Medical Billing and Coding - What You Need to Know

Billing and coding needs are essential to each and every organization and so to the health facility. Medical billers and coders are the healthcare professionals in charge of processing patient data such as records of treatment and related insurance information (Lucyk et al., 2017). The latter is tasked with coding a patient’s diagnosis along with a payment request from the patient’s insurance company. As a result, both the medical billing and coding are involved in medical reimbursement cycle. This ensures that the healthcare providers are accurately and efficiently paid for the service they offer. Basically, increasing demands on the providers with decreasing reimbursement requires medical officers to invest in the highly skilled medical billers (Lucyk et al., 2017). The medical biller acquires the necessary knowledge to successfully optimize and maximize a practice’s revenue performance. The financial health and its fitness greatly depend on the effectiveness and overall performance of the billing office.

The primary role of the medical coder is to review clinical statements and assign standard codes Medical coding stands to be a process of translating medical reports into a code used in the healthcare (Jones et al., 2015). The use of the medical codes aid in summarizing medical services and the reports. The codes sets help the medical coders document the condition of the patient and describe the healthcare procedures performed on a patient in particular in response to the condition. On the other hand, medical billing is a process of submitting and following up on claims with health insurance companies in order to receive payment of the service rendered by the healthcare provider. The medical biller needs to understand how to read medical records like CPT, HCPCS Level II, and ICD-10-CM codes. Though the medical biller’s duties vary based on where they work, their duties are generally charged entry, claim transmission, payment posting, insurance and patient follow-up (Jones et al.,2015). Their main responsibility in the healthcare is to follow the claim to ensure the practice receives proper reimbursement for the work performed by the provider.

Strategic planning is of huge importance and is a useful tool for guiding all types of the organizations including the healthcare facility. The level at which the planning process is relevant depends on the unit’s size, its complexity and the differentiation of the service provider (Atasu et al., 2017). For instance, a cardiology unit can be at the appropriate level, as long as the plan aligns with other plans at the higher levels. The process of the planning should be programmable, systematic and rational thus allowing the healthcare organization to focus on the relevant and lasting transformations for the future. To successfully implement the strategy, a change in the organizational culture is required. The culture will guide the behavior of the individuals which may be founded on the shared purpose, value and the behavioral norms (Atasu et al., 2017). Adopting a new organizational structure will facilitate the implementation of the overall strategy. The healthcare future will be based on the integrated systems, patient-centered, which is a new relationship between the hospitals and the physicians. The organization should focus on the high –quality, medical excellent procedures, innovative techniques and participation in the international network and scientific publications. A healthcare facility needs to adopt recent IT platform so as to complement an efficient delivery system. This will facilitate follow up of the patient’s services, by use of a common data definition and containing all patient data. Healthcare IT is acknowledged as an instrumental in the attempt to reduce medical error, enhancing staff productivity improving quality and lowering the costs (Atasu et al., 2017). The healthcare network will be used to implement the continuous process of quality assessment and improvement, risk management and to establish a better communication with the patients. The healthcare will require a well-organized administrative board for its successful operation. The board should incorporate all the stakeholders together with the shareholders. This will enhance proper decision making that suits everyone in the facility thus leading to the effective running of the organization.

Healthcare compliances require the organizations and the providers to develop effective processes policies and the procedures to define appropriate conduct, train the staff and monitor the adherence of the policies and the procedures. The compliance affects every type of health organization from the lowest solo practitioner to the highest global healthcare (Strauss, 2018). To some, the compliance is viewed as unnecessary government intrusion and imposition of unneeded oversight on underappreciated people devoted to helping others. Others view the compliance as a means of improving the quality and availability of the facility while controlling the emerging costs. The government oversight and regulation of the healthcare will never be eliminated entirely. In fact, they will increase as the agencies and other third-party payers implement more quality-based requirements (Strauss, 2018). The purpose of this examination is to provide an overview of the basics of healthcare compliance for organizations and the providers.

The governing body of the healthcare facility is responsible for the conduct of the organization. The body and the executive officers of the healthcare organization will bear the ultimate responsibility of the healthcare compliance. As a result, the governing body will be responsible for directing the organization’s administrators to develop and implement the compliance program. The body must rely upon the individuals of the organization to accomplish the compliance goal. For healthcare data security, cyber risks need to be addressed that affect the operation of the facility. Hacking of information such as patient’s name, medical record numbers, dates of birth and medication pains the health care providers to a greater extent (Strauss, 2018). Such incidences stand to be a looming security problem for all within the reach of the healthcare data. Technology is said to run the risks of the security breach and is a key ingredient for a strong and effective security strategy in an era of regulated compliance. Data compromise is often preceded by theft and asset intrusion. This calls the security managers and compliance officers to take proactive steps to improve their records security and data privacy while maintaining records privacy (Strauss, 2018). It is therefore important for the privacy, security and compliance leaders to have the deep understanding of the relevant regulations including the scope and intent.

Health Information Systems (HIS) captures, stores and manage information related to the health of the individuals. A well –functioning HIS is an integrated effort to collect, process and report the use of the health information and the knowledge to influence policy and decision making (Nielsen &Saeba, 2016). Information system, particularly at the lower levels of the health systems, needs to be simple and sustainable rather than being a burden on the delivery staff and costly to run. The staff needs feedback on how the routine data they collect can be used and should understand the importance of good quality data for improving health. Capacity building is required to ensure policymakers at all levels have the ability to use and interpret health data, whether it originated from the routine systems or special operational research (Nielsen &Saeba, 2016). Local use of data collected at the lower levels of the health systems is a key step for improving overall data quality. Furthermore, aggregate patient information improves the quality and use of health information. A Health Information System requires the following components for its smooth running. His information resources such as legislative, regulatory and planning frameworks are required for the latter system to be functional. The resources will involve the personnel, financing, logistic support, information, and communication technology (ICT) together with coordinating mechanisms (Nielsen &Saeba, 2016). A core set of indicators and related targets is the basis for a health information system plan and strategy. The indicators need to encompass determinants of health, health system inputs, output and outcomes and health status. Data sources such as individual, service, and resource records are crucial to the provision of important information which may not be available elsewhere. Data management will cover all aspects of data handling from the collection, storage, quality assurance, and flow in order to process compilation and analysis (Nielsen &Saeba, 2016). Information products data must be transformed into information that will become the basis for evidence and knowledge to shape health action. In terms of dissemination and use, the value of the health information is enhanced by making it readily accessible to decision-makers and by providing incentives which will facilitate the information useful.

References

Atasu, A., Toktay, B., Yeo, W. M., & Zhang, C. (2017). Effective Medical Surplus Recovery . Production & Operations Management, 26(6), 1142-1162. doi:10.1111/poms.12641

Jones, C. A., Bull, J., Acevedo, J., & Kamal, A. H. (2015). Top Ten Inpatient Palliative Medicine Billing and Coding Mistakes (and How to Fix Them This Week).  Journal Of Palliative Medicine, 18(3), 211-216. doi:10.1089/jpm.2015.0005.18.3

Lucyk, K., Tang, K., & Quan, H. (2017). BMC Health Services Research .Barriers to data quality resulting from the process of coding health information to administrative data: a qualitative study. 171-10. doi: 10.1186/s12913-017-2697-

Nielsen, P., & Saeba, J. I. (2016). Three Strategies for Functional Architecting : Cases from the Health Systems of Developing Countries. Information Technology for Development,    22(1), 134-151.

STRAUSS, L. J. (2018 ). Enforcing the Privacy and Security Rules . Journal Of Health Care Compliance, 20(4), 55-58.