Guidelines To Be Followed By Billers and Coders

Guidelines To Be Followed By Billers and Coders

Billing and coding are very much different from each other. One one hand, the duty of medical coder includes abstracting the information from the documents assigned, allotting the appropriate codes and creating the claim that is to be paid by the patients. Whereas medical billing is a process of submitting and following up the coded claims created by the medical coder to receive payments for the services provided by the hospital. Both the biller and coder deals with some very sensitive information related to patients and the health insurance cover on a daily basis. They have to perform their duty according to the guidelines set by Healthcare Reform Act 2010, the Office of the Inspector General (OIG) and Health Insurance Portability and Accountability Act (HIPAA).

Medical biller and coder have to follow these guidelines strictly, as the failure may result in federal investigation. An overview of all the guidelines are given below:-

Health Insurance Portability and Accountability Act (HIPAA)

It was passed by Congress under the presidency of Bill Clinton in 1996. The basic aim behind this compliance is to increase the security and privacy level to keep the patients related information secure. The guidelines covered under this act, covers all the processes involved in collecting the information of patients from the initial stage to the final stage. Standards are established in order to restrict the fraudulent activities involved in the billing and coding process.

All the Billers and coders have to comply with the guidelines while performing their duty. As per the tile 1 of this act, Billers and coders have to process claims that involves all the employees who are benefited with health care plans and their dependents as well as the employees who have lost their job or in urge of switching their jobs. Benefits of the same health care plan can be claimed by the dependents of the employee that they used to claim when the employee was employed with those health benefits. Patients with the pre-existing conditions will also be benefited as per the guidelines of this act.

Tile 2 covers all the points related to privacy and security. Unique identifiers must be created for the employers, employee and patients according to Electronic Data Interchange Rule.

Billers and coders cannot share patient’s Protected Health Information report (PHI includes- patients medical report, fees paid, etc.) with any third party.

Healthcare Reform act 2010

It came into existence to increase the health care access and to cover more Americans with it. Many preventive measures are included in this act, for instance, free of cost medical care, annual wellness visit, etc. for the enrollees.

Under the Health Care Reforms Act 2010, EHR is made mandatory for medical billing. EHR came into existence to lessen the burden of billers and coders of handling the huge paperwork. Necessary reorganisations have to be made by the billers and coders to handle transaction electronically. The electronic transaction system had came into existence to meet the privacy and security requirements of Health Insurance Portability and Accountability Act of 1996

OIG Compliance

The principal duties of OIG consist of prevention of all fraudulent activities related to medical coding and billing industries. OIG deals with various fraudulent activities like, submitting separate claims that could be fit on separate bills, tampering with the records of patients and intentional over and under coding. All the billers and coders must take care of all the activities that are considered as fraudulent by the OIG. All the federal healthcare laws and regulations must be properly followed by the billers and coders while performing their task.

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