Healthcare organizations must follow
regulations and mandates posed by the government in order for their
establishment to function correctly. Guidelines affect every aspect of
healthcare, especially billing and coding. Every provider must also understand
the role they play in reimbursement. Healthcare professionals must always ensure
compliance is attained with respect to the agreement made between themselves
and the third-party payers who are providing reimbursement services to the

The claim forms vary from payer to payer
but coding must meet the guidelines implemented by the International
Classification of Diseases (ICD-9-CM) and ICD-10-CM. The American Hospital
Association (AHA), the American Health Information Management Association (AHIMA),
and NCHS are the organizations who approved the morbidity classifications (Harrington,

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 Health Care Financing Agency implemented the
new Outpatient Prospective Payment System (OPPS). This program, mandated by the
Balanced Budget Act of 1997, applies to hospital outpatient departments,
community mental health centers and for some services provided by comprehensive
outpatient rehabilitation facilities, home health agencies and services
provided to hospice patients for the treatment of a nonterminal illness
(Rosenberg & Browne, 2001).

HIPAA entails for all healthcare
organizations to follow these coding laws because without them, payers will not
reimburse them for their services. Healthcare organizations may also be in
default and could possibly be fined, closed, and at risk for revocation of licensing.
All coders must be capable enough to know that there is no room for mistakes
when it comes to adhering to coding guidelines.

use the ICD-9-CM coding to determine payment categories for various Prospective
Payment Systems (PPS). Hospital Inpatient uses Medicare-severity diagnosis-related
groups (MS-DRG), Hospital Rehabilitation uses case-mix groups (CMGs), Long-term
Care uses long-term care Medicare-severity diagnosis-related groups (LTC-MS-DRGs),
and Home Health uses home health resource groups (HHRGs) (Harrington 2016).

Billing and coding is a complex and
comprehensive duty that must be continuously updated and reinforced. Although
there is no room for error in the healthcare field, mistakes do tend to happen.
Coders may come into situations where incorrect documentation can lead to
delays in payment or the organization can receive inappropriate payments for
services that weren’t made. Medicare abuse may include misusing codes on a claim,
charging excessively for products or services, and billing for services that
were not medically necessary. Both Medicare fraud and abuse can expose
providers to criminal and civil liability (Harrington, 2016). I believe that
the Fraud Prevention System implemented by the CMS has proven to be helpful in
improving healthcare costs. In 2012, the government recovered $4.2 billion
dollars from individuals committing fraud (Harrington, 2016). Another great
tool which healthcare organizations have at their disposal to help assist them
in adhering to the rules, guidelines, and regulations related to the PPS is the
Federal Register. This documents is updated annually and changes are published
through the Notice of Proposed Rulemaking (NPRM). Prospective payment thus
provides a potential solution to the problem of increasing hospital
expenditures that threatens the solvency of the Medicare program (Guterman
& Dobson, 1986).





S., & Dobson, A. (1986). Impact of the Medicare prospective payment system
for hospitals. Health Care Financing Review, 7(3), 97–114


M. K. (2016). Healthcare Finance: and the Mechanics of Insurance and          Reimbursement. Burlington, MA: Jones
& Bartlett Learning


M. A., & Browne, M. J. (2001). The impact of the inpatient prospective payment
system and  diagnosis-related groups: A
survey of the literature. North American Actuarial Journal, 5(4), 84- 94