What is the importance of correctly linking procedures and diagnoses
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What is the importance of correctly linking procedures and diagnoses

Course Number: HCR 220, Spring 2011

College/University: University of Phoenix

Word Count: 334

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What is the importance of correctly linking procedures and diagnoses? Correct claims report the connection between a billed service and a diagnosis. The diagnosis must support the billed service as necessary to treat or investigate the patient's condition. Payers analyze this connection, called code linkage, to decide if the charges are for medically necessary services What are the implications of incorrect...

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is What the importance of correctly linking procedures and diagnoses? Correct claims report the connection between a billed service and a diagnosis. The diagnosis must support the billed service as necessary to treat or investigate the patient's condition. Payers analyze this connection, called code linkage, to decide if the charges are for medically necessary services What are the implications of incorrect medical coding? Implications of incorrect medical coding can lead to denied claims, a delay in claims, wrong amounts being paid, provider being investigated for billing fraud. Incorrect medical coding can also effect the patient due to service that would have been covered, and not billed correctly, could become the patients responsibility. How are medical coding, physician, and payer fees related to the compliance process? In every geographic area, there is a normal range of fees for commonly performed procedures. Different practices set their fees at some point along this range. They analyze the rates charged by other providers in the area, what government programs and pay, the payments of private carriers to develop their list of fees. Most try to set fees that are in line with patients' expectations so as to be competitive in attracting patients Medical insurance specialists update the practice's fee schedules when new codes are released. When new or altered CPT codes are among those the practice reports, the fees related to them must be updated, too Payers, too, must establish the rates they pay providers. There are two main methods: charge-based and resource-based. Charge-based fee structures are based on the fees that providers of similar training and experience have charged for similar services. Resource-based fee structures are built by comparing three factors: (1) how difficult it is for the provider to do the procedure, (2) how much office overhead the procedure involves, and (3) the relative risk that the procedure presents to the patient and to the provider. In addition to setting various fee schedules, payers use one of three main methods to pay providers: 1. Allowed charges 2. Contracted fee schedule 3. Capitation

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