Position of a Biller in a Physicians Office - Research Paper Example

?Position of a Biller r in a Physician’s Office or Hospital Business Office Introduction It is important for billing and coding professionals to acquire an understanding of the billing, coding and reimbursement guidelines and procedures. They are also required to ensure that proper reimbursement is maintained. The main aim for the guidelines and procedures is to ensure that proper reimbursement for the products and services provided by the hospital is enhanced (Richards, 2009). The reimbursement of the products and services in the hospital is acquired from the self sponsored patients, government programs and insurance firms. Having worked as a coder in the hospital’s business office, I have acquired a broader experience in billing and coding. The various procedures and guidelines are, however, bound to be frequently reviewed due to the changing insurance policies. My main responsibility as a coder in the hospital’s business is to assign codes to the medical services and procedures, which are later used in the billing process. Being a new employee, one’s main duties include examining the medical charts and records of the patients, and then assigning codes to the products and services offered to the patients. It is important for one to keep in mind that accuracy is highly required in this field, as simple errors could result to severe effects; hence, one is required to ensure that the codes assigned to the various treatments are as correct as possible (Wanda, 2008). One is also required to cooperatively work with the physicians and other professionals to ensure accuracy of the patients’ charts (Richards, 2009). Additionally one’s computer skills are essential in this field as the job includes interacting with different coding software. The coding and billing process begins when a patient reports to the hospital for diagnosis for a certain condition, disease or injury. The coder is required to obtain the patient’s demographic and insurance information. The insurance information is essential in determining how payment for the treatment will be made. In other cases, the patients could be self sponsored or sponsored by some government programs. After these details have been obtained from the patient, they are registered into the hospital’s information systems. The physician then specifies the treatment and care services that the patient requires, and they are recorded on the patient’s account (Wanda, 2008). After treatment has been administered on the patient, the different charges are posted to the patient’s account by the various departments. When the patient is leaving the hospital, all the information is gathered from their account for billing. The process of billing also involves the submission of the patient’s bill to the third party payer, such as insurance firms or the government programs, so as to get the reimbursement. In summary, a coder’s main responsibilities includes registering the patients using their details as specified, posting the details and charges to the patient’s account, reviewing the charts, preparing claim forms, submitting the forms and following up for the payment of the outstanding accounts (Richards, 2009). One is also required to fill a medical claim that is later submitted to the third party payer of the hospital bill. The coder must ensure that the information filled in the claim form has no errors. The information required on the claim form includes the patient’s name, address, age, date of birth, group number and identification number. The claim form also includes all the procedure code and diagnosis code to clearly show the medical requirements of the patient. It should also identify the payer of the medical bills, as well as the payer’s identification number and mailing address (Wanda, 2008). Additionally, a coder should ensure that the claim form is submitted to the payer on time, which in most cases involves Medicare. Medicare is a health coverage plan that caters for all the health care needs of the patient including diagnosis and treatment, among other patient care services. When one submits the claim form to Medicare, the information indicated is verified and authorized, after which payment is made according to the information submitted on the claim form. There are, however, two types of claim forms that are submitted to Medicare. These forms include the CMS-1500 and the UB-92 (Von Gunten et al., 2000). The charges for the services provided at the hospital based care are submitted in the CMS-1500. The charges on CMS-1500 also include the physician’s services if the physician is an employee of the hospital. On the other hand, the charges submitted on the UB-92 form do not include charges for the physician’s services. The UB-92 form is where the inpatient charges are submitted (Von Gunten et al., 2000). Moreover, if the patient is admitted at the emergency department, the charges will also be included in the UB-92 claim form. In non patient cases where the specimen are received and processed in the absence of the patient, the coder also submits the details in the UB-92 claim form. The coder uses the UB-92 claim form to submit the charges catered for under Medicare part A, while he uses the CMS-1500 form while submitting charges for the medical equipment involved, covered under Medicare part B (Von Gunten et al., 2000). After filling in the claim forms, the coder can either submit them, manually using paper or using the electronic data interchange (EDI), which is more efficient as compared to the manual method (Richards, 2009). The table below shows the various types of information submitted in the two different of forms; UB-92 CMS-1500 Ambulatory surgery performed in the hospital outpatient department Durable medical equipment provided Ambulatory surgery performed in a certified Ambulatory surgery center. Hospital-based primary care office emergency Department Other hospital-based services Ancillary departments: Radiology A specimen received and processed in the patient’s absence(non patient) Other outpatient services i.e. Infusion Therapy and Observation The claim the coder submits must be clean, such that, Medicare does not have to investigate it to verify the charges. If the claim is clean, it successfully goes through the internal bill edits, Medicare specific edits, and is later paid without any necessary interventions. If the coder submits a claim that does not pass the Medicare specific edits, intervention is then required for closer verification. During verification, the coding professionals closely review the submitted claim information to ensure that a clean claim is submitted (Von Gunten et al., 2000). It is, therefore, necessary that the coding professionals have a broader understanding of the payer procedures and guidelines to ensure compliance, and to avoid payment delays. To avoid such cases of intervention and unnecessary verification procedures, it is essential that the coder ensures that the information he submits is accurate, by reviewing it before submission. The payment and reimbursement methods are categorized into traditional methods, fixed payment methods and the prospective payment system (Von Gunten et al., 2000). The traditional method is where the payment was basically based on the submitted charges. The traditional method was paid in various ways such as fee for fee services, where the payment is based on the charges for every service, fee schedule where the fee is based on the allowed amounts for each service, percentage of accrued services, where the payment is based on the percentage of accrued charges, as well as the usual, customary and reasonable method (Richards, 2009). The fixed payment method, on the other hand, is where payment is based on the fixed amount on the member per month. The prospective payment system is an outpatient prospective payment system used by Medicare to cater for outpatient services. References Richards, C. (2009). Coding Basics: Medical Billing and Reimbursement Fundamentals. Connecticut: Cengage Learning. Von Gunten, F., Ferris, F.,Kirschner, C. & Emanuel, L. (2000). Coding and reimbursement mechanisms for physician services in hospice and Palliative Care. Journal of Palliative Medicine. Journal of palliative medicine, 33 (2):157. Wanda, A. (2008). Adams' Coding and Reimbursement: A Simplified Approach. Amsterdam: Elsevier Science Health. Read More