Reimbursement Review

Introduction

There are a variety of reimbursement methods that require detailed documentation to support medical claims.  Third party payers are very concerned about fraud and abuse in claims processing.  Bills and claims accuracy is an important part of healthcare compliance.  A reimbursement claim is a statement of services submitted by a healthcare provider to a third-party payer.

The claim documents the medical or surgical services provided to a patient for a specific episode of care.  The operational and financial health of a healthcare organization is dependent upon accurate reimbursement. One major role of the HIM professional in the reimbursement process is to ensure that health record documentation supports services billed.  Another major role of the HIM professional in healthcare reimbursement is assigning diagnostic and procedural codes according to patient record documentation in compliance with coding guidelines. 

Objectives

Upon completion of this module, the student will be able to:
  • Explain the prospective payment system utilized for Medicare reimbursement for ambulatory surgery procedures
  • Identify the characteristics of the resource-based relative value scale (RBRVS) for Medicare reimbursement for physicians
  • Define unbundling
  • Identify the characteristics of ambulatory patient classification (APC) groups
  • Define various payment methodologies used for physician office, hospital, other outpatient reimbursement

Readings & Resources

Kuehn, Lynn.  Procedural Coding and Reimbursement for Physician Services:  Applying Current Procedural Terminology and HCPCS.  AHIMA Press. 2012 edition. Chapters 10, 11
 
 
Required Textbook reading:  Smith, Gail.  Basic Current Procedural Terminology and HCPCS Coding.  AHIMA Press.  Most current edition Chapter 11
 
AMA, Current Procedural Terminology (CPT) 2013. Professional Edition.
 
Center for Medicare and Medicaid. Determine the names and addresses of the Medicare Part A fiscal intermediary and Part B for given state
 
ICD-10-CM (Center for Disease Control)

Assignments and Activities