Overcoding? Use bell curve as guide only.
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In summary, it is also important to remember the hidden rules: 1) Just because there is a code in the manual, it doesn't mean it can be billed to insurance, or that once billed, it will be reimbursed. 2) Just because a code was paid once, doesn't mean it will ever be paid again--or that you get to keep the money! 3) The healthcare provider is responsible for knowing all the rules, but then it is impossible to know all the rules! And not knowing all the rules can lead to fines, penalties or worse! New codes are added annually (quarterly for OPPS), definitions of existing codes are changed, and it is the responsibility of healthcare providers to keep abreast of all coding updates and changes. In addition, the federal regulations are constantly updated and changed, making compliant billing a moving target. All healthcare entities should focus on complete documentation, the adherence to authoritative coding guidance and the provision of detailed explanations and specialty education to the payor, as necessary.
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This article reviews the kinds of electronic transactions required under the Health Insurance Portability & Accountability Act (HIPAA) and relates them to relevant data contained in an electronic oral health record (EOHR). It also outlines the structure of HIPAA transactions using the claim transaction as an example. The relationship of the HIPAA resource management function to those of patient care are discussed. The discussion points out potential future uses of other existing resource management transactions to realize the maximum potential of linking the primary patient care functions to those functions related to managing resources in support of that care. This is needed in all aspects of oral health using the informatics standards activities in which the American Dental Association (ADA) actively participates. The article concludes by providing the dentist a perspective on how to relate these capabilities to his/her individual practice setting.
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We calculated a sample of AHRQ Quality and Patient Safety Indicators for UVa hospitalized patients over a 3 year period using diagnoses and procedure codes from two different billing systems. Significant differences in results were observed suggesting that quality indicators calculated from hospital billing sources alone may be understated.
Practices depend on proper coding of procedures and diagnoses to obtain maximal reimbursement. Proficient coding by both educated physicians and staff is dependent on transmission of correct information. A well-designed encounter form is one key to enhance the process. This article provides some practical guidelines for making the encounter form more effective.
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