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Don't follow the guidelines its possible to face a federal investigation. Health Insurance Portability Accountability Act (HIPAA) was approved by Congress and signed by President Clinton in 1996. HIPAA was created to keep patients’ medical insurance and patients' medical record secured. HIPAA also makes sure there are no fraudulent medical records. Anyone who violates HIPAA guidelines faces criminal charges. To document a patient’s diagnosis and treatment, the medical biller and coding specialist use set codes. These codes are also used to submit a claim to the insurance company so the provider can be reimbursed for the service provided to the patient.
HIPAA created the use of ICD codes for diagnosis, CPT and HCPCS codes. These codes are used for medical billing to create claims. HIPAA also created the use of electronic medical transactions. All providers and billers covered by HIPAA are required to submit electronic claims using approved code set numbers. Each transaction forms have their own rules. ICD-10 codes (International Classification of Disease) are used by physicians and healthcare to provide code for all diagnosis, symptoms, and procedures CPT codes (Current Procedural Terminology) are used to report medical, surgical, and diagnostic procedures and services.
HCPCS codes (Healthcare Common Procedure Coding System) are used for coding products, supplies, and services such as ambulance services, durable medical equipment, prosthetics, orthotics, and supplies. HCPCS codes for medical, surgical, and diagnostic services.
HIPAA contains three rules, the privacy rule, the transaction rule for standard formatting for electronic transactions, and the security rule. When a patient is feeling ill and goes to the doctor, the provider diagnosis the patient and prescribes medication.
When the provider does this the provider is providing medical service to the patient and needs to get paid for the service. The provider’s office then generates a medical report and set the code and transfer to the biller. The biller reviews the document and determines how much to pay the provider. The biller creates a claim form and sends the claim electronically to the insurance company. The insurance company will then reimburse the provider. If a claim is not submitted correctly the insurance company will deny the claim. A letter of explanation of denial of the claim form will be sent to the patient.
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