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Healthcare facilities are required to maintain licensure, certification, and accreditation in order to receive payments from federal government programs such as Medicare. Healthcare facilities must meet the minimum standards in order to operate, such as sufficient staffing, personnel employed to provide services, the quality of equipment, buildings, and supplies, and services provided, including health records. (LaTour, 2013) Medicare has developed Conditions of Participation and Conditions for Coverage, which identifies specific criteria that must be met in order to receive reimbursement from Medicare. Medicare implements these guidelines in order to

The patient is informed about their coverage and the amount of copayment they would have to pay.

“the contractor shall further insure that all medical, dental, and mental health services are secured from a Medicaid approved provider and that charges for services shall be at the Medicaid approved rates. If no Medicaid provider is available the contractor must make every

The second obligation pertained to the circulation of the yearly prescription costs that followed the simple design for health costs which was normally the main part of the program’s expenses which were caused by a small number of the programs enrollees. The costs from the small amount of enrollees have the ability to be an enormous amount. Therefore, in order for the Medicare prescription program to offer most support for the participants that required it more than the catastrophic coverage had to have a lower co-pay amount attached to it. The model’s ending fee level has a five percent co-insurance obligation without a limit of on coverage. (Kaplan 2011)

Medical codes are assigned to procedures and diagnoses to bill insurance companies for the services doctors and other health care workers provide to patients. Diagnosis codes must be correctly linked to procedures to establish medical necessity.

The Medicare set-aside requirement is intended to prevent workers' compensation insurers from shifting the expense of the claimant's future medical treatment to Medicare. It is therefore only a hindrance to settlement when the settlement is intended to include compensation for future medical expenses. Some states have enacted workers' compensation laws that permit the settlement of only the indemnity portion of the claim, ending the insurer's liability for that portion while leaving the medical aspect of the claim open. In such instances, the insurer remains liable for the claimant's future medical treatment, and there is therefore no potential for shifting the cost to Medicare. As such, Medicare

The topic of transitioning to the ICD-10 coding system has become a very big issue within the medical practice field. In fact, as of October 1, 2015, all physicians, hospitals, and medical providers are required by the federal government to be in full compliance using ICD-10 coding. ICD-10-CM codes allow for medical providers to provide as much information as possible about the patients state of health and all treatment provided as such. In addition, "The CPT coding system offers doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency (Ama-assnorg, 2015)."

Realizing that Part A had some flaws, and could prove to become very expensive for those patients who were chronically ill and might not be able to afford treatment within the given coverage guidelines of Medicare Part A, CMS devised an optional Medicare Part B program, commonly referred to as “physician services”.  Medicare Part B not only adds additional insurance, but also covers other health care needs, particularly those not covered by Part A.  This Supplemental Medical Insurance (SMI) does not cover the services 100%, but rather 80%, where the beneficiary would only be responsible for the remaining 20%, also known as a coinsurance. (Lonchyna)

My mother, on a fixed income, decided that she did not want to pay the annual premium for Medicare B or D and didn’t want to have a Replacement (E) or supplement, so she only enrolled in Medicare A. Had my mom, however, been equipped with the info we’ve just covered before she completed her enrollment, she would have been better prepared for the bill that she received. She would know that her effort to cut costs would lead to her actually paying more as this “free” coverage would not provide adequate coverage for her particular health

Due to the advances in technology, medical practitioners are more able to retrieve medical information. Coding systems, such as ICD-10-CM, CPT, and HCPCS are used to code and enter such information into a database. These coding systems are useful in administrative and statistical purposes. The Center for Medicare & Medicaid Services, CMS uses a prospective payment services, which was effected in 2012 and 2013 to ensure better health care at lower costs (CMS, 2015).

Medical coding is a very detailed process in which health care professionals use to code an insurance claim, to submit for reimbursement of services. In the following scenario, my task would be to explain the process and steps I took, to code patients cases using ICD-9. When coding it’s very important to code correctly to avoid delays in reimbursement and proper reimbursement. The following will explain the steps I took to perform proper medical coding.

In the prior weeks, I had noted that many health care professionals utilize many different methods of practice, as well as implement a certain something to each of the medical cases that reflects that clinician’s style. No matter the endless routes to get to a diagnosis or the many diverse recommendations of treatment for that diagnosis, codes are the same. The medical field having a universal set of codes for diagnoses and procedures/interventions is very important because this set of codes keeps all clinicians, medical facilities and insurance companies on the same page. From what I read, the universal set of codes consists of two volumes

Medical billing is the health care area selected for the discussion. Medical billing is the process of submitting and tracking claims with health insurance companies in order to receive payments for the services rendered by healthcare providers to ensure business finances success. (https://en.wikipedia.org/wiki/Medical_billing). Usually, the process is performed by electronic means and each claim must be a mirror image of the patient encounter. Although electronic billing carries sensitive information most practice management billing software relies on the clearinghouse which converts the data into HIPAA format. Thus, information is encrypted to minimize any unauthorized access. The actual diagnosis code system will be replaced by ICD-10 on October 1, 2015. Hence, the need for greater coding accuracy and specificity has heightened considerably since the implementation of ICD-9-CM (Bowman S., 2008).

ABN, notification is a notification to the patient in advance of services that Medicare probably will not pay for and the estimated cost to patient (formerly WOL, waiver of liability). Medicare has a form that can be downloaded and each commercial payer may have their own ABN form that needs to be requested by the providers.

The outmoded coding professional’s role was to describe and apportion diagnosis, procedure, and other medicinal service codes using ICD-9-CM and HCPCS/CPT coding classifications while referencing the Coding Clinic for ICD-9-CM, Coding Clinic for HCPCS,