Question

PLEASE ANSWER ALL THE QUESTIONS:

1) Periodic, internal audits of your coding, billing, and documentation practices is one of the best ways to detect and eliminate upcoding and downcoding (and many other compliance risks, in addition). For example, you might self-audit 20 records per provider, every six months, to pinpoint inconsistencies between provider documentation and the codes reported. The goal of these internal audits is to ensure that documentation guidelines are met and that services, procedures, and diagnoses are supported at the level they are billed. Medical documentation should be unambiguous (to the auditor, not only to the documenting provider) and the entire note must be legible. Be sure to share audit results with providers, as well as with coding and billing staff, and enact education and policies (including follow-up audits) to correct errors, going forward. Quarterly audits may be even more effective to correct bad habits, and you might also consider using an external auditor, on occasion, to verify your findings. Please explain, why or why not?

2) "The Bureau of Labor Statistics (BLS) is reporting that the healthcare industry is changing in dramatic ways. These changes are brought on by healthcare reform, an aging U.S. population and cutting edge technology that will bode well for medical coders. Their career outlook is bright! A student on track to earn a medical coding and/or billing certificate is poised to benefit from the 22 percent employment surge through 2022 and beyond." Please explain, what is A.H.I.M.A. and AAPC certification? And why is important in medical coding?

Answer 1

Answer:- (1)

"Upcoding" means reporting a higher-level service or procedure or a more complex diagnosis, than is supported by medical necessity, medical facts, or the provider's documentation. For example, reporting a diagnosis of chronic bronchitis if the patient has acute bronchitis qualifies as upcoding, as would charging a dimension 5 assessment and the executives (E&M) benefit (e.g., 99215) for a minor patient issue, or coding for extraction of a 2.5 cm skin injury (e.g., 11403 Excision, kind sore including edges, with the exception of skin tag (except if recorded somewhere else), trunk, arms or legs; extracted width 2.1 to 3.0 cm) when the sore really estimated 1 cm (e.g., 11401 … extracted breadth 0.6 to 1.0 cm).

Upcoding — regardless of whether purposeful, or not — is a genuine consistence hazard that may prompt payer reviews, repayment take backs, and charges of harsh or false charging.

"Downcoding" is the contrary side of the upcoding coin. Normally, downcoding happens in light of the fact that the supplier neglects to give pertinent documentation subtleties to relegate an administration, strategy, or finding to the ideal dimension of particularity. For instance, diabetes is oftentimes undercoded. Numerous suppliers default to diabetes without confusions. While, right coding necessitates that the supplier archive the sort and strategy for control.

Some providers may downcode as a defensive strategy to avoid denied claims, audits, etc. For example, many payers now examine frequency distributions for E&M billing codes to identify "outlier" providers who bill a greater than average number of higher-level E&M services. Providers may purposely undercode in the mistaken belief that they must mirror these "E&M Bell Curves" to be compliant.

You should avoid this strategy. Regarding E&M services, in particular, not every provider whose billing patterns fall outside the average is engaged in undercoding or overcoding. Various components — including the supplier's subspecialties, practice socioeconomics, persistent sharpness measurements, managerial modifications and denied claims examination, and even neighborhood general wellbeing information — may genuinely influence the supplier's circulation of E&M benefit levels. For example, a supplier may see a high level of patients with incessant medical issues, which may stick his charging midpoints.

Undercoding conceivably hurts patients (for example, by under reporting a conclusion), seizes real income (for example, in light of the fact that the administration charged repays not exactly the administration really performed), and speaks to a consistence hazard equivalent to that of overcoding. As indicated by the National Correct Coding Initiative (NCCI) General Correct Coding Policies, "Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider should report CPT code 19302 (Mastectomy, partial ..., with axillary lymphadenectomy).  

A doctor ought not report CPT code 19301 (Mastectomy, halfway ...) in addition to CPT code 38745 (Axillary lymphadenectomy; finish)." Occasional, inside reviews of your coding, charging, and documentation rehearses is a standout amongst other approaches to identify and take out upcoding and downcoding (and numerous other consistence dangers, also). For instance, you may self-review 20 records for each supplier, at regular intervals, to pinpoint irregularities between supplier documentation and the codes revealed. The objective of these interior reviews is to guarantee that documentation rules are met and that administrations, techniques, and findings are upheld at the dimension they are charged. Therapeutic documentation ought to be unambiguous (to the reviewer, not exclusively to the archiving supplier) and the whole note must be decipherable.

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