Healthcare Cost And Utilization Project

The Current Procedural Terminology (CPT) codes, are codes a medical biller uses to report healthcare procedures and services. Both medical billers and providers use CPT codes as a way to communicate with insurance companies. Proper coding and documentaition is essential for reimbursement. Proper coding and documentation also makes the difference between full reimbursement and reduced reimbursement or even a denial. Each code that is sent to a payer on a claim, has to have supporting documentation. For example, if a patient is seen for a urianary tract infection and during the visit the patient receives a urianalysis, you would expect to see an order, the correct CPT code, and the results for a urinalysis in the patients chart. I have always

One of the greatest milestones in the United States health system is the use of electronic health records codes to ensure consistency in diagnosis and treatment procedures provided by physicians (Romano & Stafford 2011). The purpose of the case scenario of the sixteen year old female who visits the emergency department is to show how electronic health record coding is done and its impact on health reimbursement. The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) codes are brought out well in the case study showing how they help in ensuring physician consistency in coding diagnosis and treatment procedures for the purpose of health reimbursement.

This standardized dialect is also pertinent for medical schooling and teaching in addition to clinical research and studies conducted by scholars, scientists, and physicians by providing a valuable foundation for domestic and coast-to-coast operation evaluations. CPT is used to describe doctor’s services, a vast amount of administrative services in addition to operating services executed in medical facilities, treatment care centers, and outpatient divisions. Providing support for clerical duties and functions such as processing medical claims and initiating strategies and procedures for the evaluation of clinical care is another cause of relevance for CPT. The system also meets the need for tracking trends and identifying improvements, plus progression goals and scaling the value of healthcare services received by patients. The CPT coding system provides physicians throughout the United States with a consistent method for classifying and coding clinical procedures which in return provides a more efficient tool for recording and reporting task that were completed. Physicians, scholars and payors, have been dependent upon CPT to interconnect with other fellow associates, patients,

Healthcare providers use Current Procedural Terminology (CPT) codes for communicating what services was rendered to the patient, to insurance companies for billing purposes. CPT category 1 codes are codes that relate to the services and procedures rendered to patient's primarily in an outpatient facility. Category 1 codes are updated yearly and are for procedures that are consistent with medical practices and procedures widely performed. Category 1 CPT codes are sectioned into six categories which include evaluation and management (EM), anesthesiology, surgery, radiation, pathology/laboratory, and medicine. CPT category 2 codes are codes that are used to communicate services rendered performance measurements and is also updated yearly.

Centers for Medicare and Medicaid Services. (n.d.). Development of the ICD-10 Procedure Coding System (ICD-10-PCS) [PDF]. Retrieved from https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2015-pcs-final-report.pdf

On the other hand, many physicians do not know the importance of the program. In this case, there is an extensive amount of pressure on organizations for them to perform quality care, use correct coding, and get measured accurately through the MACRA. In addition, engaging physicians with their clinical documentation process may be an important factor though a difficult task in all healthcare organizations. Clinical documentation has become a critical part of every patient encounter. In terms of meaningful use, it must provide efficient, accurate, and timely services because it is what patients depend on. The clinical documentation improvement (CDI) program is intended to facilitate an accurate depiction of the clinical status of patients as it gets transferred into coding. At the same time, coded data has the responsibility to report physician’s clinical information, reimbursement, and tracking trends. Physicians must have the right education towards coding necessities, which is vital to correct reimbursement and quality reporting under MACRA’s quality payment program. Essentially, clinical documentation improvement (CDI) programs must be implemented into physician practices as it helps educate them on the general specifications that documentation and certain practices for the ICD-10

An accurate and specific documentation of universally accepted set of codes are important for the protection of healthcare providers as well as increased reimbursement for services received. These codes are for the validation of which services the patient received from their health care provider ( (Page, 2009). Having the correct codes in place insures the provider with the information needed by the health insurance carrier. Maintained by the AMA (American Medical Association), this universal numeric assignment is also used for developing guidelines for medical care review as well as data collection for medical education and research (Scott, 2013).

One way CMS (Center for Medicare & Medicaid Services) collects proof is through HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Surveys. This “initiative …provides a standardized survey instrument

The International Classification of Diseases, Tenth Revision (ICD-10) has been in development since 1983 to replace the outdated Ninth Revision (ICD-9) that has been in use in the U.S. for over 35 years (Giannangelo, 2015). Due to the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification regulation published in 2009, the Clinical Modification (ICD-10-CM) will replace ICD-9-CM Volumes 1 and 2, and the Procedure Coding System (ICD-10-PCS) will replace ICD-9-CM Volume 3 for all HIPAA transactions effective October 2015 (Giannangelo, 2015). These new code sets accommodate new procedures and diagnoses and allow for greater specificity in clinical documentation (Centers for Medicare & Medicaid Services [CMS],

The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and supported by the Agency for

To describe this treatment, I would use the health care common procedure coding system (HCPCS). HCPCS serve to report services provided by a physician to a patient. Together with the current procedure terminology (CPT), HCPCS became the only adequate system for reporting medical services (Giannangelo, 2010).

The Affordable Care Act was signed into law March 23, 2010 by President Barack Obama; however, the constitutionality of the law remained in question. In a controversial 5-to-4 ruling, The U.S. Supreme Court upheld the law on June 28, 2012. The ACA is thought by some as the United States health care rescue, and as its downfall by others.

In 2015, HDHP covered 24% of the workers in the employers that offer it, up from just 4% in 2006 (Kaiser/HRET, 2015). The increase in the number of the HDHP enrollees didn’t only occur in an employment-based market, but also in an individual-based market due to high deductibles. In fact, 90 percent of the individuals covered by the Affordable Care Act (ACA) marketplace pay higher deductible than the deductibles of the HDHP (Health Affairs, 2016). One of the reasons for this increase is the saving options that the HDHP offer to drive more consumers. The consumers will face high health care prices and this will make them think about whether deciding to look for care or not. As a result, this will reduce health care spending. A study showed that when individuals shifted from the low deductible health plan toward HDHP, their health spending dropped by 14% (RAND, 2011).

In recent years, health care has been a huge topic in public debates, legislations, and even in deciding who will become the next president. There have been many acts, legislations, and debates on what the country has to do in regards to health care. According to University of Phoenix Read Me First HCS/235 (n.d.), “How health care is financed influences access to health care, how health care is delivered, the quality of health care provided, and its cost”.

The old saying of health is wealth is as valid today as it was in any other period of history. The definitions of health have been changed and many other measures of physical and mental performance have been added to it. However, the essence and need of healthy life is always there. This is the reason; the responsible authorities of every period have tried to provide best possible healthcare services to the people.