Medical Billing and Coding Interview

Interview, Pages 8 (1769 words)

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Analysis of Medical Billing and Coding

Medical office billing and coding are the engines of the healthcare system. Without this process, the medical field would not be able to effectively transmit information, and the providers would have a difficult time getting the services they rendered paid for. A medicals coders job is to help the providers report a patient’s visits into an alphanumeric or numeric cod which in the medical field is used as a claim for the insurance companies.

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Using ICD-10 CM codes allow medical billers and coders to keep this data accurate for billing procedures. They key element of being a biller or coder is having the educational background or knowledge of the medical field and having attention to detail in all aspects of this field. We will discuss the qualities, skills, and knowledge one will need to posses to have a career in this field.

Medical Office Billing and Coding Professional Interview

In this profession some may say that this career field is challenging if they do not have self-discipline, the skill set on how to use the systems required to complete the tasks at hand and doing it correctly.

In order to excel in this profession a person will also need to require little to no supervision and being okay with not having someone micromanage their work. Behavior is the number one factor at being successful in billing and coding. You must be able to focus and know what your limitations are (Hairston, 2018). In addition, ICD-10 codes are the source of a patients visit and they are inputted with every medical claim that is submitted along with the NPI number, TIN number, and DEA number.

Without ICD-10 codes the medical biller’s job would not be effective and it would hinder the providers office, insurance office, and the flow of claim submissions.

National Provider Identifier (NPI) and Tax Identification Number (TIN)

National Provider Identifier (NPI) is a HIPAA mandated identifier for health care providers who are covered entities under HIPAA. Providers use this to transmit electronic health information, however this does not transmit information about the provider, such as the state where you practice, the provider type, or specialty. Standard HIPPA electronic transactions are considered covered entities, but the NPI must be used in place of the providers identifiers, for instance Provider Transaction Access Number (PTAN), Online Survey Certification & Reporting (OSCAR), and National Supplier Clearinghouse (NSC Centers for Medicare & Medicaid Services, 2018). An NPI number is a 10-digit numeric identifier, which is used to replace the Provider Identification Number (PIN) and the Unique Physician Identification Number (UPIN). The NPI is used to improve the efficiency of the health care system to help reduce fraud and abuse. There are two kinds of NPI’s, individual and group. On base we use it to identify our providers. It also ensures that the provider is using the right type of code for whatever procedure they are doing. That is why each healthcare provider has their own NPI, and if the provider works with a health care group, the group also has an NPI. If the provider is an individual or group practice, the individual NPI will be referenced on the claim, and the individual or group practice NPI will be referenced as the billing provider on the claim.

The Tax Identification Number (TIN) also referred to in our question as a TID, Social Security Number or Employer ID numbers will not replace the national provider identifier (NPI). These will still be used for income, tax purposes and reporting to the Internal Revenue Service (IRS), hence why tax is included in its name. In the tax identification number, it has the billing provider’s tax identification number, as well as the national provider identifier. These two elements are always required on claims that are going to be submitted to insurance companies for billing purposes (Hariston,2018). The interviewee stated that the national provider identifier must be used so the provider can be identified on electronic transactions performed by other entities. Here at Naples Naval Hospital we use it to processes credit cards and bills. Our bills are generated online and it is paid directly to the government.

Claim Submittals

There are several differences between submitting claims for a hospital and submitting claims for a doctors’ office. The military does not have a private practice, so the closet compression would be the parent died is the hospital and the child DMIS-ID is the sub clinic (Hairston, 2018). Professional billing is usually located in medical offices, whereas Institutional billing is inside of hospitals. Professional billing is the process of medical claims that have been generated from the medical work performed by physicians, suppliers and other non-institutional providers. A non-institutional provider would be considered a physician assistant, social worker or nurse practitioner. The professional billing claims are billed on a CMS-1500 (Centers for Medicare and Medicaid) (Hicks 2018). Institutional billing is only used when the medical treatment(s) have been performed in a hospital, skilled nursing facilities, and/or other inpatient and outpatient services. These billing claims would also include the use of supplies, equipment, or different services rendered such as labs and radiology for example (Hicks 2018). Institutional charges are billed on a UB-04. They usually are only responsible for billing, but in some instances, they can be responsible for both billing and collections.

One big difference between professional and institutional billing is a professional biller does more than just billing. Their job responsibilities may have them greet patients, schedule appointments, collect money, and many more tasks. Subsequently hospital coding is more complex than physician coding, because these tasks are only performed by coders (Hicks 2018). Unfortunately, we do not use any of this at our hospital but is aware of these two types of billing procedures. We use a system called Abacus for billing military personnel. All the physicians input the coding into CHCS and the system Alta will generate the ICD-10 code. This allows the billing system for Abacus to provide a diagnosis and completes the billing system. After that it is sent to the CRS system and then CRS sends the bill out to the hospital (Hairston, 2018). The closest system that Naval Hospital Naples Italy uses would be the CMS-1500 since it the main data sheet required by all insurance companies to use.

Employment and Career Qualifications

In order to excel in this profession a person would need to require little to no supervision, focus on them completing whatever task is at hand, self-discipline, and being okay with not having someone micromanage their work. Behavior is the number one factor at being successful in billing and coding. You must pay attention to detail and know what your limitations are (Hairston,2018). Here in our billing office, there are only three foreign nationals and they work in a separate office from the interviewee who is the supervisor. The qualifications required at a minimum would be to computer savvy. This is key, the way technology is evolving one would have to know the basics especially since the job revolves around computers. They would also need to be familiar with the systems that the organization is using, and what systems have been used in the past. In order to be here at the hospital, the interviewee, prefers someone with experience using CHCS, ABACAS, and CRS. As for experience, the longer you have done something the more familiar you are with it since you are around it constantly. One would understand the ends and outs of the systems and know work arounds verse someone who has only been doing the job for three months. The interviewee also stated that you can be taught anything, but if you are not willing to learn and apply yourself you will not make it in this profession or any profession at that matter.

Denied Claims

One of the most common reasons for a claim to be denied, according to the Interviewee, the patient did not provide the correct ICD-10 code. If the ICD-10 code is inputted incorrectly a general code is inputted and the insurance company is unable to identify the code because it is unspecified. The appropriate code lets the insurance payer know the symptoms and illness the patient was being treated for. If the medical office is using an older coding book that is not up to date, they will not have the accurate code to bill the health insurance company and the claim will be denied. If the patient does not give you correct information for instance them changing their insurance company a claim can be denied as well. Verifying the billing information every office visit, will prevent from billing an older insurance company, which in turn cause the claim to be denied. Failure to verify patient’s insurance could cause the office to overlook a terminated coverage, service that are not authorized and/or covered by their plan and see if maximum benefits have been met. In addition, if the claim is filled in a timely matter, depending on insurance such as BlueCross its two years to file a claim. Whereas others like here in Europe its six months. Another reason a claim can be denied is if inaccurate or incomplete patient information. Inaccurate information can consist of patient’s name spelled incorrectly, date of birth incorrect, and invalid insurance information. Or if you have mixed the patients up with a family member verse the patient being serviced (Hairston, 2018).

Medicare

A claim can be filed to Medicare by paper if there is a limited situation. CMS has a listing of exceptions to electronic claim submission. Some of the exceptions include small provider claims, claims from providers that submit fewer than 10 claims per month on average during a calendar year, and claims for payment under a Medicare demonstration project that specifies paper submission. CGS also identified where it may be essential for home health and hospice providers to submit paper claims. The reason for doing so are claims for dates of service that exceed Medicare timely filing guidelines and claims that have been denied by the Federal Black Lung program and the provider is requesting Medicare payment. So, if the claim does not meet any of these exceptions, the Administrative Simplification Compliance Act (ASCA) now requires all initial Medicare claims be submitted electronically as of October 16, 2003. Here in Naples we do not use paper claim forms. We reference the Health Care Information Technology (HIT) which is a part of the Patient Protection and Affordable Care Act of 2010(ACA also, “PPACA”). All organizations are supposed to move towards utilization of technology. Hence paper billing claims are obsolete. (Hairston, 2018)