Medical coding is like translation. People behind medical coding take medical reports and convert them into a set of codes. In a medical claim, these codes play a great role. In this article, we are going to take a look at medical coding and the relevant statistics. Read on to know more.

The Reason to Code Medical Reports

You may be wondering why we need to code medical reports. Isn’t it enough to just describe the diagnoses, symptoms, and procedures? After all, these reports can be sent to an insurance company.

According to the reports released by the Centers for Disease Control (CDC), over the past 12 months, there were more than 1.4 billion patients who visited hospitals. This includes patients who visit emergency rooms, outpatient facilities, and physician offices.

Suppose there are only 5 pieces of coded info against each visit. It would be a whopping 6 billion pieces of info that the professional would need to transfer each year. This estimate is unrealistically low, though. So, medical coding helps make it easier to transfer a lot of data.

Aside from this, coding helps you distribute the same documents between different medical facilities. For instance, the code of strep throat is the same whether you are in Hawaii or Arkansas. With the help of uniform data, you can perform research and analysis in an efficient manner. Health and government agencies make use of the info in order to keep an eye on health trends. For instance, if the CDC needs to analyze the spread of viral pneumonia, the ICD-10-CM code can help them.

Lastly, coding helps you find out if a treatment is effective. As a matter of fact, this is a lot more important for large facilities, such as hospitals.

Now, we should go ahead and find out more about 3 types of code. If you are a medical coder, you will find this information pretty useful.

Three Types of Code

ICD

ICD is short for the International Classification of Diseases. These diagnostic codes provide a uniform vocabulary to describe the possible causes of death, illness or injury. In the 1940s, the World Health Organization (WHO) established this code. Over the past 60 years, it’s has been revised many times.

These codes help represent the diagnosis and the condition of the patient. As far as the billing process goes, these codes help professionals determine the necessity of medical treatment.

CPT

CPT is short for Current Procedure Terminology. These codes are used in order to document most of the medical procedures at a doctor’s office. The American Medical Association (AMA) published and maintained this code. So, AMA reserves the copyrights and updates the codes on a yearly basis.

HCPCS

HCPCS refers to the Healthcare Common Procedure Coding System. It’s also known as “hick picks”. Primarily, HCPCS codes correspond to equipment, procedures, and services that CPT codes don’t cover, which includes medicines, drugs, ambulance rides, prosthetics, and medical equipment.

So, this was an introduction to medical coding. Hope you will find this guide helpful.

As the name implies, a Credit Balance happens when excess money is collected compared to the Charges for a service rendered by the Provider. This could be due to many reasons and has to be fixed while the final steps of medical claims processing are done. The Credit Balance could be due to an excess patient payment in the form of Co-insurance or Deductible; or it could be due to over-payments from the Insurance Payers. Let us analyze some scenarios and why it is important to be handled promptly:

Patient Credit Balance:

Patients might have paid an amount up front based on the assumption of what their Payers would cover. Once the medical claims processing is completed and the Payer pays in full, then the Patient’s payment is in excess. The physician billing solution can also call the patient and give the option of adjusting this excess against future visits or sending a check. But in either scenario, the Patient’s consent has to be obtained and is mandatory.

Payer Credit Balance:

Many a times the Credit Balance happens because of Over-payments by the Payers. Even the Patient’s Credit Balance is usually because the Payer paid more than anticipated. In medical claims processing, it is very important to handle the payments from Payers on priority. This not only projects the correct Cash flow as a result of the physician billing solution, but also prevents inflated AR. Some scenarios on Payer Credit Balances:

1) Both Primary and Secondary Payer pay as Primary

2) Payer pays more than Allowed amount by error

3) Cross-over errors, especially between Medicare and Medicaid

4) Privately purchased Plans – always pay as Primary, though there could be another Primary

Rules:

In all these instances, there are very strict guidelines and time frames within which the excess money has to be returned either to the Payer or to the Patient, as the case may be. In case of Payer errors, the Payer has to be notified of the error within 30-120 days depending on the Payer. Failure to notify within the timeframe could be viewed as ‘Fraud’ by the Payer and the State with stiff penalties. If the Payers refuse the refund (as in the case of privately purchased Plans), then that money belongs to the Patient and the Patient has to be notified. The medical claims processing and physician billing solution providers have to keep these requirements in mind and process the Credit Balances on a daily/weekly basis to avoid any trouble for the Provider and the Practice.

Recoupments and Offsets:

Some payers would adjust the payments for current and future claims against Credit Balances owed to other Payers which are Recoupments. When the Payers adjust the payments for current and future claims against the over-payments made in the past in their own Plans, these are called Offsets.

The best option to handle the Credit Balances is to outsource medical billing to a professional medical claims processing company.

Log on to http://www.mgsionline.com/medical-claims-billing.html to know more about medical Claims billing and processing.

Many people are confused when they get a copy of their credit report and see a collections for “Medical Payment Data”. This is seen when someone obtains their credit report with a third party involved, such as applying for a mortgage or at the car dealership. This would not be shown if you were to obtain your report on your own without a third party.

When you see Medical Payment Data on your report, you do not contact them. Because in reality there is no “them” to contact as it is just a term denoting a medical collections on your credit report.

This is done in order to protect the individual’s name requesting the credit report, due to federal privacy laws. What your next step would be is to call the credit bureaus that list the collections on medical report. When you call the credit reporting agencies, they can inform you who currently owns the debt.

Once you receive the information from the credit reporting agencies you can contact the medical collection agency directly. This is because they are the owners of the debt and the hospital is out of the picture now. It is not fully known how the credit agencies treat different debts, but it is thought that hospital debt is not as bad on your credit report.

Certainly if you are working with a human reviewing your application such as at a small bank or car dealership you may have some leeway with having medical payment data on your credit report. This is because it may show you had extenuating circumstances. This especially helps when no other collections are on the report.

If you feel this is harming your credit profile you can work with the collection agency in removing the bad mark off of your report. Usually the longer it has gone unpaid, the worse it gets, to a point. When a collection is a few years old it has already done its damage. If you can pay the collection agency right after they obtain it from the hospital you may be able to avoid it going onto your credit report at all.

The older the debt is, the more, the less you should offer to pay off the debt. A debt that is multiple years old you only may offer a fraction of the original bill. If the debt is new, you may pay the full amount or close to it. The best thing to do is have the ding completely removed, this would help your score the most. If not you could at least have the bill on your report marked paid in full.

Many people face major problems if they have unpaid medical expenses. These expenses can become a threat to your home, savings or income. Without any medical insurance an extended stay at a hospital can become a financial burden amounting to tens of thousands or even hundreds of thousands of dollars. If a reasonable payment plan is not initiated before treatment begins, the unpaid bills will become a major collection action shortly after the treatment period ends. Depending on the state in which you live, your home, savings or other personal property can be attached to offset the unpaid medical bills.

Even if you do have insurance, the financial risk of co-pays, large deductibles and uncovered treatment can be significant. There are instances in which out of network physicians are brought in during any procedure without the knowledge of the patient or their approval. Some policies cover only a small portion of these charges. Although the Affordable Care Act requires insurers to pay these charges, there have been instances in which portions of what should have been covered was not.

What happens if you obtain medical treatment which costs tens or hundreds of thousands of dollars and your insurer rejects the claim because of an unmet deductible, a co-pay, an out of network physician, or for a treatment or medicine that is not approved? Who pays the doctor and the hospital? If there is no insurance or the amount is limited, your doctor, hospital or other medical facility will compel you to guarantee full payment of the costs billed, less any amount actually reimbursed by your insurer. Whatever amount your insurance company does not pay will be the responsibility of the patient.

What happens when a patient cannot pay?

What happens when a large medical bill can’t be paid? Usually the result is a lawsuit filed by the hospital or a collection agency with a judgment and a lien filed against the patient’s home and accounts. In most states, a portion of the debtor’s employment earnings can be garnished. Many times before this point is reached, the patient files a personal bankruptcy to stop the wage garnishment and eliminate the medical bills and other debts. This requires forfeiting all assets including savings, real estate and equity in real estate. Some of these assets are exempt in a bankruptcy will be turned over to the court and divided among the creditors.

How Patients Protect Against These Events

Family Savings Trust

Asset protection with an expressly designed Family Savings Trust can often shelter savings from these events. A Family Savings Trust is exceptionally flexible in form and can incorporate provisions, which merge the features of many domestic arrangements within the language of the plan documents. All of your assets can be contained in the trust-but be administered by special terms appropriate for that asset.

For those concerned with protection against unforeseen medical bills, a trust can be customized to specifically to address the issue of medical expenses. The trust may be planned to hold your home, savings and brokerage accounts with the aim of shielding these assets from unexpected medical expenses. It is often designed to safeguard the tax benefits associated with the home (including the mortgage interest deduction, property taxes, and avoidance of gain on a future sale), while carrying out proper estate planning and asset protection goals for family wealth.

In the 1960s, a physician named Lawrence L. Weed first described the concept of computerized or electronic medical records. Weed described a system to automate and reorganize patient medical records to enhance their utilization and thus lead to improved patient care.

Weed's work formed the basis of the PROMIS project at the University of Vermont, a collaborative effort between physicians and information technology experts started in 1967 to develop an automated electronic medical record system. The project's objectives were to develop a system that would provide timely and sequential patient data to the physician, and enable the rapid collection of data for epidemiological studies, medical audits and business audits. The group's efforts led to the development of the problem-oriented medical record, or POMR. Also, in the 1960s, the Mayo Clinic began developing electronic medical record systems.

In 1970, the POMR was used in a medical ward of the Medical Center Hospital of Vermont for the first time. At this time, touchscreen technology had been incorporated into data entry procedures. Over the next few years, drug information elements were added to the core program, allowing physicians to check for drug actions, dosages, side effects, allergies and interactions. At the same time, diagnostic and treatment plans for over 600 common medical problems were devised.

During the 1970s and 1980s, several electronic medical record systems were developed and further refined by various academic and research institutions. The Technicon system was hospital-based, and Harvard's COSTAR system had records for ambulatory care. The HELP system and Duke's 'The Medical Record' are examples of early in-patient care systems. Indiana's Regenstrief record was one of the earliest combined in-patient and outpatient systems.

With advancements in computer and diagnostic applications during the 1990s, electronic medical record systems became increasingly complex and more widely used by practices. In the 21st century, more and more practices are implementing electronic medical records.

Medical negligence occurs when medical treatment falls below expected standards. If a patient becomes injured as a result of medical negligence, that patient might file a lawsuit claiming medical malpractice. If a patient dies, the family might then file a wrongful death lawsuit.

The most common type of medical negligence involves surgery, but it can happen with any nurse, physician, medical technician, or medical facility. The different types of medical negligence are almost endless. Here are some examples:

Damage to a neighboring organ during surgery.

A wrong diagnosis that leads to no treatment for the condition or the incorrect treatment for the condition.

A doctor who tells a patient that he or she is okay, causing a delay in treatment that eventually leads to injury. This is especially dire if an illness is progressive, such as cancer.

A dentist whose negligent treatment causes the patient to lose teeth.

An incorrect medication or the prescription of a medication in a harmful dosage. This can be negligence on the part of a doctor prescribing the medication, a nurse administering the medication, or a pharmacist.

Unnecessary surgery that results, for example, in the inability of the patient to have children.

A botched cosmetic procedure that causes an injury or a severely displeasing result.

A medical instrument accidentally left inside a patient during surgery.

Mistakes on a medical chart that lead to incorrect medical procedures or medications.

Improper or ineffective anesthesia administered prior to surgery.

A mistake made during childbirth that leads to the death of the infant or permanent injury to the infant, such as brain damage. Cerebral palsy is often a result of this kind of medical negligence.

The Difficulty of “Causation”

In order for a patient to have a medical malpractice claim for medical negligence, he or she has to prove (1) that the medical professionals had a duty to provide a standard of care and failed to do so, (2) that the patient suffered an injury or injuries, and (3) that the injury was caused by the alleged medical negligence.

What does “standard of care” mean? It varies from state to state. Some laws restrict the standard to physicians in the same area of the country, while others extend the standard to doctors on a national level. For example, a heart surgeon will be held to the standard of other surgeons in the same field. If he or she acted in a way that differs from the way most heart surgeons would have acted in similar circumstances, that surgeon may be found to have been medically negligent.

Since the body consists of interconnected systems, “causation” is a complicated issue in medical negligence. The medical personnel might argue that the treatment did not cause the injury but that it was instead caused by a condition the patient already had.

Psychologists and psychiatrists can also be sued for medical negligence, although these types of cases are much more difficult to prove because not only are the injuries non-physical, but causation is particularly complex.

In any type of case, the attorneys assigned by the physicians’ malpractice insurance company will likely try to argue that the injury was not caused by medical negligence.

For this reason, people who suffer injuries are advised to hire a lawyer to help them negotiate a settlement to recover the costs they incurred. Lawyers in this situation work on a “contingency” basis, which means that they do not require the client to pay them. Their fees are contingent upon receiving settlement monies from the medical malpractice insurance company. If the lawyer is successful in obtaining a settlement for the client, he or she then takes a percentage of the money as a fee. If the lawyer is not successful, he or she does not earn any money for the work. As a result, lawyers work hard to obtain settlements for their clients.

In some states, the settlement might include funds for pain and suffering, which is not a reimbursement for costs but a payment for the emotional stress experienced from the injury. Some states also allow for “punitive damages” if gross negligence or misconduct is involved. The amount allowed for such damages is often restricted. In the state of California, for example, no more than $250,000 can be awarded for non-economic damages.

When gross negligence or misconduct is involved, the local authorities might also bring a criminal action against the physician or medical facility. This action is separate from a medical malpractice case. In a criminal action, the plaintiff is the city or the state. A medical malpractice lawsuit is called a “civil” action, and the plaintiff in that case is the injured patient. Both the criminal and civil cases would have one or more defendants in common, however. The defendant is the person who is defending the claim – the party or parties who are alleged to have been medically negligent.

Note that only in cases of gross negligence does the health department take away a doctor’s medical license.

Do All Medical Negligence Cases Go to Trial?

Most of these cases are settled out of court, but when the parties cannot agree on a settlement amount, the case goes to trial. A judge or jury then makes the decision as to whether the patient is entitled to monies and how much. Before a case goes to trial, however, years of negotiations might pass. During that period, the lawyers for both sides prepare legal papers that answer the questions of the other party. These are called “pre-trial discovery” papers.

Depositions are also often taken of the parties. These are interviews that allow the opposing side’s attorneys to ask questions.

It is not unusual for a settlement to take place at the courthouse during the jury selection process. This is a tactic that pushes both sides against the wall, trying to coerce them to give in. The plaintiff wants the defendant to give in by offering more money in the settlement, while the defendant wants the plaintiff to give in by accepting the current settlement offer. No one ever wants to take a case to trial if it can be helped because the costs of court are much higher than out-of-court settlements.

If a defendant’s lawyer believes, however, that there is money to be saved by refusing a high settlement demand, a trial is then likely.

At the doctor’s office, hospital, or clinic, patients rarely consider the medical equipment around them. Medical equipment is an integral part of diagnosis, monitoring, and therapy. Even the simplest physical exam can often require a variety of high-tech medical equipment.

In 15th century Europe, during and after the horrors of the bubonic plague, autopsies began to be performed at universities, and a primitive form of ‘scientific method’ began to take hold in the minds of the educated. Practical surgery and anatomy studies began. These curious medieval Europeans laid the foundation for modern science. They also laid the foundation for the well known process of identifying a problem, creating a hypothesis, testing the hypothesis by most importantly observing and experimenting; interpreting the data and drawing a conclusion.

Medical equipment prior to and even during the scientific revolution was based on classical Greek and Roman theories about science, which were not based on science at all, but on philosophy and superstition. Human health was viewed as a balance of 4 internal ‘humors’ in the body. The 4 humors– blood, yellow bile, black bile, and phlegm, were analogous to the 4 elements of the universe to the classical thinker, fire, air, water, and earth. Ailments, both physical and mental, were caused by an imbalance of humors. The ideal mind and body balanced all 4 humors, gracefully. To heal, doctors prescribed foods or procedures which would balance the fluids in the body. Some of the prescriptions seem to make sense– fevers were treated with cold, dry temperature to combat the hot, wet over stimulation in the body. But when that failed, often the next step was blood letting. Unnecessary purging and enemas were also common cures, which might have helped some people, but also might have caused more problems than they solved. George Washington’s death has recently been attributed, not to the strep throat he probably had as he died, but to the bloodletting and mercury enema given to him to cure it.Not-quite-scientific medical cures are still available and used by many, even today.

Since the 15th century, Western science has focused on examining and observing the body, and has created tools to make this easier. X-ray imaging and today MRI devices are merely extensions of the first autopsies and anatomical studies, which strove to understand how the human body actually operates. Diagnostic instruments like ophthalmoscopes, blood pressure monitors, and stethoscopes are likewise extensions of the medieval examination. Exam tables, gloves, and other medical accessories are simply the newest versions of tools that have been used for centuries. Medical technology and medical knowledge feed off of each other. Take for instance hypertension. Although devices for measuring blood pressure have existed for over 100 years, only in the last 20 years have the connections of blood pressure to disease, genetics, and lifestyle been fully explored. As the importance of measuring blood pressure increased, new technologies were explored to keep accurate measurements and records. It wasn’t until the prevalence of automatic blood pressure monitors that a correlation could be made between readings taken by a human and readings taken in a controlled, isolated environment. The medical equipment and the medical knowledge then form a constantly twisting Gordian Knot, one side tightening, as the other loosens, back and forth.

What does the future hold for this push and pull of technology and scientific inquiry? Recent developments in nanotechnology and genetics, along with more and more powerful supercomputers might create a situation where what it means to be human actually changes, due to technology. For example, scientists have actually created simple life forms out of previously non-living DNA material. While it doesn’t seem that dramatic at first glance, it’s an important development. Medical equipment acts as an extension for investigation of the how’s and why’s of the human body, and as science catches up and surpasses the investigations, completely new kinds of medical diagnosis, monitoring and therapy may result. Imagine the ability to grow new organs inside the body. Limb re-growth is possible in other organisms, why not in humans? And if it is possible, would the developments be truly ‘human?’ The future is unknowable; the only aspect about it we can understand is that it will look nothing like we could have previously imagined. In retrospect, we’ll see the signs, like we always do, but this is hindsight, not foresight. Presently, technology marches forward and it continues, as a process, to change human life.