Week 8: Billing, Coding, and Reimbursement
Week 8: Billing, Coding, and Reimbursement

Billing, Coding, and Reimbursement

Throughout this course, we have discussed and explored informatics as it applies specifically to aspects of clinical practice. However, another rich source of data is administrative data. Administrative data include billing information derived from insurance claims, inpatient discharges (or hospital bills), and outpatient visits (the bill for emergency room visits that do not result in being admitted to the hospital or services delivered in a hospital but not part of an overnight admission). Administrative data include documentation of clinical diagnoses and use of health services as recorded through predefined coding systems such as the International Classification of Diseases, ninth revision, Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPTs), or Healthcare Common Procedure Coding System (HCPCS).

Reimbursement codes are assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. This is a critically important intersection between the clinical and administrative teams. If the patient encounter, procedure, or diagnosis are incorrectly entered into a clinical management system, the billing and coding process will also be incorrect. Providers play an important role in ensuring the success of the business by clearly identifying the diagnosis and service codes that are appropriate for each patient visit. Therefore, it is imperative for APNs to have knowledge of the link between billing, coding, and the EHR. Success application of ICD-10 codes are not intuitive and require training beyond the scope of this course.

Resources

A free Web reference available to providers on this coding can be found at  http://www.icd10data.com (Links to an external site.) . Educational tools and manuals can also be accessed at the CMS Web site:  http://www.cms.gov/Medicare/coding/ICD10/downloads/pcs_refman.pdf. (Links to an external site.)

Diagnosis-related groups (DRGs) or major diagnostic categories (MDCs) systematically group these more specific codes into meaningful broader categories. The purpose of the DRG group is to facilitate payment through the prospective payment system, whereas MDCs organize diagnoses that affect similar physiological systems. Although administrative data reflect diagnoses and utilization, it is important to remember that their primary purpose is for billing. Therefore, more expensive services are likely to be identified first in the administrative record, not necessarily as events or procedures occurred chronologically or even simultaneously.

Billing and Coding – Part 1

Click to view the interactive.

Billing and Coding – Part 1 (Links to an external site.)

Transcript

Billing and Coding – Part 2

Click to view the interactive.

Billing and Coding – Part 2 (Links to an external site.)

Transcript

Billing and Coding – Part 3

Click to view the interactive.

Week 8: Billing, Coding, and Reimbursement

Billing, Coding, and Reimbursement

Throughout this course, we have discussed and explored informatics as it applies specifically to aspects of clinical practice. However, another rich source of data is administrative data. Administrative data include billing information derived from insurance claims, inpatient discharges (or hospital bills), and outpatient visits (the bill for emergency room visits that do not result in being admitted to the hospital or services delivered in a hospital but not part of an overnight admission). Administrative data include documentation of clinical diagnoses and use of health services as recorded through predefined coding systems such as the International Classification of Diseases, ninth revision, Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPTs), or Healthcare Common Procedure Coding System (HCPCS).

Reimbursement codes are assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. This is a critically important intersection between the clinical and administrative teams. If the patient encounter, procedure, or diagnosis are incorrectly entered into a clinical management system, the billing and coding process will also be incorrect. Providers play an important role in ensuring the success of the business by clearly identifying the diagnosis and service codes that are appropriate for each patient visit. Therefore, it is imperative for APNs to have knowledge of the link between billing, coding, and the EHR. Success application of ICD-10 codes are not intuitive and require training beyond the scope of this course.

Resources

A free Web reference available to providers on this coding can be found at  http://www.icd10data.com (Links to an external site.) . Educational tools and manuals can also be accessed at the CMS Web site:  http://www.cms.gov/Medicare/coding/ICD10/downloads/pcs_refman.pdf. (Links to an external site.)

Diagnosis-related groups (DRGs) or major diagnostic categories (MDCs) systematically group these more specific codes into meaningful broader categories. The purpose of the DRG group is to facilitate payment through the prospective payment system, whereas MDCs organize diagnoses that affect similar physiological systems. Although administrative data reflect diagnoses and utilization, it is important to remember that their primary purpose is for billing. Therefore, more expensive services are likely to be identified first in the administrative record, not necessarily as events or procedures occurred chronologically or even simultaneously.

Billing and Coding – Part 1

Click to view the interactive.

Billing and Coding – Part 1 (Links to an external site.)

Transcript

Billing and Coding – Part 2

Click to view the interactive.

Billing and Coding – Part 2 (Links to an external site.)

Transcript

Billing and Coding – Part 3

Click to view the interactive.

Week 8: Tracking Patient Outcomes

Tracking Patient Outcomes

The Affordable Care Act created the National Prevention Council, which developed the National Prevention Strategy (NPS). In 2011, the National Prevention Council released the National Prevention Strategy: America’s Plan for Better Health and Wellness, a comprehensive plan that sets forth evidence-based and achievable means for improving health for all Americans at every stage of life. These efforts are designed to stop disease before it starts and to create strategies for a healthy and fit nation, recognizing that prevention must be part of daily life. The NPS guides the nation in identifying the most effective and achievable means for improving health and well-being. It prioritizes prevention by integrating recommendations and actions across multiple settings to improve health and save lives. Because many of the strongest predictors of health and well-being fall outside the health care setting, the strategy envisions a prevention-oriented society where all sectors recognize the value of health for individuals, families, and society and work together to achieve better health for all Americans. The National Prevention Strategy identifies four strategic directions—the foundation for all prevention efforts—and seven targeted priorities designed to improve health and wellness for all Americans (National Prevention Council, 2014). The goal of the NPS is to transform us from a system of sick care to one based on wellness and prevention. 

With the rapid evolution of technology in health care, it is important to be knowledgeable about current healthcare information. Resources such as the NPS, Healthy People 2020, and the USPSTF recommendations are essential tools to help clinicians keep up to date with current best practices. All of these initiatives have Web sites that provide updates to the current printed reports. The NPS encourages partnerships among federal, state, tribal, local, and territorial governments; business, industry, and other private sector partners; philanthropic organizations; community and faith-based organizations; and everyday Americans to improve health through prevention. Initiatives such as Healthy People 2020 and the USPSTF recommendations are excellent examples of well-researched tools that can help to enhance health promotion and disease prevention. The end result will be comprehensive care to patients with the goal of optimal health for all.

The Healthy People 2020 initiatives continue to have a significant impact on primary health care in the United States. The incorporation of health-promoting and disease prevention strategies has become the foundation for primary care. It is believed that all of the goals of Healthy People 2020 are achievable with support from individual healthcare providers, local and national government agencies, and, most important, the active participation of individual patients.