Hca 530 Coder Interview Directions
Select a provider or health care facility coder/biller to interview and review the process
they go through to satisfy reimbursement requirements for billing purposes.
Write a paper of 750-1,000 words that describes the processes that are utilized in
producing a final bill. Include in the paper:
1. How health care charging and pricing processes are different from those in other
industries.
2. How private and government insurers and payers impact actual reimbursement.
3. Cite a minimum of three references to support your rationale.
Prepare this assignment according to the guidelines found in the APA Style Guide, located
in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment
to become familiar with the expectations for successful completion.
You are required to submit this assignment to Turnitin. Please refer to the directions in the
Student Success Center.
Jessie
• How does charging and pricing process work?
• How does each type of payer (self, third and government) differ?
• How does each type of payer (self, third and government) impact the actual
reimbursement?
• How health care charging and pricing processes are different from those in other
industries
o Other industries have automated processes
o Health care requires technology be applied in a patient by patient basis
• How does charging and pricing process work?
o Each charge code is associated with a revenue code linking to revenue
categories used in the hospitals accounting and billing systems (Pilato, 2014)
o Every chargeable item in the hospital must be part of the charge description
master (CDM) in order for a hospital to track and bill a patient, payer, or
another healthcare provider (Pilato, 2014)
o For each chargeable procedure, item, or service, the CDM includes a unique
item number, technical description, CPT/HCPCS and revenue codes, the
assigned price, and several other elements. Multiple subsystems interface
with the CDM including radiology, laboratory, respiratory, pharmacy,
central supply, and billing (Pilato, 2014)
o The CDM’s primary functions are to (Pilato, 2014):
▪ Produce an itemized statement
▪ Assign charges on the inpatient claim
This study source was downloaded by 100000815611969 from CourseHero.com on 01-12-2023 01:16:12 GMT -06:00
https://www.coursehero.com/file/23650531/Coder-Interview-Directions/
, Hca 530 Coder Interview Directions
▪ Assign charges, codes, and descriptions on the outpatient claim
▪ Track statistics
▪ Monitor the cost of care for patients
▪ Provide cost account data to financial systems
• Golden rules in coding and billing : “If it is not documented, do not code it or bill it”
(Evolve, 2011)
• Phases of patient care process (Evolve, 2011):
o Patient arrives at hospital for care (outpatient, ambulatory services,
inpatient) Patient admission (tasks required to receive a patient at the hospital
on an outpatient or inpatient basis) Patient care services (diagnostic,
therapeutic, palliative, or preventative) Medical record documentation (all
information regarding the patients care is recorded in the medical record)
Charge capture (coding) Patient discharge (HIM – review/coding) Billing
process (review record and charges, prepare charges for submission) Accounts
receivable management (monitor and follow-up on outstanding accounts
• How does each type of payer (self, third and government) differ?
o HIM department is responsible for coding clinical data required for
submission of claim forms to various third-party payers (Evolve, 2011)
o Coding worksheet is often utilized to abstract information regarding the
patient’s diagnosis and procedure(s), which is then used to input codes into
the computer (Evolve, 2011)
▪ Many utilize computer program “Encoder” to assist with code
assignment
o Goal is to submit third-party payer claims accurate and in a timely manner
the first time (Evolve, 2011)
o Patient transactions (Evolve, 2011)
▪ Payment determination is made, the payer communicates how the
claim was processed and the payment status with the hospital
utilizing a remittance advice (RA), a document prepared by payers to
communicate payment determination to hospitals and patients.
• Includes detailed information about charges submitted and
explanations of how the claim was processed
▪ Third-party payer
• Actions on claim may include:
o Denial or rejection of the claim and reason
o Payment of the claim (covered and noncovered charges)
o Request for additional information
▪ Process of posting transactions to a patients account:
• Third-party payer payments are posted to account
• Contractual adjustment is applied if needed
• Balance in billed to patient or forwarded to a secondary or
tertiary payer
• Claim denials require research to determine whether the
denial is appropriate
• How does each type of payer (self, third and government) impact the actual
reimbursement?
o Reimbursement from Medicare is a three-step process (Beck & Margolin,
2007):
▪ Appropriate billing coding of the service provided by utilizing current
procedural terminology
▪ Appropriate coding of the diagnosis using ICD-9 code
This study source was downloaded by 100000815611969 from CourseHero.com on 01-12-2023 01:16:12 GMT -06:00
https://www.coursehero.com/file/23650531/Coder-Interview-Directions/
Select a provider or health care facility coder/biller to interview and review the process
they go through to satisfy reimbursement requirements for billing purposes.
Write a paper of 750-1,000 words that describes the processes that are utilized in
producing a final bill. Include in the paper:
1. How health care charging and pricing processes are different from those in other
industries.
2. How private and government insurers and payers impact actual reimbursement.
3. Cite a minimum of three references to support your rationale.
Prepare this assignment according to the guidelines found in the APA Style Guide, located
in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment
to become familiar with the expectations for successful completion.
You are required to submit this assignment to Turnitin. Please refer to the directions in the
Student Success Center.
Jessie
• How does charging and pricing process work?
• How does each type of payer (self, third and government) differ?
• How does each type of payer (self, third and government) impact the actual
reimbursement?
• How health care charging and pricing processes are different from those in other
industries
o Other industries have automated processes
o Health care requires technology be applied in a patient by patient basis
• How does charging and pricing process work?
o Each charge code is associated with a revenue code linking to revenue
categories used in the hospitals accounting and billing systems (Pilato, 2014)
o Every chargeable item in the hospital must be part of the charge description
master (CDM) in order for a hospital to track and bill a patient, payer, or
another healthcare provider (Pilato, 2014)
o For each chargeable procedure, item, or service, the CDM includes a unique
item number, technical description, CPT/HCPCS and revenue codes, the
assigned price, and several other elements. Multiple subsystems interface
with the CDM including radiology, laboratory, respiratory, pharmacy,
central supply, and billing (Pilato, 2014)
o The CDM’s primary functions are to (Pilato, 2014):
▪ Produce an itemized statement
▪ Assign charges on the inpatient claim
This study source was downloaded by 100000815611969 from CourseHero.com on 01-12-2023 01:16:12 GMT -06:00
https://www.coursehero.com/file/23650531/Coder-Interview-Directions/
, Hca 530 Coder Interview Directions
▪ Assign charges, codes, and descriptions on the outpatient claim
▪ Track statistics
▪ Monitor the cost of care for patients
▪ Provide cost account data to financial systems
• Golden rules in coding and billing : “If it is not documented, do not code it or bill it”
(Evolve, 2011)
• Phases of patient care process (Evolve, 2011):
o Patient arrives at hospital for care (outpatient, ambulatory services,
inpatient) Patient admission (tasks required to receive a patient at the hospital
on an outpatient or inpatient basis) Patient care services (diagnostic,
therapeutic, palliative, or preventative) Medical record documentation (all
information regarding the patients care is recorded in the medical record)
Charge capture (coding) Patient discharge (HIM – review/coding) Billing
process (review record and charges, prepare charges for submission) Accounts
receivable management (monitor and follow-up on outstanding accounts
• How does each type of payer (self, third and government) differ?
o HIM department is responsible for coding clinical data required for
submission of claim forms to various third-party payers (Evolve, 2011)
o Coding worksheet is often utilized to abstract information regarding the
patient’s diagnosis and procedure(s), which is then used to input codes into
the computer (Evolve, 2011)
▪ Many utilize computer program “Encoder” to assist with code
assignment
o Goal is to submit third-party payer claims accurate and in a timely manner
the first time (Evolve, 2011)
o Patient transactions (Evolve, 2011)
▪ Payment determination is made, the payer communicates how the
claim was processed and the payment status with the hospital
utilizing a remittance advice (RA), a document prepared by payers to
communicate payment determination to hospitals and patients.
• Includes detailed information about charges submitted and
explanations of how the claim was processed
▪ Third-party payer
• Actions on claim may include:
o Denial or rejection of the claim and reason
o Payment of the claim (covered and noncovered charges)
o Request for additional information
▪ Process of posting transactions to a patients account:
• Third-party payer payments are posted to account
• Contractual adjustment is applied if needed
• Balance in billed to patient or forwarded to a secondary or
tertiary payer
• Claim denials require research to determine whether the
denial is appropriate
• How does each type of payer (self, third and government) impact the actual
reimbursement?
o Reimbursement from Medicare is a three-step process (Beck & Margolin,
2007):
▪ Appropriate billing coding of the service provided by utilizing current
procedural terminology
▪ Appropriate coding of the diagnosis using ICD-9 code
This study source was downloaded by 100000815611969 from CourseHero.com on 01-12-2023 01:16:12 GMT -06:00
https://www.coursehero.com/file/23650531/Coder-Interview-Directions/
