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As you know, working medical coders and billers, as well as recent graduates from vocational training programs should seek certification as soon as possible to succeed!

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Using The Right Codes

Medical providers use a standardized system of numerical codes for patient services, required by Medicare, Medicaid, and other Government programs. In this way, insurers and the Government do not have to decipher what services were provided from myriad records or from thousands of different types of coding or billing systems.

*Example: Each Medicare billing code is tied to a particular group of services and will eventually result in a reimbursement to the physician or other provider (hospital, psychologist, chiropractor, etc.) based upon the code entered by the provider.

Upcoding: A Big "No-No"!

Misuse of these standardized codes to obtain more money than is allowed by law is commonly termed upcoding, or upcharging. Some providers—or the organizations for which they work—are tempted to upcharging or increasing their claims by exaggerating or even falsely representing what medical conditions were present and what services were provided. Their reasoning is that by reporting a more serious medical condition, or listing more medical conditions as being present or treated, the more extensive the services rendered were, and the greater their reimbursement payment will be.

Upcoding Examples

An example of upcoding would be when a two-minute visit for diagnosis and treatment of an upper respiratory condition (i.e. a cold without complications) is “upcharged” from a very low reimbursement rate code by instead intentionally using codes for a more serious ailment.

Thus, the "URI" diagnosis is altered to falsely diagnose the patient as suffering from a more severe bronchitis and sinus infection, with some breathing impairment requiring nebulizer treatment, all requiring a one-hour office visit. In either case, whether the additional services billed were not even provided or if provided, but not needed medically, a fraudulent upcharge occurs.

* Note: In a hospital setting or other specialized area of medicine there are many more applicable codes than those that appear pre-printed on the bill from your outpatient visit to the family doctor.

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Free Forms, Templates, Worksheets for the Medical Office

Forms that can be customized for use in your practice: Physicians Practice Tools and Form

Attention Medical Coders and Billers:

New graduates get certified based on training. Working individuals get certified based on employment and experience!

Run Your Business Like a Business!

The federal government strongly encourages health compliance programs and promotes voluntary billing compliance and self-policing in a variety of ways. For instance, in the case of Medicare and the OIG, the existence of a corporate compliance program influences the approach to a violation of a federal requirement in terms of an innocent mistake or a fraudulent act. The existence of a corporate billing compliance program may determine whether the matter can be routinely handled as an overpayment by the payer or it must be investigated by the OIG, or even referred to the Department of Justice to be pursued as a civil infraction or as a criminal matter. Do not ever “touch up” or otherwise change your notes or chart and be careful when using modifier 25 and 59. Precision and accuracy eliminates the risk of errors that could lead to billing errors and then an audit! An audit can hurt the business.

MEDICARE Fee Fixed: After more than two years of hard work the AMA welcomed news that the House and Senate on February 21, 2003 passed the Omnibus Appropriations package (H. J. Res. 2) which includes plans to fix the Medicare payment issue. As it turns out the Medicare physician payment system need to be truly reformed. If not, Medicare payment rates in 2014 will be little more than half what they were in 1991, after adjusting for practice cost inflation.

Both houses of Congress recently passed budget legislation that will freeze Medicare physician payments at the 2005 level. This action will reverse the physician payment cut of 4.4% that went into effect on January 1, 2006.

For additional information go to the AMA Website!

Read Medicare Physician Fee Schedule Final Rule.

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Benefits of Medical Billing and Coding Certification... Countless job seekers face barriers to employment and promotion because they lack professional credentials! Certified professionals are more readily hired at higher pay than their non-certified counterparts. Since 1989 over 150,000 health care professionals have earned the recognition and rewards gained from passing NHA certification exams. By attaining certification they have joined a growing distinguished group of knowledgeable and expert health care professionals. NHA grants Certified Billing and Coding Specialist credentials to: new graduates based on their training working individuals based on experience through NHA's Home Study Program		Reasons Behind the High Demand For Medical Billers Medical, therapeutic, and pharmaceutical services play an important role in our nation's economy! Driven by the ever increasing need for medical services wherever there are people the opportunities in healthcare related disciplines never cease to exist. There is plenty of room for men and women in healthcare occupations as long as they have the drive to achieve their dreams. Employment is not limited by location, gender, race, religion, or even disability. Recruiters and employers are readily hiring qualified staff to better serve their patients and clients; this includes medical billers, whose job it is to make sure healthcare providers get paid for the medical services they have provided in their community.