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Billing and Coding

Medical Ethics

Medical ethics are standards of conduct based on moral principles. They are generally accepted as a guide for behavior towards patients, physicians, co-workers, the government, and insurance companies.

Medical Billing and Coding as a Career

There are many different titiles that fall under this paticular specialty. It is a diversidfied position and can be very broad or very narrow in the duties to be performed depending on the size of the office.

Compliance Regulations

Most billing-related cases are based on HIPAA and False Claims Act.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Created the Health care Fraud and Abuse Control Program enacted to check for fraud and abuse in the Medicare and Medicaid programs, and private payers.

Insurance Reform

Primary purpose is to provide continuous insurance coverage for workers and their dependents when they change or lose their jobs.
Limits the use of preexisting conditions exclusions.
Prohibits discrimination for part or present poor health.
Guarantees certain employees and individuals the right to purchase new health insurance coverage after losing a job.
Allows renewal of health insurance coverage regardless of an individual's health condition that is covered under the particular policy.

Possible consequences of inaccurate coding and incorrect billing include

delayed processing and payment of claims
reduced payments; denied claims
fines and/or imprisonment


This is defined as incidents or practices, not usually considered fraudulent, that are inconsistent with the accepted medical business or fiscal practices in the industry.

Adminstrative Simplification

The goal is to focus on the health care practice setting to reduce administratice costs and burdens.

False Claims Act (FCA)

Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim.

National Correct Coding Initiative (NCCI)

Developed by the CMS to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B health insurance claims.

Possible consequences of inaccurate coding and incorrect billing include

Delayed processing and payment of claims.
Reduced payments; denied claims.
Fines and/or imprisionment.
Exclusion from payer's programs; loss of physician's license to practice medicine.

The Office of Inspector General (OIG)

has the task to investigate and prosecute health care fraud and abuse.


Knowingly and intentionally deceiving or misrepresenting information that mey result in unauthorized benefits.

Patient Confidentiality

All patients have a rifght to privacy and all information should remain privileged.


primarily for the purpose of discussion of the patient's case with other providers.


providers submit claims on behalf of patients.


for purposes such as staff training and quality improvement

Employer Liability

The license to practice medicine is governed by each individual state.

Employee Liability

"Erros and omissions insurance" is protection against loss of monies caused by failure through error or unintentional omission on the part of the individual or service submitting the insurance claim.

Medical Records

is a documentation of the patient's social and medical history, family history, physical examination findings, progress notes, radiology and lab results, consultation reports and correspondence to patient.

Medical Report

is part of the medial record and is a permanent legal document that fomally states the consequences of the patient's exam or treatment in letter or report form.


date of service


place of service


type of service

dx or DX


Reasons for Documentation

It is important the every patient seen by the physician has comprehensive legible documentaation about the patient's illness, treament and plans.

Retentoin of Medical Records

is governed by state and local laws and may vary from state-to-state. Most physicians are required to retain records indefinitely; deceased patient records should be kept for at least five (5) years.

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