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By: Belinda Z. Burgos González, MPH | Interviewing: Lilybeth Rivera
Medical coding and billing are a crucial component of the healthcare system. They involve an efficient translation of medical services into codes. In turn, this ensures the solvency of operations in all billing to insurers. It is important to know all the factors that affect a correct billing process.
A correct coding process becomes even more important in services under the federal Medicare and Medicaid programs. Correct coding ensures providers receive payment for their services in compliance with established regulations. Per Lilybeth Rivera, certified professional coder at Provider Network Solutions, “The coding of health conditions is fundamental for the federal Medicare and Medicaid programs in Puerto Rico since this process affects not only patient premiums, but also the quality of medical care and adequate reimbursement for providers.” Rivera highlighted some points about the benefits associated with an adequate coding process:
Failure to employ a rigorous coding process for services billed to Medicare and Medicaid can have adverse implications for both medical services and patients. Along these lines, Rivera highlighted that among the negative consequences that could occur is the patient receiving inadequate treatment due to incorrect coding of their treatment or procedure.
Rivera also stated, “Coding errors can result in audits by regulatory authorities. If the audit finds erroneous coding, for example, 'upcoding', codes for procedures not performed, among others, doctors face substantial financial penalties, loss of medical license and even incarceration."
On the other hand, Rivera indicated that Provider Puerto Rico has been implementing proactive measures to guarantee accuracy in medical coding.
Some of the established strategies are:
As external support for these preventive measures, Rivera also noted that they have “guidelines from regulatory agencies such as CMS (Center for Medicare and Medicaid Services) and the Office of the Inspector General, as well as the guides established in the code book known as ICD-10” to ensure the greatest accuracy in guiding providers and their teams through the coding process.
The key is to stay updated
Coding guidelines in health services change annually. For this reason, Rivera provided recommendations for providers to continue offering quality service and, above all, to ensure that the patient meets the patient's needs.
Rivera explained, “At Provider we are a company that is dedicated to offering high-quality services and expert care to patients. We have professional staff such as medical directors, nurses, certified coders, HEDIS experts, and pharmacy graduates. This team focuses on reducing the administrative burden on providers, thus allowing them to focus all their time and efforts on caring for their patients.”
"Our vision is clear: to be the organization that stays one step ahead and provides support to the entire healthcare system. This includes health plans, providers, and, above all, quality services for patients through compassion and empathy. All while adhering to the best practice guidelines established by regulatory agencies," concluded the coding educator.
