion.<br />
<br />
If you are really eager to learn but don’t have a lot of money to invest, free medical billing training is possible if you are willing to work for a while for little or no pay. This can be a great way to get your foot in the door and establish yourself in the field. That’s how I got started. Fortunately the billing service I worked for paid me well so I saw it as basically getting paid to learn medical billing.<br />
<br />
<br />
<span style="font-size: x-large;">Medical Coding Training</span><br />
<br />
Medical coding training can run the whole spectrum from associate’s degree to a diploma or certificate program. On the longer end is an associate’s degree in Healthcare Reimbursement. Some schools may describe this degree slightly differently. This is the most comprehensive medical coding training and can typically take 18 months to 2 years to complete.<br />
<br />
<b>The curricula would typically cover:</b><br />
<br />
<ul>
<li>Basic keyboard skills</li>
<li>Human anatomy</li>
<li>Career planning</li>
<li>CPT, ICD, & HCPCS coding</li>
<li>Billing and insurance reimbursement</li>
<li>Medical terminology</li>
<li>Advanced billing and reimbursement</li>
<li>Office procedures</li>
<li>Medical ethics and law</li>
<li>Communications</li>
<li>Fine arts or humanities</li>
<li>Mathematics</li>
<li>Social Sciences</li>
</ul>
<br />
The associates program would prepare a student to take a certification exam by either <a href="http://www.aapc.com/" rel="nofollow" target="_blank">American Academy of Professional Coders (AAPC)</a> or <a href="http://www.ahima.org/" rel="nofollow" target="_blank">American Health Information Management Association (AHIMA)</a>.<br />
<br />
A diploma program is a more abbreviated medical coding training compared to an associate program. This type of program would include more detailed training in procedures and the nuances of healthcare billing. Approximately twice as many courses as the shorter certificate program typicall taking 9 months to 1 year to complete.<br />
<br />
<b>The curricula would typically cover:</b><br />
<br />
<ul>
<li>Basic keyboard skills</li>
<li>Human anatomy</li>
<li>CPT, ICD, & HCPCS coding</li>
<li>Billing and insurance reimbursement</li>
<li>Medical terminology</li>
<li>Office procedures</li>
<li>Medical ethics and law</li>
</ul>
<br />
<br />
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com3tag:blogger.com,1999:blog-5704808848752223620.post-35013838001460820952012-06-13T05:56:00.000-04:002012-06-13T05:57:56.830-04:00The Medical Billing Claim Process<br />
When a patient visits a physician, the doctor writes down the observed conditions and treatment. This information is then given to a medical coder who assigns the appropriate <b><a href="http://contexomedia.blogspot.in/2012/05/icd-9-codes.html">ICD-9 diagnosis</a></b> and <b><a href="http://contexomedia.blogspot.in/2012/05/cpt-codes.html">CPT medical billing codes</a></b> (and CPT modifiers if necessary). The coder may get a written or voice audio dictation file from the doctor that contains the details of the diagnosis and procedures performed on each patient.<br />
<br />
The coder may use reference books to look up the correct diagnosis codes (like the ICD-9-CM Expert for Physicians - 2010 Edition) and the corresponding CPT treatment codes and modifiers (CPC-Current Procedural Coding Expert - 2010 Edition). There are also online coding references such as CodingToday that have the latest treatment and diagnosis codes. These services require a subscription for access but can be a real time saver.<br />
<br />
It’s very important that the ICD-9 and CPT codes be correct so the claim doesn’t get rejected. Depending on how thorough a doctor is, coding from the providers dictation or handwriting can be very time consuming. However once you get to know the doctor’s preferences and habits the process goes much more efficiently.<br />
<br />
This is where the medical billing specialist gets involved. The codes are then typically entered or checked on a superbill or patient encounter form. You've probable seen one of these when visiting the doctor. Some practices now do this electronically. They take the superbill and input the information into the electronic medical billing software. Paper claims are printed out on a <b>CMS-1500</b> insurance form and mailed to the insurance carrier.<br />
<br />
Electronic claims are sent as an electronic file either directly to the insurance company or to a clearinghouse. The clearinghouse takes the claim information, checks the claim for errors, and sends the claim information electronically to insurance companies. Most clearinghouses have a large payer list and can send claims to mostly all of the major insurance companies. This can be a real time saver as each insurer can have different submittal requirements and interfaces. Claims sent electronically are paid much faster than paper claims. Depending on the practice this could be just a few claims or over 40 claims a day.<br />
<br />
If the claim is rejected, the medical billing specialist follows up to find out why it was rejected, correct the claim, and resubmit. An appeal may also need to be written and submitted with supporting information to the insurance company.<br />
<br />
When a payment is received from the insurance carrier, it is accompanied by and EOB (Explanation of Benefits). This information is then entered into the medical billing software. If there is any patient responsibility such as co-pays and co-insurance, a patient statement is printed and mailed. This is usually done in batches on a monthly basis. Some patients also have secondary insurance which requires a second claim be submitted with the EOB to the secondary insurer.<br />
<br />
Sometimes a patient has questions about their bill. This requires the <b><a href="http://contexomedia.blogspot.in/2012/05/what-is-medical-billing.html">medical billing specialist</a></b> to look up their account information and explain the charges and why they were not covered. Many patients don't understand the limits of their insurance coverage and must be referred to their insurer to explain.Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com1tag:blogger.com,1999:blog-5704808848752223620.post-73386650526866448742012-06-05T08:53:00.001-04:002012-06-05T08:53:43.892-04:00Diagnosis Codes<br />
<div style="text-align: center;">
<span style="font-size: large;">Diagnosis Coding</span></div>
In healthcare, <b>diagnostic codes</b> are used to group and identify diseases, disorders, symptoms, human response patterns, and medical signs, and are used to measure morbidity and mortality. As the plural with the name of this lemma indicates, there will be never one code for all purposes, but many codes for some distinct purposes each.<br />
<br />
The codes may be quite frequently revised as new knowledge is attained. DSM changes some of its coding to correspond to the codes in ICD. In 2005, for example, DSM changed the diagnostic codes for circadian rhythm sleep disorders from the 307-group to the 327-group; the new codes reflect the moving of these disorders from the Mental Disorders section to the Neurological section in the ICD.<br />
<br />
<br />
Commonly used diagnosis coding systems:<br />
<br />
<ul>
<li>ICD-9-CM (volumes 1 and 2 only. Volume 3 contains Procedure codes)</li>
<li>ICD-10</li>
<li>ICPC-2 (Also includes reasons for encounter (RFE), Procedure codes and process of care)</li>
<li>ICSD, The International Classification of Sleep Disorders</li>
<li>NANDA</li>
<li>Diagnostic and Statistical Manual of Mental Disorders or DSM-IV (primarily psychiatric disorders)</li>
<li>Mendelian Inheritance in Man (genetic diseases only)</li>
<li>Read code used throughout United Kingdom General Practice computerised records</li>
<li>SNOMED (D axis)</li>
</ul>
<br />
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-66613286383186862882012-06-03T03:36:00.000-04:002012-06-03T03:38:42.187-04:00Ambulatory Procedure Codes<div style="text-align: center;">
<span style="font-size: large;">Ambulatory Procedure Codes Explained<br />(APCs)</span></div>
<div style="text-align: left;">
APC stands for Medicare's ambulatory payment classification. Hospitals use Medicare APC codes to bill the federal government for hospital services given to Medicare and Medicaid patients. Every item, machine or procedure used to care for a Medicare or Medicaid patient has a specialized code that is submitted by the hospital during the billing process.</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
</div>
<span style="font-size: large;">What are APCs and where did they come from?</span><br />
<br />
With passage of the balanced budget act of 1997, congress required HCFA to create an Outpatient Prospective Payment System (OPPS). The new payment system, which began being used this past summer, is known as "Ambulatory Payment Classifications" or "APCs."<br />
<br />
<span style="font-size: large;">What was the impetus to create APCs?</span><br />
<br />
<ul>
<li>To transfer financial risk from Medicare to the hospital providing outpatient services.</li>
<li>To reduce Medicare beneficiary co-payments from 20% of Medicare BILLED CHARGES to 20% of the Medicare ALLOWABLE CHARGES</li>
<li>Change reimbursement for hospital outpatient services from a cost basis(unique to each hospital) to a more standardized prospective payment, similar to the physician fee schedule.</li>
<li>Prior to APCs hospitals had always been reimbursed for outpatient services on a cost reporting methodology. Hospitals used to report costs, and then were paid a percentage of those costs. Fundamentally, with the APCs, hospitals get paid a fixed amount regardless of costs for outpatient services, much as they have been getting fixed payments for inpatient services. Essentially, APCs are to outpatient services what DRGs are to inpatient services.</li>
</ul>
<br />
<span style="font-size: large;">Does every service have it's own unique APC?</span><br />
<br />
No. APC's group services together which are similar clinically and in regards to cost. Within one APC group are many services that are deemed to have comparable resource utilization for provision of services. The designated APC for a service is the method Medicare uses to determine reimbursement. All services within that APC will get the same payment. APCs apply only to the hospital reimbursement, and the Medicare physician fee schedule is not affected by APCs.<br />
<br />
<span style="font-size: large;">What determines which APC a particular service will get assigned to?</span><br />
<br />
APCs are defined solely on the CPT codes. HCFA dropped its original proposal to modify payments based on diagnosis codes. Hospitals still need to report diagnosis codes, however, they will not affect payment.<br />
<br />
<span style="font-size: large;">What are the various APCs, and which apply to emergency department visits?</span><br />
<br />
There are 225 surgical APCs. There are 188 "Ancillary Services" APCs (Radiology, Pathology, other diagnostics and special medications). There are 30 CPT codes which describe outpatient physician-patient encounters, and the 30 CPT codes map to seven "Medical Visit" APCs; four of the seven medical visit APCs deal with emergency department visits:<br />
<br />
<ul>
<li>APC 610 (Low level visit) - CPT codes 99281,99282</li>
<li>APC 611 (Mid level visit) - CPT code 99283</li>
<li>APC 612 (High level visit) - CPT code 99284, 99285</li>
<li>APC 620 (Critical care) - 99291</li>
</ul>
<br />
<span style="font-size: large;">How does a facility choose which level of service to assign? Does that level need to match the physician E/M level?</span><br />
<br />
HCFA has stated that a hospital must follow its own system for assigning different CPT levels. The assigned levels must "reasonably relate to the intensity of hospital resources." Hospitals now need to define their services using the CPT E/M codes (99281-99285, and 99291). Hospitals can continue to use current ED levels of service but must map them to corresponding CPT E/M code for billing Medicare. HCFA will monitor outpatient visit facility level data, and could standardize coding requirements in the future. HCFA has stated that physician and hospital E/M codes do not need to correlate, and may assign different levels. This was contrary to what many people anticipated when APCs were being developed.<br />
<br />
<span style="font-size: large;">What services are included in the APC payments to hospitals for E/M visit levels?</span><br />
<br />
Items included (no separate payment) within APCs include: incidental services (venipuncture), medical/surgical supplies and equipment, introduction of needle catheters, pharmaceuticals (most), observation services, capital related costs and surgical dressings.<br />
<br />
<i><b>Besides the visit level services (99281-99285 and critical care), what else are hospitals reimbursed for?</b></i><br />
<br />
APCs for visit levels are a basic payment for facility and staff costs. Additional payments are made for additional procedures performed by the nurse or physician. Nursing services that get additional payments include IV infusions and IM injections. These procedures are NOT subject to discount for multiple procedures. This is a change for hospitals that in the past would charge for the medication, and in the charges for the medication was the nursing component. Now, with APCs, the facility is paid for the procedure (such as an injection or infusion), but not for the medication. The physician or nurse may perform the procedures.<br />
<br />
Items excluded (additional payments are made) from visit APCs include: blood products, diagnostic laboratory services, radiographic studies, some expensive medications (such as thrombolytics), immuno-suppressives, Durable Medical Equipment (such as crutches and walkers) and some high cost, infrequently used medications. Two new APCs were created for splinting and strapping. All of the CPT codes for splinting and strapping map to these two new APCs (APC 05 for all leg splints, and APC 059 for all arm splints).<br />
<br />
<span style="font-size: large;">How are payments determined?</span><br />
<br />
Each APC has its own relative weight. Payment for each APC varies, based on the relative weight of that APC. The "two times rule" requires that the ratio of the highest cost service to lowest cost service within an APC cannot be more than 2.<br />
<br />
<b>Medicare reimbursement formula:</b><br />
<br />
Reimbursement for each APC equals: (APC "relative weight") (conversion factor). The conversion factor for 2000 is $48.48. For example, critical care code 99291 maps to APC 620. APC 620 has a relative weight of 8.60. The 2000 conversion factor is $48.487. The 2000 payment for critical care is: 8.60 x $48.487 = $416.99.<br />
<br />
The Local Wage Index is factored. Sixty percent of the APC payment is deemed due to employee wages. So, 60% of APC payment is multiplied by the local wage index, and adjusted accordingly. Forty percent of the APC is not subjected to the local wage index. After the APC is adjusted for the local wage index, a payment is determined, which is the "adjusted payment rate." The co-pay is determined through a historical formula.<br />
<br />
Can beneficiary co-payments vary from hospital to hospital?<br />
<br />
Yes. Hospitals can now compete on the basis of price by lowering patient co-payments. There are minimum and maximum co-payments established for all APCs. Hospitals can elect to reduce co-payments for each calendar year. The decision to reduce co-payments must be for the entire APC category and must apply to the entire year. Hospitals must collect at least the minimum co-payment.<br />
<br />
<span style="font-size: large;">What are some of the new coding issues facing hospitals?</span><br />
<br />
Hospitals are required to use modifiers when both visit levels and procedures are coded to avoid claims of unbundling. Use of modifiers is brand new to hospital coders. Hospitals should still list supplies/medications, although no separate payments will be made. Diagnosis codes should still be assigned to document the medical necessity of services provided. Status codes are assigned to APCs. Surgical procedures that are assigned to an APC with a Status code "T" will pay the full payment for the highest value service. Additional services provided within the same, OR OTHER APC GROUP designated with a "T" status will be paid at 50% of the listed payment. APCs designated with an "S" or an "X" are not subject to the discount for multiple procedures.<br />
<br />
<span style="font-size: large;">How are observation services affected?</span><br />
<br />
No additional payment will be made for observation services which creates an increased financial incentive for physicians to make disposition decisions in a more timely fashion (admit rather than "observe" for hours in the ED). Observation services are bundled into the facility levels. The hospitals will not get extra payment for continued ED observation if the patient is already at the highest APC level. Additionally, there is now an incentive to quickly admit critically ill patients in to inpatient status instead of remaining in outpatient status while in the ED; the hospital will get reimbursed under a DRG instead of an APC if the patient expires.<br />
<br />
Hospitals may still want to report observation services even though they are not getting paid for it. HCFA will continue to monitor for future payment consideration; however if hospitals stop reporting the service, it may be more difficult for HCFA to assess this need.<br />
<br />
<span style="font-size: large;">What are the projected payment implications of APCs?</span><br />
<br />
HCFA is now projecting a minimal decrease or actual increase in payments as a result of implementation of APCs. HCFA is phasing in payments over a four-year transition period. For four years, hospitals experiencing lower payments than they would have without APCs will receive additional payments. Hospitals that generate more revenue during the 4-year transition will get to keep the additional payments.<br />
<br />
<b>How must hospitals adapt to the APC reimbursement methodology?</b><br />
<br />
APCs are a fee schedule based on services provided, much like the physician fee schedule. This fee schedule represents a new approach for hospitals that used to be reimbursed based on their costs. All outpatient services are defined in the CPT manual; there are about 300 distinct procedures provided in the ED. These specific procedures must be listed on the UB92 billed to Medicare.<br />
<br />
Hospitals must identify physician and nursing procedures for outpatient areas—something that they have not needed to do previously for reimbursement.<br />
<br />
Procedures had previously been bundled into the facility levels. Procedures are now billed separately, which for the hospital is essentially like unbundling of services compared to their prior practice. Procedures such as laceration repairs, EKG monitoring, splinting, CPR, etc. must now be identified and coded appropriately (including the use of modifiers) in order to be reimbursed by Medicare at the rate for the corresponding APC. Outpatient nurses need to be trained to identify the procedures they perform and to support the visit level assigned through documentation. There must be an established tiered visit level structure, and coding staff must follow the requirements for assigning the various levels.<br />
<br />
CPT/HCPCS codes are generally a new concern to hospital coders. Hospitals may want to consider outsourcing their coding of emergency department visits. Hospital coders have not had to concern themselves with the issues surrounding outpatient ED services. Training and/or retaining coding staff with expertise in CPT/ HCPCS methodology may prove difficult, and revenue may be lost if coding is done poorly. Maintenance of the charge master is another huge operational challenge that hospitals are facing; if coders have successfully adapted to assigning the appropriate codes, the charge master must be able to identify these codes. Extensive revisions to the charge masters are needed. The charge masters must be able to identify all procedures and list them appropriately as identified in the APC categories. Hospitals may not want to apply APC criteria to all of their payers, because by ignoring each payer's unique billing criteria revenue may be lost.<br />
<br />
<b>Is economic physician profiling one step closer?</b><br />
<br />
Yes. Late physician documentation will delay submission of hospital bills. Additionally, unlike with other hospital services, late charges are unlikely to be allowed once the APC is determined and paid. Medicare will be assigning the APC codes based on the codes submitted by the hospital. Once the APC is assigned, there will not be an easy mechanism for revision. Emergency physicians will need to be timely and thorough in completing their documentation.<br />
<br />
Resource utilization by physicians will come under increased scrutiny. Higher expense medications now represent pure cost, as they provide no added revenue. Choices of medications and the cost of supplies used go directly to the hospital's bottom line. There may be more economic impetus to develop practice guidelines. As mentioned earlier, the choice to admit a patient, versus observing in the ED results in a DRG payment versus an APC payment. The codes assigned will need to be supported through physician and nurse documentation as will the medical necessity of those services. Although there is no requirement for physician documentation to support the visit level assigned, physician documentation will add to the coding in areas where nursing documentation is lacking. In addition, in practicality, coders will be looking to physicians to appropriately and comprehensively identify their own procedures in order to assign the most accurate codes.<br />
<br />
<span style="font-size: large;">What are some future considerations of APCs?</span><br />
<br />
HCFA has not stated that they plan on expanding APCs in to one payment for all services provided in hospital outpatient departments, including the emergency department. However, a single hospital payment would clearly simplify the reimbursement system for Medicare. If there was one global payment that included physician services, ED physicians could find themselves in a difficult position; how would that one lump payment be split up? Would it be left up to the hospital to determine how to split up the payment? It could prove quite difficult dividing up the payments between the ED physicians, medications, radiology, supplies, respiratory therapy etc. and other physician services.<br />
<br />
Additionally, if Medicare saves money through implementation of APCs, it might not be long before we see other payers attempting to utilize the same reimbursement methodology.<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com2tag:blogger.com,1999:blog-5704808848752223620.post-70067709114291243982012-06-01T07:25:00.000-04:002012-06-01T07:25:22.940-04:00ICD-10 Codes<div dir="ltr" style="text-align: left;" trbidi="on">
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (<b>ICD-10</b>), of 1992, is a medical classification list by the World Health Organization (WHO), for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. The code set allows more than 14,400 different codes and permits the tracking of many new diagnoses. Using optional subclassifications, the codes can be expanded to over 16,000 codes. Using codes that are meant to be reported in a separate data field, the level of detail that is reported by ICD can be further increased, using a simplified multiaxial approach.<br />
<br />
The WHO provides detailed information about ICD online, and makes available a set of materials online, such as an ICD-10 online browser, ICD-10 Training, ICD-10 online training, ICD-10 online training support, and study guide materials for download.<br />
<br />
The International version of ICD should not be confused with national Clinical Modifications of ICD that include frequently much more detail, and sometimes have separate sections for procedures. For instance, the US ICD-10 CM has some 68,000 codes. The US also has ICD-10 PCS a procedure code system not used by other countries that contains 76,000 codes.<br />
<br />
Work on ICD-10 began in 1983 and was completed in 1992.<br />
<br />
Some 25 countries use ICD-10 for reimbursement and resource allocation in their health system. A few of them made modifications to ICD to better accommodate this use of ICD-10. The article below makes reference to some of these modifications. The unchanged international version of ICD-10 is used in about 110 countries ICD-10 for cause of death reporting and statistics.<br />
<br />
The United States will begin official use of ICD-10 on October 1, 2014, using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding. All HIPAA "covered entities" must make the change; a pre-requisite to ICD-10 is the adoption of EDI Version 5010 by January 1, 2012. Enforcement of 5010 transition by CMS, however, was postponed by CMS until March 31, 2012, with the federal agency citing numerous factors, including slow software upgrades. The implementation of ICD-10 has already been delayed. In January 2009, the date was pushed back by two years, to October 1, 2013 rather than a prior proposal of October 1, 2011</div>Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.comtag:blogger.com,1999:blog-5704808848752223620.post-75148932786982108412012-06-01T07:24:00.000-04:002012-06-01T07:24:12.966-04:00ICD-9 Codes<div dir="ltr" style="text-align: left;" trbidi="on">
ICD-9-CM (International Classification of Diseases, 9th edition, Clinical Modifications) is a set of codes used by physicians, hospitals, and allied health workers to indicate diagnosis for all patient encounters. The ICD-9-CM is the <a href="http://www.blogger.com/#">HIPAA</a> transaction code set for diagnosis coding.<br />
<br />
ICD means International Statistical Classifications of Diseases. ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings.<br />
<br />
These classifications are developed, monitored and copyrighted by the World Health Organization (WHO). In the United States, the NCHS (National Center for Health Statistics), part of CMS (Centers for Medicare and Medicaid Services) oversees all changes and modifications to the ICD codes, in cooperation with WHO.<br />
<br />
Here is how WHO describes the ICD system: ICDs apply to "all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines." <br />
<br />
The current International Classification of Diseases can trace its roots back to the Bertillon Classification first published in 1893. Starting in 1900, experts met about every 10 years under the auspices of the French government to revise the classifications. The fifth revision was published just before World War II. The World Health Organization took over responsibility for ICD in 1946 with publication of ICD-6. The intended purpose of the ICD-9 diagnosis codes (Volume 1 and 2) is for statistical tracking of diseases. Nothing more. Codes are added only when it can be demonstrated that it will help in the identification and monitoring of the disease.<br />
<br />
The current edition in the United States for morbidity classification, ICD-9-CM, has been in use since 1979. The original intent for the diagnosis codes was for epidemiological and not billing functions, although in the US, the codes are used by payers for billing and reimbursement purposes.<br />
<br />
ICD-9 diagnosis codes consist of 3-5 numeric characters representing illnesses and conditions, and alpha-numeric E codes, describing external causes of injuries, poisonings, and adverse effects; and V codes describe factors influencing health status and contact with health services.<br />
<br />
ICD-9-CM consists of three volumes. Physicians use Volumes 1 and 2 only to assign diagnosis codes. Physicians use Current Procedural Terminology (CPT), published by the American Medical Association, to report medical and surgical procedures and physician service codes, rather than Volume 3 of the ICD-9-CM codes. The 3rd Volume of ICD-9-CM is used by Hospitals for reporting inpatient procedures and resource utilization.<br />
<br />
<b><span style="font-size: large;">There Are Several ICD Code Sets</span></b><br />
<br />
There are actually several lists of these codes, all of which relate to each other. While the code numbers may be the same, sometimes they will have extra numbers or letters attached to them for different uses. In these examples, the use of # will relate to a number. See a description for these numbers, below.<br />
<br />
ICD-##-CM codes are used for diagnosis purposes. CM means "clinical modification." It is used by hospitals and other facilities to describe any health challenges a patient has, from his diagnosis to symptoms to outcomes from treatment, to causes of death. As we move more and more into electronic medical records, these codes will be used even further by physicians and other medical professionals.<br />
<br />
ICD codes are used by government health authorities to track certain diseases. For example, if someone contracts the flu, an ICD-9-CM 486 will be recorded. Certain diseases, often those that are highly contagious, or those that have public health interest like lung cancer or HIV, are tracked by authorities to help ascertain how they spread, where they are prevalent, and perhaps to help budget programs or research to work on prevention.<br />
<br />
ICD codes are also used to describe a cause of death. They are added to death certificates to explain why someone has died. Many of these, too, are tracked by health authorities.<br />
<br />
ICD codes are used internationally (remember, they emanate from WHO) and each country may tailor the codes to fit their own needs. Therefore, some code sets will have extra letters addended to them to describe which country they come from. For example, ICD-##-CA codes are used in Canada and ICD-##-AM codes are used in Australia.<br />
<br />
<span style="font-size: large;">What Do the Numbers Mean? ICD-09, ICD-10 and Others</span><br />
<br />
ICD codes were first developed in 1893 in France by a physician, Jacques Bertillion. They were called the Bertillon Classification of Causes of Death. In 1898, they were adopted in the United States, and were considered, in effect, ICD-1 because that was the first version of code numbers.<br />
<br />
Since then, as medical science has progressed and new diagnoses have been developed, named and described, the code lists have been updated. The number designation changes when the updates are so extensive that a wholesale change needs to be made. There may be annual updates, too, but those are considered to be relatively minor, and the basic code set doesn't change. For example, the upgrade in 1949, ICD-6, was the first time mental disorders were added to the code set. The upgrade in 1977 to ICD-9 was the first time procedure codes were added, and the CM designation was included.<br />
<br />
Most of the codes we see in the United States today are version 9, called ICD-9-CM codes. With few exceptions, the paperwork we receive when we leave a doctors office will contain both CPT codes (Current Procedural Terminology) to describe the service that was rendered for billing purposes, and ICD-9-CM codes to describe why that service was provided. Further, most death certificates filed since 1977 will have an ICD-9 code on them.<br />
<br />
The most current list of codes in use is ICD-10. This list was first used in the United States in 2007. Minor revisions added to ICD-10 codes were made available in early 2009 by the NCHS. Globally, most other countries in the world have implemented the ICD-10 codes. There are some major differences between the two code sets, the transition is very expensive, and most American providers have not yet upgraded to the ICD-10 system.<br />
<br />
ICD-11, the next major update, is projected to be ready in 2010, with expected implementation by 2015. </div>Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.comtag:blogger.com,1999:blog-5704808848752223620.post-30269317714896407512012-06-01T07:21:00.000-04:002012-06-01T07:21:17.159-04:00HCPCS Codes<div dir="ltr" style="text-align: left;" trbidi="on">
<div>
<span style="font-size: large;">Healthcare Common Procedure Coding System</span></div>
<div>
<br /></div>
<div>
The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks") is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT). </div>
<div>
<br /></div>
<div>
HCPCS Codes are numbers assigned to every task and service a medical practitioner may provide to a Medicare patient including medical, surgical and diagnostic services. Since everyone uses the same codes to mean the same thing, they ensure uniformity. For example, no matter what doctor a Medicare patient visits for an allergy injection (code 95115) that doctor will be paid by Medicare the same amount another doctor in that same geographic region would be.</div>
<div>
<br /></div>
<div>
<span style="font-size: large;">History</span></div>
<div>
<br /></div>
<div>
The acronym HCPCS originally stood for HCFA Common Procedure Coding System, as the Centers for Medicare and Medicaid (CMS) was previously (before 2001) known as the Health Care Financing Administration (HCFA). The Healthcare Common Procedure Coding System (HCPCS) was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care. Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.</div>
<div>
<br /></div>
<div>
<span style="font-size: large;">Levels of codes</span></div>
<div>
<br /></div>
<div>
<b>HCPCS includes three levels of codes:</b></div>
<div>
<br /></div>
<div>
<ul style="text-align: left;">
<li>Level I consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric.</li>
<li>Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services not covered by CPT-4 codes (Level I).</li>
<li>Level III codes, also called local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.</li>
</ul>
</div>
<div>
</div>
</div>Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.comtag:blogger.com,1999:blog-5704808848752223620.post-4066462445393367672012-06-01T07:20:00.000-04:002012-06-01T07:20:52.256-04:00CPT Codes<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-size: large;">CPT (Current Procedural Terminology) codes</span><br />
<br />
<span style="font-size: small;"><b>CPT Codes</b> </span>are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer. Since everyone uses the same codes to mean the same thing, they ensure uniformity.<br />
<br />
It should be noted, however, that uniformity in understanding what the service is, and the amount different practitioners get reimbursed will not necessarily be the same. For example, Doctor A may perform a physical check up (99396) and be reimbursed $100 by your insurance company. If you went to Doctor B, his reimbursement by your insurance company for that same checkup, Code 99396, might only be $90. (This is not true for Medicare patients. Medicare uses <a href="http:/#">HCPCS codes</a> instead.)<br />
<br />
(There is another set of codes used by physicians and facilities, too. These are called ICD codes, like ICD-9 or ICD-10 codes. They do not relate directly to billing, so are described separately.)<br />
<br />
CPT codes are developed, maintained and copyrighted by the <a href="http:/#">AMA</a> (American Medical Association.) As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded. Thousands of codes are in use, and they are updated annually. Development and maintenance of these codes is overseen by editorial boards at the AMA, and the publications of all the software, books and manuals needed by those who use them brings millions in income (*see note below) to the AMA each year.<br />
<br />
The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.<br />
<br />
New editions are released each October. The current version is the CPT 2011. It is available in both a standard edition and a professional edition.<br />
<br />
CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim.<br />
<br />
CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Health Care Procedure Coding System. <br />
<br />
<b>Types of codes</b><br />
<br />
There are three types of CPT codes: Category I, Category II, and Category III.<br />
<br />
<b>Category I:</b><br />
<br />
Category I CPT Code(s). There are six main sections:<br />
<div style="text-align: left;">
</div>
<ul style="text-align: left;">
<li>Codes for Evaluation and Management: 99201-99499</li>
<li>Codes for Anesthesia: 00100-01999; 99100-99150</li>
<li>Codes for Surgery: 10021-69990</li>
<li>Codes for Radiology: 70010-79999</li>
<li>Codes for Pathology & Laboratory: 80047-89398</li>
<li>Codes for Medicine: 90281-99199; 99500-99607</li>
</ul>
<div style="text-align: left;">
<br />
<b>Category II:</b><br />
<br />
Category II CPT Code(s) – Performance Measurement (optional) (Category II codes: 0001F-7025F)<br />
<br />
<b>Category III:</b><br />
<br />
Category III CPT Code(s) – Emerging Technology (Category III codes: 0016T-0207T)</div>
<br />
<br />
<br />
<b>Examples of CPT Codes:</b><br />
<ul style="text-align: left;">
<li> 99214 may be used for a physical</li>
<li> 90658 indicates a flu shot</li>
<li> 90716 may be used for chicken pox vaccine (varicella)</li>
<li> 12002 may be used to stitch up a one-inch cut on a patient's arm</li>
</ul>
<div style="text-align: left;">
<br />
If you use Medicare, you'll see CPT codes, but used a bit differently. Medicare uses HCPCS codes (Healthcare Common Procedure Coding System.)</div>
<div style="text-align: left;">
<br />
<b>Matching CPT Codes to the Services They Represent</b><br />
<br />
As patients, our interest in these codes is usually related to our doctors' and insurance billings. Until recently it was difficult to find out what certain CPT codes meant without contacting your insurance company or doctor's office.<br />
<br />
You won't find a freely-available comprehensive list of CPT codes, because the AMA controls their publication. Groups that have tried to make them available for free to the public have been cited for violations, fined by the AMA and have been forced to remove them from the Internet. Since the AMA developed and copyrights the system, it has a right to make sure access to these lists is paid for. It licenses CPT code lists to groups who wish to publish the codes to make them available to others. Those groups then charge a fee for access, too.<br />
<br />
We patients don't have the large sums of money needed to subscribe to websites or purchase publications that list CPT codes. To make them more accessible to us, the AMA does provide on its website a means for looking up the individual CPT codes you might find on your doctor's bills or EOBs (estimates of benefits). </div>
</div>Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.comtag:blogger.com,1999:blog-5704808848752223620.post-86923605806093663272012-06-01T07:19:00.000-04:002012-06-01T07:19:41.153-04:00Medical Billing and Coding Career<div style="text-align: center;">
<span style="font-size: large;">Medical Billing and Coding Career Reference Guide</span></div>
<br />
<b>Considering a medical billing and coding job?</b><br />
<b><br /></b><br />
A career in medical billing or coding offers an opportunity in a field that will always need employees. ContexoMedia will provide you with a brief introductory guide to what a medical billing specialist and medical coder does, what kind of training is needed, expected salary range, and what the career options are.<br />
<br />
You've probably have seen the ads promising at home medical billing and coding jobs. I’ll discuss the reality of medical billing and coding jobs from home based on my experiences.<br />
<br />
<div style="text-align: center;">
<span style="font-size: large;">Career Options</span></div>
<div style="text-align: left;">
Not only is there a need for medical billing and coding specialists for doctors and hospitals, there's also opportunities for medical billing and coding careers as:</div>
<ul>
<li>Consultants for practices advising on billing and coding practices and compliance issues.</li>
<li>Specialists who work for medical billing and coding services and serve multiple practices and specialties.</li>
<li>Insurance and coding specialists for commercial and private insurance and local, state, and federal government agencies.</li>
<li>Advisers for liability and malpractice.</li>
<li>Consumer billing advocates.</li>
</ul>
<div style="text-align: center;">
<br />
Proceed to the NEXT Level...</div>
<br />
<div style="text-align: center;">
<a href="http:/#"><span style="font-size: large;">What is Medical Billing?</span></a></div>Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-82339461349212803342012-06-01T07:15:00.001-04:002012-06-01T07:16:25.079-04:00Medical Auditing<br />
<span style="font-size: large;">What is Medical Auditing?</span><br />
<br />
Medical Auditing Medical auditing is a key step in the livelihood of a compliant and profitable process. Ensuring medical necessity, correct coding and compliance with regulatory issues, a medical audit focuses on many areas of a practice including:<br />
<br />
<ul>
<li>Compliance and Regulatory Guideline Knowledge</li>
<li>Coding Concepts</li>
<li>Scope and Statistical Sampling Methodologies</li>
<li>Medical Record Auditing Skills and Abstraction Ability</li>
<li>Quality Assurance and Risk Analysis</li>
<li>Communication of Results and Findings</li>
<li>The Medical Record</li>
</ul>
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0tag:blogger.com,1999:blog-5704808848752223620.post-2141235742788028052012-06-01T07:12:00.000-04:002012-06-01T07:16:49.738-04:00Medical Reimbursement<br />
<span style="font-size: large;">What is Medical Reimbursement?</span><br />
<br />
Reimbursement for procedures and services performed by providers is made by commercial payers such as Aetna or United Healthcare or federal intermediaries acting on behalf of a half-dozen programs. Reimbursement is based on claims and documentation filed by providers using <a href="http://contexomedia.blogspot.in/2012/05/icd-9-codes.html">medical diagnosis</a> and <a href="http://contexomedia.blogspot.in/2012/05/cpt-codes.html">procedure codes</a>.<br />
<br />
Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Save for specific national mandates such as reimbursement for childbirth, commercial payers determine their own rules of medical necessity or payment and reimbursement fee schedules. Federal intermediaries are regulated as contractors by the Centers for Medicare & Medicaid Services (<a href="http://www.cms.gov/" rel="nofollow" target="_blank">CMS</a>).<br />
<br />
Medicare reimburses physicians and other providers/suppliers for services rendered to Medicare beneficiaries on a fee-for-service (FFS) basis. CMS develops fee schedules for physicians, ambulance services, clinical laboratory services and durable medical equipment, prosthetics, orthotics and supplies.<br />
<br />
For a one-stop resource on the informational needs and interests of Medicare FFS providers, including physicians, other practitioners and suppliers, go to the Provider Center on the CMS Web site.Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com1tag:blogger.com,1999:blog-5704808848752223620.post-71768444647654500112012-06-01T06:38:00.000-04:002012-06-01T07:17:15.863-04:00Medical Coding<span style="font-size: large;">What is Medical Coding?</span><br />
<br />
Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers. The diagnoses and procedures are usually taken from a variety of sources within the health care record, such as the transcription of the physician's notes, laboratory results, radiologic results, and other sources.<br />
<br />
Diagnosis codes are used to track diseases and other health conditions, whether they are chronic diseases such as diabetes mellitus and heart disease, to contagious diseases such as norovirus, the flu, and athlete's foot. These diagnosis and procedure codes are used by government health programs, private health insurance companies, workers' compensation carriers and others.<br />
<br />
Medical classification systems are used for a variety of applications in medicine, public health and medical informatics, including:<br />
<br />
<ul>
<li>statistical analysis of diseases and therapeutic actions</li>
<li>reimbursement; e.g., based on diagnosis-related groups</li>
<li>knowledge-based and decision support systems</li>
<li>direct surveillance of epidemic or pandemic outbreaks</li>
</ul>
<br />
<span style="font-size: large;">What does a Medical Coder do?</span><br />
<br />
Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The Coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS.<br />
<br />
A medical billing coder analyzes patient charts and assigns the appropriate medical diagnosis codes and CPT medical billing codes. These codes are derived from <a href="http://www.blogger.com/#">ICD-9 codes</a> and corresponding CPT treatment codes and any related CPT modifiers. Some medical billing and coding specialists obtain some type of certification from a recognized professional organization. In general the more certifications the greater the income potential. Proper coding is very important to getting fairly reimbursed.<br />
<br />
Good coding complements the billing process and insures the provider is getting fairly compensated. Even if you want to stick strictly to medical billing, having a basic understanding of what the medical coding specialist does is important. If you are a biller, the more you can learn about coding, the more valuable you are to a practice or billing company. Most small practices don't have dedicated coders or billers - they multi-task and may perform limited coding functions in addition to billing.<br />
<br />
The medical billing specialist really needs to know enough about coding to see when the CPT medical billing coding are not compatible with the ICD 9 codes. For smaller practices the provider may do their own coding and the medical billing specialist acts more to identify out of date codes so the provider can correct them. Most practices use a lot of the same <a href="http://www.blogger.com/#">CPT</a> and ICD-9 codes so once you become familiar with the codes and medical billing modifiers, you've conquered the most difficult part. The most commonly used ones may be listed on the practice superbill.<br />
<br />
For family or internal medicine practices, you may see a wider variety of codes and modifiers than for specialty providers. My medical billing company serves smaller practices that may need coding services, so we offer medical coding services to complement our billing services. Many medical billers prefer to stay strictly with medical billing services and that's great. But if you can become proficient in coding - even if you are not an expert - you're much more valuable to a provider.Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com3tag:blogger.com,1999:blog-5704808848752223620.post-16209618769617741662012-06-01T06:25:00.000-04:002012-06-01T07:17:30.573-04:00Medical Billing<span style="font-size: large;">What is Medical Billing?</span><br />
<br />
Medical billing & coding is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government sponsored programs. Medical billers are encouraged, but not required by law to become certified by taking an exam such as the CMRS Exam, RHIA Exam and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field.<br />
<br />
<span style="font-size: large;">So what does a Medical Biller do?</span><br />
<br />
Basically everything involved to get a doctor or other health care professional paid for their services. This is both payment from the insurance carrier and the patient. A medical billing specialist should be detailed oriented, have good math and data entry skills, understand insurance claims procedures, medical billing terms, medical diagnosis codes, and become familiar with medical billing guidelines.<br />
<br />
<br />
<span style="font-size: large;">Medical Billing as a Profession</span><br />
<br />
<b>A medical biller is not a medical coder, but a medical biller might need basic medical coding knowledge, since both disciplines are so closely related and co-dependent.</b><br />
<br />
We can't discuss <b>medical coding</b> unless we also speak about <b>medical billing</b>, so closely are these two tied in with each other. Both discipline's goal is to assure that medical reimbursement claims are promptly processed and submitted to health insurance carriers, and the health care provider and facility gets paid for medical services rendered.<br />
<br />
<span style="font-size: large;">A Medical Biller Is...</span><br />
<br />
Medical billers must understand all aspects of common health care and medical insurance options, including the different plans, carrier requirements, and state and federal regulations. It is also essential that they are able to find and pinpoint relevant information from source documents so that all claims for care and procedures are properly processed. As the saying goes: A medical biller is the provider's key to getting paid!" In order for the doctor's medical practice, clinic, or hospital to prosper the medical biller must know the concept of a clearinghouse and an A/R, and understand how to verify insurance coverage, determine eligibility, collect data, submit all claims, avoid denials, contact patients and communicate with insurance companies to ensure the highest possible return of revenue for their employer, or client.<br />
<br />
<br />
Medical billing for facility-based providers is different from billing for non-facility based providers; just like inpatient coding is different from outpatient coding. Health care provider billing involves submitting claims for individuals, such as physicians, chiropractors, nurse practitioners, physical therapists, podiatrists, dentists, etc.; hospital billing involves claims for inpatient services, which, in turn is different from ambulatory emergency services for people who were treated in the ER, but not admitted to the hospital's nursing ward.<br />
<br />
<span style="font-size: large;">What are Billable Health care Costs?</span><br />
<br />
The biggest segment of health care cost and expenses comes in form of bandages, prostheses, devices, implants, medications, equipment, apparatuses, and countless other items required for modern care. These items and the services associated with them must be properly coded and billed to the patient, or their health insurance provider for reimbursement. This also includes wound care, and hospital stays. Understanding the reason for an insurance company's claim denial is very important.<br />
<br />
<span style="font-size: large;">Submitting Medical Claims</span><br />
<br />
Submitting medical claims is just as diverse as any other job. The medical biller must know the claims processing guidelines for common health care plans, such as Blue Cross/Blue Shield, Tricare, Medicare and Medicaid, etc, and state regulations that apply. There are three basic areas for billing:<br />
<br />
<ul>
<li> inpatient hospital </li>
<li> outpatient services </li>
<li> physician billing</li>
</ul>
<br />
<br />
This goes along with other sub-areas of specialized billing, such as for DME (durable medical equipment), and for home health care, these are the three areas most entry level medical billers are expected to handle.<br />
<br />
<br />
<span style="font-size: large;">Do Medical Billers Code?</span><br />
<br />
A medical biller with enough medical coding knowledge is certainly capable of verifying that medical codes are used correctly, however, the initial medical coding process is not necessarily their forte. Why? Because often they are not specifically trained in medical coding. If they attempt to do it anyway and something goes wrong it can create liability for them. The medical biller's strength lies in their knowledge of different health insurance plans, provider contracts, state rules and regulations and getting denied claims overturned and paid when the denial was incorrect. Of course, experienced medical billers with enough general knowledge of the medical coding process are certainly allowed to handle the medical coding and billing process from start to finish.<br />
<br />
<br />Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com2tag:blogger.com,1999:blog-5704808848752223620.post-73260696889285693322012-05-31T04:34:00.000-04:002012-06-01T07:20:20.633-04:00Diagnosis-related group DRGDiagnosis-related group (<b>DRG</b>) is a system to classify hospital cases into one of originally 467 groups. The 467th group was "Ungroupable". This system of classification was developed as a collaborative project by Robert B Fetter, PhD, of the Yale School of Management, and John D Thompson, MPH, of the Yale School of Public Health. The system is also referred to as "the DRGs", and its intent was to identify the "products" that a hospital provides. One example of a "product" is an appendectomy. The system was developed in anticipation of convincing Congress to use it for reimbursement, to replace "cost based" reimbursement that had been used up to that point. DRGs are assigned by a "grouper" program based on ICD (International Classification of Diseases) diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each "product", since patients within each category are clinically similar and are expected to use the same level of hospital resources. DRGs may be further grouped into Major Diagnostic Categories (MDCs).<br />
<br />
<span style="font-size: large;">Purpose</span><br />
<br />
The original objective of diagnosis related groups (DRG) was to develop a classification system that identified the "products" that the patient received. Since the introduction of DRGs in the early 1980s, the healthcare industry has evolved and developed an increased demand for a patient classification system that can serve its original objective at a higher level of sophistication and precision. To meet those evolving needs, the objective of the DRG system had to expand in scope. Today, there are several different DRG systems that have been developed in the US. They include:<br />
<ul>
<li> Medicare DRG (CMS-DRG & MS-DRG)</li>
<li> Refined DRGs (R-DRG)</li>
<li> All Patient DRGs (AP-DRG)</li>
<li> Severity DRGs (S-DRG)</li>
<li> All Patient, Severity-Adjusted DRGs (APS-DRG)</li>
<li> All Patient Refined DRGs (APR-DRG)</li>
<li> International-Refined DRGs (IR-DRG)</li>
</ul>
<span style="font-size: large;">History</span><br />
<br />
The system was created by Robert Barclay Fetter and John D. Thompson at Yale University with the material support of the former Health Care Financing Administration (HCFA), now called the Centers for Medicare & Medicaid Services (CMS).<br />
<br />
DRGs were first implemented in New Jersey, beginning in 1980 with a small number of hospitals partitioned into three groups according to their budget positions - surplus, breakeven, and deficit - prior to the imposition of DRG payment.<br />
<br />
The New Jersey experiment continued for three years, with additional cadres of hospitals being added to the number of institutions each year until all hospitals in the Garden State were dealing with this prospective payment system.<br />
<br />
DRGs were designed to be homogeneous units of hospital activity to which binding prices could be attached. A central theme in the advocacy of DRGs was that this reimbursement system would, by constraining the hospitals, oblige their administrators to alter the behavior of the physicians and surgeons comprising their medical staffs. Moreover, DRGs were designed to provide practice pattern information that administrators could use to influence individual physician behavior.<br />
<br />
DRGs were intended to describe all types of patients in an acute hospital setting. The DRGs encompassed elderly patients as well as newborn, pediatric and adult populations.<br />
<br />
The prospective payment system implemented as DRGs had been designed to limit the share of hospital revenues derived from the Medicare program budget, and in spite of doubtful results in New Jersey, it was decided in 1983 to impose DRGs on hospitals nationwide.<br />
<br />
In that year, HCFA assumed responsibility for the maintenance and modifications of these DRG definitions. Since that time, the focus of all Medicare DRG modifications instituted by HCFA/CMS has been on problems relating primarily to the elderly population.<br />
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In 1987, New York state passed legislation instituting DRG-based payments for all non-Medicare patients. This legislation required that the New York State Health Department (NYHD) evaluate the applicability of Medicare DRGs to a non-Medicare population. This evaluation concluded that the Medicare DRGs were not adequate for a non-Medicare population. Based on this evaluation, the NYDH entered into an agreement with 3M to research and develop all necessary DRG modifications. The modifications resulted in the initial APDRG, which differed from the Medicare DRG in that it provided support for transplants, high-risk obstetric care, nutritional disorders, and pediatrics along with support for other populations. One challenge in working with the APDRG groupers is that there is no set of common data/formulas that is shared across all states as there is with CMS. Each state maintains its own information.<br />
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In 1991, the top 10 DRGs overall were: normal newborn, vaginal delivery, heart failure, psychoses, cesarean section, neonate with significant problems, angina pectoris, specific cerebrovascular disorders, pneumonia, and hip/knee replacement. These DRGs comprised nearly 30 percent of all hospital discharges.<br />
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The history, design, and classification rules of the DRG system, as well as its application to patient discharge data and updating procedures, are presented in the CMS DRG Definitions Manual (Also known as the Medicare DRG Definitions Manual and the Grouper Manual). A new version generally appears every October. The 20.0 version appeared in 2002.<br />
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In 2007, author Rick Mayes described DRGs as:<br />
<blockquote class="tr_bq">
<b><span style="font-size: large;">“</span></b> ... the single most influential postwar innovation in medical financing: Medicare's prospective payment system (PPS). Inexorably rising medical inflation and deep economic deterioration forced policymakers in the late 1970s to pursue radical reform of Medicare to keep the program from insolvency. Congress and the Reagan administration eventually turned to the one alternative reimbursement system that analysts and academics had studied more than any other and had even tested with apparent success in New Jersey: prospective payment with diagnosis-related groups (DRGs). Rather than simply reimbursing hospitals whatever costs they charged to treat Medicare patients, the new model paid hospitals a predetermined, set rate based on the patient's diagnosis. The most significant change in health policy since Medicare and Medicaid's passage in 1965 went virtually unnoticed by the general public. Nevertheless, the change was nothing short of revolutionary. For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry. Medicare's new prospective payment system with DRGs triggered a shift in the balance of political and economic power between the providers of medical care (hospitals and physicians) and those who paid for it - power that providers had successfully accumulated for more than half a century.<b><span style="font-size: large;">”</span></b></blockquote>
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<span style="font-size: large;">CMS DRG version 25 revision</span><br />
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As of October 1, 2007, with version 25, the CMS DRG system resequenced the groups, so that for instance "Ungroupable" is no longer 470 but is now 999. To differentiate it, the newly resequenced DRG are now known as MS-DRG.<br />
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Before the introduction of version 25, many CMS DRG classifications were "paired" to reflect the presence of complications or comorbidities (CCs). A significant refinement of version 25 was to replace this pairing, in many instances, with a trifurcated design that created a tiered system of the absence of CCs, the presence of CCs, and a higher level of presence of Major CCs. As a result of this change, the historical list of diagnoses that qualified for membership on the CC list was substantially redefined and replaced with a new standard CC list and a new Major CC list.<br />
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Another planning refinement was not to number the DRGs in strict numerical sequence as compared with the prior versions. In the past, newly created DRG classifications would be added to the end of the list. In version 25, there are gaps within the numbering system that will allow modifications over time, and also allow for new MS-DRGs in the same body system to be located more closely together in the numerical sequence.<br />
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<span style="font-size: large;">MS-DRG version 26 revision</span><br />
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MS-DRG Grouper version 26 took effect as of October 1, 2008 with one main change: implementation of Hospital Acquired Conditions (HAC). Certain conditions are no longer considered complications if they were not present on admission (POA), which will cause reduced reimbursement from Medicare for conditions apparently caused by the hospital.<br />
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<span style="font-size: large;">MS-DRG version 27 revision</span><br />
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MS-DRG Grouper version 27 took effect as of October 1, 2009. Changes involved are mainly related to Influenza A virus subtype H1N1.<br />
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Source <a href="http://en.wikipedia.org/" rel="nofollow" target="_blank">Link</a>Anonymoushttp://www.blogger.com/profile/17825854599192162941noreply@blogger.com0