Healthcare Reimbursement

Topics: Medical classification, ICD-10 Procedure Coding System, Diagnosis codes Pages: 6 (2290 words) Published: March 18, 2013
My paper will be discussing medical coding systems: past, present, and future. I will be comparing the International Classification of Diseases 9th Revision Clinical Modification and the International Classification of Diseases 10th Revision Clinical Modification, why the International Classification of Diseases 9th Revision Modification is being changed to the International Classification of Diseases 10th Revision Modification, history and background of medical coding systems, how fraud impacts coding systems in physician’s offices and talking about the effect of coding errors. ICD-10-CM should be easier to find the codes because of all the new codes and distinguishing of different body parts. CODING FRAUD

To understand how fraud impacts coding systems one must understand how medical professionals and health care facilities are reimbursed for their services. In most cases a patient does not pay for a service directly. Most payments to medical professionals and health care facilities are made by a third party payer, whether it is private insurance or a government program like Medicare. “The ICD-9-CM is used by physician’s offices to code and classify morbidity data from medical records, physician offices, and surveys conducted by the National Center for Health Statistics” (Valerius, Bayes, Newby, Seggern, 2012, p. 128). This is the coding process. They billing or coding specialist fills out the coding form to send to the third-party payer (insurance company) so the hospital or physician’s office can be reimbursed for the services rendered. Coding can be very complicated and can lead to fraud by upcoding, assumption coding, billing invalid/outdated codes, downcoding and various other problems. “Upcoding is the use of a procedure code that provides higher payment” (Valerius, Bayes, Newby, Seggern, 2012, p. 243). Upcoding is very easy to accomplish, and difficult to detect. All a physician has to do is embellish a patient’s diagnosis to justify higher payments from both the patient and the third party payer. It is easy to do, because the patients and the payers know very little about medicine and what the correct diagnosis should be. “Assumption coding is reporting undocumented services the coder assumes have been provided due to the nature of the case or condition” (Valerius, Bayes, Newby, Seggern, 2012, p. 242). Coding specialist can make this mistake by just assuming a service was provided when in reality was never done. “Downcoding is coding a lower level code” (Valerius, Bayes, Newby, Seggern, 2012, p. 243). This can happen because coding specialist don’t take the time to find the correct code and instead just downcode to a lower level code which means the hospital or physician doesn’t receive the correct reimbursement amount. Routine blood tests, urinalyses, and radiographs can be categorized as unnecessary billing when a patient does not need them, or they are perfectly healthy. ICD-9-CM VS ICD-10-CM

There are several problems with the current classification system including: “The ICD-9-CM Tabular List is running out of numbers to assign for codes and in some cases, new code proposals could not be adopted because of the limited space. The current ICD-9-CM diagnosis codes do not provide sufficient clinical specificity to describe the severity or complexity of the various disease conditions. In particular, the codes for healthcare encounters for other than disease (V codes) do not provide enough specificity. Consequently, there are increasing requirements for submission of additional documentation in order to support claims. The exchange of meaningful healthcare data with healthcare organizations and professionals around the world is hindered by the fact that many countries are presently using ICD-10 or a clinical modification of it (Australia and Canada, for example, have modifications). Even in the US, mortality statistics (information on death certificates) have been collected using ICD-10...
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