Healthcare providers are obliged to comply with the formulated guiding regulations and standards when coding patients’ information. Compliance strategies are affected by various factors and they vary with situations. Having knowledge of compliance strategies is essential for effective operation. Coding compliance entails the strategy of ensuring that the coding of the procedures and diagnosis abide by all coding guidelines and regulations. The process includes five major components: detection, correction, prevention, verification and comparison (Richards, 2010). Compliance strategies are inherent in the medical billing cycle model which spells the major steps that need to be undertaken from the time of the registration of the patient to the final step of following up and collecting payments. Common compliance strategies comprise three basic steps that include reviewing coding compliance, reviewing billing compliance and checking our patients. Knowledge of the compliance strategies is essential in eliminating the detrimental consequences of incorrect coding.
Importance of Correctly Linking Procedures and Diagnoses
Linking procedures and diagnosis is a practice of great relevance. Initially, this undertaking is important because it ensures correct diagnosis of the presented condition. Medical care is a sensitive process that demands high level of accuracy. The detrimental consequences of incorrect diagnosis cannot be re-emphasized. For example, incorrect diagnosis may make a patient succumb to a condition that could easily be managed if diagnosed correctly. Through linking procedures and diagnosis, the physician stands high chances of diagnosing the issue correctly. Furthermore, linking procedures with diagnosis is necessary in avoiding complicating the situation (Richards, 2010). The physician can establish which specific procedures to apply to each patient without causing harm. For example, the physician may avoid procedures or administering drugs that may have severe side effects on the patient. The practice is also essential in avoiding unnecessary wastage that characterizes incorrect diagnosis. Linking procedures with diagnosis prevents healthcare givers from suffering unnecessary legal consequences by abiding to the stipulated standards and procedures (Becker, 2010). Lastly, linking procedures and diagnosis is important because it reduces cases of wrong medical billing. The practice ensures that the correct procedure is followed, which minimizes the incidents of disputed claims.
The Implications of Incorrect Medical Coding
Incorrect medical coding is characterized with various detrimental consequences. Initially, incorrect medical coding can result to disputed claims. Insurance and other bodies that offer medical cover follow clearly defined criteria when evaluating the viability of the raised claims. These organizations fail to compensate claims that fail to qualify the provided criteria. This means that with poor coding, a genuine claim may be disputed on grounds of failing to meet the required minimum threshold for compensation. Furthermore, incorrect medical coding causes a delay in the compensation of the raised claims. Lack of clarity and the emergence of conflicts due to wrong coding cause a delay because the issues or concerns presented may need to be resolved first, for the compensation to be made. It is apparent that resolving such conflicts may include tedious and long court processes. It is also worthwhile noting that incorrect coding is likely to cause wrong billing, which may result to a wrong amount of compensation being offered (Richards, 2010). This may attract serious integrity concerns or unnecessary loss of funds in cases where the mistake fails to be recognized. With incorrect coding, genuine claims may fail to be compensated while the ones that are not genuine are paid. In other words, incorrect coding can result to unjust or corrupt patient’s claim compensation plan. The implication of unreliable claims’ compensation plan includes increased cases of fraud. Surprisingly, with wrong medical claim coding system, the healthcare providers may suffer charges for fraud allegations that they may have committed ignorantly. Incorrect coding may affect the reputation of the healthcare provider as one may easily be challenged in the grounds of accountability. As identified earlier, incorrect coding may cause wrong billing. This may attract disputes that may warrant investigations. Consequently, the healthcare care provider may experience bad public publicity if such investigations reveal cases of misappropriation of funds.
Relationship between Compliance Process and Medical Coding, Physician, and Payer Fees
Medical coding, physician and payer fees relate to the compliance process because they spell special requirements or provisions that need to be observed. For example, particular provisions that the healthcare provider need to observe may vary with the adopted medical coding system. It is also worthwhile noting that different physicians set different fees, which explains the relationship between physicians and the compliance process. In similar way, the payer-fees relate with the compliance process because each client is covered or offered the services that he or she can afford (Becker, 2010).
The significance of having knowledge and practicing medical compliance cannot be re-emphasized considering the negative consequences of incorrect coding. The benefit of complying with the medical coding provisions is apparent. However, it is indisputable that aspects such as medical coding, payer fees and physician affect the compliance process. This highlights the significance of adopting a universal compliance strategy to ensure a common ground, thus avoiding conflicts.
References
Becker, J. M. (2010). A guide to coding compliance. Clifton Park, NY: Delmar Cengage Learning.
Richards, C. A. (2010). Coding basics: Medical billing and reimbursement fundamentals. Clifton, NY: Delmar, Cengage Learning.
