Healthcare organizations must followregulations and mandates posed by the government in order for theirestablishment to function correctly. Guidelines affect every aspect ofhealthcare, especially billing and coding. Every provider must also understandthe role they play in reimbursement. Healthcare professionals must always ensurecompliance is attained with respect to the agreement made between them and thethird-party payers who are providing reimbursement services to their organization.
The claim forms vary from payer to payerbut coding must meet the guidelines implemented by the InternationalClassification of Diseases (ICD-9-CM) and ICD-10-CM. The American HospitalAssociation (AHA), the American Health Information Management Association(AHIMA), and NCHS are the organizations who approved the morbidity classifications(Harrington, 2016). Health Care Financing Agency implemented thenew Outpatient Prospective Payment System (OPPS). This program, mandated by theBalanced Budget Act of 1997, applies to hospital outpatient departments,community mental health centers and for some services provided by comprehensiveoutpatient rehabilitation facilities, home health agencies and servicesprovided to hospice patients for the treatment of a nonterminal illness(Rosenberg & Browne, 2001).
HIPAA demands for all healthcareorganizations to follow these coding laws because without them, payers will notreimburse them for their services. If they don’t follow the rules many healthcareorganizations may also be in default and could possibly be fined, closed, and atrisk for revocation of licensing. All coders must know that there is no roomfor mistakes when it comes to adhering to coding guidelines. Providersuse the ICD-9-CM coding to determine payment categories for various ProspectivePayment Systems (PPS). Hospital Inpatient uses Medicare-severity diagnosis-relatedgroups (MS-DRG), Hospital Rehabilitation uses case-mix groups (CMGs), Long-termCare uses long-term care Medicare-severity diagnosis-related groups (LTC-MS-DRGs),and Home Health uses home health resource groups (HHRGs) (Harrington 2016).Billing and coding is a complex and thoroughduty that must be continuously updated and reinforced. Although there is noroom for error in the healthcare field, mistakes do tend to happen.
Coders maycome into situations where incorrect documentation can lead to delays inpayment or the organization can receive inappropriate payments for servicesthat weren’t made. Medicare abuse may include misusing codes on a claim, chargingexcessively for products or services, and billing for services that were notmedically necessary. Both Medicare fraud and abuse can expose providers tocriminal and civil liability (Harrington, 2016). I believe that the FraudPrevention System implemented by the CMS has proven to be helpful in improvinghealthcare costs. In 2012, the government recovered $4.
2 billion dollars from individualscommitting fraud (Harrington, 2016). Another great tool which healthcareorganizations have at their disposal to help assist them in adhering to therules, guidelines, and regulations related to the PPS is the Federal Register.This documents is updated annually and changes are published through the Noticeof Proposed Rulemaking (NPRM). Prospective payment thus provides a potentialsolution to the problem of increasing hospital expenditures that threatens thesolvency of the Medicare program (Guterman & Dobson, 1986). ReferencesGuterman,S., & Dobson, A.
(1986). Impact of the Medicare prospective payment systemfor hospitals. Health Care Financing Review, 7(3), 97–114 Harrington,M.
K. (2016). Healthcare Finance: and the Mechanics of Insurance and Reimbursement. Burlington, MA: Jones& Bartlett Learning Rosenberg,M. A., & Browne, M.
J. (2001). The impact of the inpatient prospective paymentsystem and diagnosis-related groups: Asurvey of the literature. North American Actuarial Journal, 5(4), 84- 94