Team assignment:
The nurse leader and all staff contribute to patient care documentation which relates back to financial reimbursement. It is important for nurse leaders to understand how the organization realizes revenue, whether as cash from clients or reimbursement from health insurers (i.e., private insurance, Medicaid, and Medicare).
As a team, research how health care organizations must bill, code, and submit claims for reimbursement. Evaluate how billers and coders process claims using ICD- 9/10, CPT, and DRG codes.
Write a 1,050-word paper evaluating the process of billing and coding in an organization and how nurses and staff contribute to the success of reimbursement through detailed patient care charting.
Assignment: I am assigned to write on DRG coding. Please write on DRG codes in about 250-500 words
Paper so far:
Introduction:
The purpose of this paper is to discuss how healthcare organizations depend on proper coding in order to receive the most reimbursement for the care provided. This paper will demonstrate how nurses and other staff’s documentation is tied to reimbursement, hoe billers and coders process claims and submit for reimbursement using ICD-10, CPT codes and DRG codes. ICD-10 was enacted October 1, 2015. ICD-10 is the abbreviation for International Classification of Diseases, 10th revision. (Centers for Disease Control and Prevention, 2020) CPT or Current Procedural Terminology, are used to demonstrate the exact procedure being performed. This code is tied to a specific dollar amount for reimbursement by insurance. (Advancing the Business of Healthcare, n.d.) DRG or Diagnoses Related Group, is when a facility enters an agreement with the health insurer to provide care within a predetermined contracted rate for the duration of the hospitalization. (HMSA Provider Resource Center, n.d.) When a facility uses the DRG for reimbursement, they provide initial documentation to the insurer to show how the member meets the criteria for that particular diagnoses. Most times, the hospital is given a few weeks approval for the members hospital stay. If more time is needed after this initial approval, the facility must provide additional documentation. Most contracts give a maximum dollar amount that the facility will spend before they are classified as an outlier. This means that the insurance company will provide additional monies when a patient has a high cost of care. When a facility is able to discharge a member before they utilize the money provided to them for payment, the facility will keep all the funds based on the DRG payment. DRG facilities can make revenue when this occurs but they assume a risk if the patient requires more care than the reimbursement but less than the outlier.
ICD-10 codes
CPT codes
DRG codes
[This is my part]
Conclusion
Reference
Advancing the Business of Healthcare. (n.d.). https://www.aapc.com/resources/medical-coding/cpt.aspx
Centers for Disease Control and Prevention. (2020). https://www.cdc.gov/nchs/icd/icd10cm.htm
HMSA Provider Resource Center. (n.d.). https://hmsa.com/portal/provider/zav_pel.fh.DIA.650.htm
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