Scribd Logo
Upload

Welcome to Scribd!

  • 106 views

    SHEARWATER ORIENTATION (Day 1)

    Uploaded by

    Erica Joy
    This document provides an overview of the U.S. healthcare system and medical coding. It discusses the types of health insurance in the U.S. like Medicare, Medicaid, HMO, PPO and describes their key features. It also outlines the revenue cycle management process and the role of medical coders in translating medical procedures, services and diagnoses into codes. Finally, it discusses career opportunities in medical coding and the skills required like attention to detail, strong computer skills and the ability to work independently.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    SHEARWATER ORIENTATION (Day 1)

    Uploaded by

    Erica Joy
    106 views7 pages
    This document provides an overview of the U.S. healthcare system and medical coding. It discusses the types of health insurance in the U.S. like Medicare, Medicaid, HMO, PPO and describes their key features. It also outlines the revenue cycle management process and the role of medical coders in translating medical procedures, services and diagnoses into codes. Finally, it discusses career opportunities in medical coding and the skills required like attention to detail, strong computer skills and the ability to work independently.

    Original Description:

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides an overview of the U.S. healthcare system and medical coding. It discusses the types of health insurance in the U.S. like Medicare, Medicaid, HMO, PPO and describes their key features. It also outlines the revenue cycle management process and the role of medical coders in translating medical procedures, services and diagnoses into codes. Finally, it discusses career opportunities in medical coding and the skills required like attention to detail, strong computer skills and the ability to work independently.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    106 views7 pages

    SHEARWATER ORIENTATION (Day 1)

    Uploaded by

    Erica Joy
    This document provides an overview of the U.S. healthcare system and medical coding. It discusses the types of health insurance in the U.S. like Medicare, Medicaid, HMO, PPO and describes their key features. It also outlines the revenue cycle management process and the role of medical coders in translating medical procedures, services and diagnoses into codes. Finally, it discusses career opportunities in medical coding and the skills required like attention to detail, strong computer skills and the ability to work independently.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7

    SHEARWATER NOTES (DAY 1)

    U.S Healthcare 101

    Health Insurance
    - has more expensive in healthcare, they spend more uninsured, are only
    benefited in public healthcare (limited health services coverage)
    - Health Insurance is a must have
    - In the PH paying yet only defined services would be covered.
    - 1800, insurance started (health insurance )
    - 1920 insurance for health insurance in teachers (Blue Cross Plan, biggest
    insurance in the US)
    - 1935, SSS act signed become old age insurance
    - 1936, popularized student insurance
    - 1985, COBRA subsidized, if an employee is retired, they still are covered with
    health expenditure, cobra protects their health.
    - ACA- also known as Obama Care (covers at least ten services) should be health
    services only

    2 types of network:
    1. In-network provider (INN) kasali sa insurance/
    2. Out-of network (ONN) hindi kaslai sa insurance magbabayad ka pa rin. In US
    insurance should be at the right amount before beneficiaries would be available.

    Coinsurance
    - is in percentage, payment before beneficiaries to patients if Out-of-pocket is
    reached, the insurance should be covered by the payment.
    Pre-auth/ Pre- Authorization
    - nurse checking if the health care/ review before performing or providing care.
    checking of intervention

    Predetermination
    - determine if how much will be the bill for the service

    Insurance Types:
    Medicare (US)
    - serves 65yrs old, younger disabled, and dialysis patients and can be compared
    to PhilHealth.

    Has 3 subtypes: (check SS/Module from Shearwater to be clarified)


    A. Hospital in-patient
    B. Outpatient
    C. Bundle Plan "MA Plans"
    D. Drugs

    Medicaid
    - partner of medicare, if low income, may avail in here, ex. prescription drugs

    PRIVATE INSURANCE
     Types:
    a. HMO
    b. PPO
    HMO
    - limited consultation, limited variation, before needs referral to be able to be seen
    by your chosen physician.
    - limited independence in choosing services (out of network no freedom).
    - can't be out of network.
    - Needs referral.

    PPO
    - larger services, has freedom, can be direct from the chosen physician.
    - can be outside to see the doctor of the network setup.
    - Does not need a referral to see another doctor.

    Catastrophic

    HEALTHCARE DELIVERY SYSTEM


    Advance care plan
    - plans set by patients when they are undecided/no capacity to make a decision in
    the near future (hospice care).
    - ex. do not intubate or DNR, power of attorney, the will
    - must be updated by the elder patient

    Medical Coding

    Introduction to the coding system (NI part)


    - The more the character of/in the coding, the longer the code the more specific
    the DX is.
    - the more added characters in the code the longer the DX.
    - 3-7 characters are valid, no more than and less than in the character in coding
    (Unang type, check the screen shot).
    - dummy "X", in preventing the changing of the code, if to be added in 6th to 7th
    character, to be specified.

    CPT
    - current terminology, ,mostly code for medical procedures
    - 5 digits/characters
    - suffix is the letter

    HCPCS
    - for drugs, supplies, and medical equipments
    - Level II mostly used
    - 5 character, one letter(start) then the rest is numbers/digits

    POS
    - code for place of the service
    - saan ginawa
    - 2 character

    LAWS
    HIPPA
    - supreme law about health information (privacy), information of patients.
    - II.
    - NPI
    - Transactions and Code Sets Standards
    - minimum necessary rule- practice to limited disclosed information
    - bare minimum
    HIPPA privacy rule- protection of health data
    (AFTERNOON SESSION)
    REVENUE CYCLE MANAGEMENT
    - Patient Pre-Authorization = should be accured by low income erners limited
    freedom in choosing health service (para ma check na siya ng physician)
    - Eligibility & Benefits Verification = done before consulting (baka di pa
    beneficiaries si patient siya pa mag suffer in payment)
    - Claims Submission = final stage/overall process (where medical coding
    happens) nurses does not have responsibility anymore once px is discharged.
    [Physician & Hospital talks regarding payment].
    - Payment posting = dicission making happens (specific approved/denied).
    - Denail Management = ex. denied due to error, check code then resubmit. if
    coding has error, chart is return edited then corrects the errors in medical coding.
    - AR Follow-Up = health care provider's responsibility to follow up px to the
    remaining balance.
    - Reporting = internal, means depends on the facility. crucial part.. then start
    again ti step 1.

    WHAT IS MEDICAL CODING?


    - is medical coding has error, the hospital would not be paid by the insurance.
    procedures/services, and equiment are translates to alpha-numeric code, use for
    uniform medical record/codes
    - The most crucial job to do. (error is a no no)

    What does a medical coder do?


    = responsible in translating medical records into unifrorm codes
    =responsible in making an accurate in avoidance of error

    HOW TO BE A MEDICAL ENCODER?


    - Complete medical coding training course (3 - 4 months)
    - Earn medical coding certificate (1-2 months)
    - Get on-the-job experience (1-2 years)
    - Earn more additional Credentials (1-2 years)
    - Pursue continuing education
    - PROFESSIONAL CODING ASSOCIATION AND CERTIFYING BODIES
    - AHIMA = American Health Information Management Association
    - AHCC = American Academy of Professional Coders
    - AAPC = The Association of HOme Care Coding & Compliance

    TOP SKILLS OF A MEDICAL CODER


    - Attention to detail is a valuable skill a medical coder should have.
    - Knowledge and understanding in medical terminologies, ana-physio, disease
    processes, pharmacology, and more.
    - Accurate and faster medical coders using coding software programs. coders
    must be/ needs to be familiarised with these programmes. good at computer
    litiracy.
    - Good communication and interpersonal skills. able to communicate well with
    co-worker/ healthcare providers.
    - Ability to work independently/ focus and drive to finish the task.

    CAREER GROWTH IN MEDICAL CODING


    - Clinical complexity
    - Nurse Abstructor
    - Risk Adjustment
    - Outpatient/Professional fee [Low Clinical Complexity]
    - Home Heath / home care
    - In patient/facility/ RAC programs
    Clinical Documentation Improvement (CDI)

    OVERVIEW OF DIAGNOSIS CODING


    ICD (International Classification of Disease) = codes for diagnosis
    .= codes for services and the treatment
    ICD-10_CM CLASSIFICATION
    Alphabetic Index = in alphabetical arrance word of disease, why? to be easily modified if
    arrange alphabetically (one word in manner)
    Tubular Index= alphanumeric list of codes divided into codes

    MAIN TERMS (LOOK IN SCREEN SHOT)

    KNOWLEDGE CHECK
    - Deep vien thrombosis = term thrombosis
    - Adhesive bursitis of the shoulder = Bursitis is the main term
    - Acute respiratory failure = failure is the term
    - Acute kidney failure =
    - Crohn's disease (emponym = named after a specific person) [rec. look for the
    eponym for easier to be located]
    ● code are not to be assume, what the doctors input that should be encoded.

    Agenda tom:
    -tabular list
    -translate coding of dx
    -review od discussio

    Reminders:
    - wag kain sa hallway at elev., pwedi dala kain at tubig.. kasi may corresponding
    penalty
    - pag asa loob na ng office pwedi kumain.
    - Millstone are the venue for on-site activiries

    You might also like