aspects of clinical practice

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

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

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Billing and Coding – Part 2

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

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Billing and Coding – Part 3

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aspects of clinical practice

aspects of clinical practice

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