|  | Healthcare Industry | Medicare

Medicare Coding Requirements

Eligibility for reimbursement in the health care setting relies on the accurate coding of diagnostic procedures, tests and several other aspects of care provided. This may be especially so when it comes to the client receiving Medicare services. In order to receive payment, the facility must ensure that all regulations and requirements are met. Failure to adhere to the Medicare coding requirements can result in delayed and denied payments to the participating organization.

  1. Diagnostic Related Groups

    • Diagnostic related groups, commonly called DRGs, consist of assigned diagnostic groups utilized for the coding and billing services to Medicare for all hospitals. Services are grouped together within one or more of the categories and payments are issued accordingly. Medicare coding requirements include the use of these assigned DRGs in order to be reimbursed. Employees coding for Medicare billing must use these preset groups correctly and ensure that the care provided falls within the right category.

    Approved Coding Methods

    • As of 2002, Medicare has required the use of a specific system, referred to as ICD-9 code, that is mandatory for health care facilities. This guides the process of coding and billing for Medicare claims. It is the responsibility of the health care agency to obtain the guidelines for these particular coding procedures. ICD-9 is approved by the Health Insurance Portability and Accountability Act (HIPAA) and those not in compliance may be in violation of this regulation. As a matter of fact, Medicare will not accept claims that are not presented utilizing the ICD-9 method of coding and billing.

    Mandatory Recovery Auditing

    • Medicare-eligible facilities must allow auditing of coding practices in order to remain eligible for Medicare reimbursement. Recovery auditing was developed in response to the overpayment of agencies through various errors, including improper coding. Medicare coding requirements stipulate that the hospital or health care agency allow these committees or contractors to perform reviews related to coding practices. This may include providing appropriate documentation, such as electronic or hard copy records, to the evaluators.

Medicare - Related Articles