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Medical Coding
The Legal Nurse Consultant as a certified RN Medical Coder can identify Medicare and Insurance Fraud and Abuse Issues.
There are three coding systems in the U.S.A.
1. ICD-9-CM
2. CPT
3. HCPCS
U.S. healthcare systems are becoming very complex when coding and billing for reimbursement thus certified RN Coders are indispensible in coding and gets all the relevant codes on the claim accurate
Certified RN Medical Coders are specially trained in Outpatient and Physician Medical Coding; hospital DRG’s and the hospital itemized statements, the Uniform Bill UB92 (CMS 1450)
The RN coder and RN auditor uses clinical knowledge of procedures and diagnosis to assure everything provided to the patient has been documented
The RN Auditor provides a second level of codes assigned to medical diagnosis and clinical procedures ensuring medical billing conforms to legal and procedural requirements.
The RN Auditor understands systems and protocols to achieve and maintain compatibility with Medicare billing requirements and compliance standards
The RN coder is knowledgeable in Medicare and HIPAA laws.
The certified RN coder can teach other RN’s or physicians how to code correctly.
Coding and billing mistakes are no longer considered negligence but qualify as abuse.
The Certified RN Coder or Auditor identifies problem areas in coding to discover the following:
- Ordering excessive tests
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Billing for care not provided
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Unbundling of known bundled services.
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Changing codes to get paid more
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Coding for items not medically necessary
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Utilization pattern doesn’t meet the standards of Industry
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Frequent billing of highest Evaluation and Management (E/M)
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Laziness always billing Level 3 E/M
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Keep billing the same code repetitiously
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Inappropriate same day admissions
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Many high dollar claims and larger volumes
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