NURS 6565: Synthesis in Advanced Practice Care of Complex Patients in Primary Care Settings | Week 8

You are now approaching graduation, your clinical exposure has allowed you to better understand the coding and billing process. An essential element in clinical practice will be reimbursement. All NPs must give due diligence and ensure all services provided are accurately coded and billed appropriately. Avoiding fraudulent billing is a key element to your success as an NP. As providers, we are ultimately responsible for billing that occurs with our assigned Medicare, Medicaid, and other third party reimbursement entities’ assigned numbers.

This week you will focus on understanding the differences in levels of billing and the importance of coding accurately. Additionally, billing barriers, which inhibit independent practice, and how this impacts your decision on relocating to an alternate state to have independent practice will be reviewed.

Learning Objectives – NURS 6565:Week 8: Coding and Billing Issues Assignment

By the end of this week, students will:

• Analyze reimbursement issues
• Compare the impact of reimbursement issues between collaborative practice and independent practice
• Analyze ethical and legal implications of reimbursement issues

Learning Resources

This page contains the Learning Resources for this module. Be sure to scroll down the page to see all of this module’s assigned Learning Resources.

Required Readings

Buppert, C. (2018). Nurse practitioner’s business practice and legal guide (6th ed.). Sudbury, MA: Bartlett & Jones Learning.

• Chapter 9, “Reimbursement for Nurse Practitioner Services” (pp. 311-325)

Discussion: Reimbursement Issues for Nurse Practitioners

Understanding the complex process of accurate coding and billing is essential to a sustainable practice. As NPs, we are ultimately responsible for ensuring all coding and billing is accurate for each patient seen. For this Discussion, you will search the health care literature and summarize a peer-reviewed journal article published within the last five years.

To prepare:

• Select one of the following topics:
  • Applying for Medicare and Medicaid Provider Numbers
  • Application process for National Provider Identifier Number
  • Incident to billing
  • Coding-Evaluation & Management
  • Fraudulent billing
  • Billing Self-Pay patients
  • Managed Care Organizations
• Conduct a search and select a peer-reviewed journal article published within the last five years related to the topic you selected.

Note: For this Discussion, all students are to avoid all written work, which reviews or outlines coding and billing at previous or current worksites as well as previous or current practicum sites.

By Day 3

Post a brief summary of the article you selected. Include the key reimbursement issue addressed and how they would impact the NP in a collaborative practice versus and independent practice. Discuss an ethical or legal implication(s) associated with your article.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days by providing a comparison between the article you selected and the article that your colleague selected

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. NURS 6565:Week 8: Coding and Billing Issues Assignment

 

 

 

ADDITIONAL INFORMATION 

Coding and Billing Issues in Healthcare

Introduction

Coding and billing are two of the most important aspects of healthcare. They’re also one of the most controversial topics in the medical field. In this article, we’ll explore some of the common coding and billing issues that occur daily in your local hospital or clinic.

Overview

The following code of conduct and ethics have been developed by the American Medical Association (AMA), which represents physicians in the United States:

• Code of Ethics and Professional Conduct. This document contains guidelines for physicians’ conduct with patients, other health care providers and society at large. It also includes provisions on conflicts of interest between doctors and their patients or others who may be involved in making medical decisions about them; protection from retaliation against individuals who speak up about such issues; confidentiality concerning patient information; rights under law related to informed consent for treatment procedures; requirements for hospitalization during pregnancy or childbirth if necessary because of complications during labor/delivery – including transferral back into an emergency situation if needed thereafter (this provision applies regardless whether the mother’s condition improves after delivery); confidentiality when communicating recommendations made by physicians regarding care plans involving children under 18 years old whose parents are divorced or separated – whether custody arrangements have been agreed upon beforehand or not…

3 Common Coding and Billing Issues in Healthcare

3 Common Coding and Billing Issues in Healthcare

• Unbundling: Unbundling is the process of removing multiple codes from a bill for a single service or procedure. It’s usually done to avoid paying multiple charges for the same service or item, but it can also be used to cover other cases where there are multiple billing codes on a single bill (for example, if you receive two medications at once).

• Modifier Misuse: This is when modifiers are used in error instead of their intended purpose. For example, if you receive an MRI scan with radiologist modifier “MR” when there should be primary care physician (“PCP”) modifier; this means that someone has incorrectly typed out your insurance plan name instead of using “PCP” as its primary modifier (and therefore misused it). The best way to prevent this is having all staff members double check each other’s work before sending an order out!

1. Unbundling

• Unbundling is the practice of selling individual services to patients or consumers, rather than providing them all together. This can be done for a variety of reasons, including:

• To provide more choice and flexibility for patients/consumers

• To increase revenue by bundling multiple products together into one price point (e.g., a car insurance policy may include collision coverage)

• To increase patient satisfaction through greater flexibility in purchase decisions

2. Modifier misuse

Modifier misuse is a common coding and billing issue that can cause confusion for both providers and payers. A modifier is used to indicate that a procedure or service was performed in a different way than usual, such as using an alternative therapy or using more resources than normal.

An example of modifier misuse is when you perform an ultrasound on a patient who has had multiple surgeries before and therefore has no other pathology present on their body at the time of examination. To avoid this error, make sure your documentation reflects what actually happened during each step of your procedure (i.e., “surgery with biopsy”). Another way to avoid this error would be if you were able to choose whether certain tests were done before others based on their expected outcomes or side effects (for example: ordering blood work after obtaining all other results).

If possible try not using modifiers at all since they can create confusion among physicians about which diagnosis applies when multiple factors are involved – including things like age differences between patients’ genders/ethnicities etcetera.”

3. Inappropriate use of evaluation and management codes

The use of evaluation and management codes is an important part of healthcare billing. The purpose of these codes is to describe the work of a physician, but they cannot be used for basic care. They are not meant to be used in routine situations or when follow-up with the patient is required; rather, they should only be used when something more complicated has gone wrong with your condition and needs immediate attention from a specialist (e.g., if you have been diagnosed with cancer). Additionally, it’s important to note that these types of codes aren’t intended for initial consultations—you’ll want one if there’s any doubt about what kind of treatment plan would be best for your condition!

Understanding coding and billing in the healthcare system is important for doctors, health care workers, and patients alike.

Coding and billing are important for doctors, health care workers, and patients alike.

Coding is the process of assigning a code to a medical diagnosis or procedure. It allows doctors to easily track the progress of patients’ treatments and medications from one visit to another.

Billing is the act of determining what services have been rendered during an encounter with a patient (or other person) at a particular time period—for example: “I took your blood pressure three days ago; here’s my bill showing that you paid $100 cash.”

Conclusion

With the rising cost of healthcare and the need for better care coordination, understanding coding and billing is a critical part of improving the quality of patient outcomes. In this article, we’ve touched on three common coding and billing issues found in healthcare today: 1) unbundling; 2) modifier misuse; 3) inappropriate use of evaluation and management codes. These issues can lead to errors in insurance reimbursements, lost revenue opportunities for providers, as well as inaccurate billing practices that affect other aspects of patient care. While there are many steps involved in solving these problems, they all start with educating yourself on how coding works so you can better understand what needs to change within your organization or industry.