Medical Billing and Coding Report: Diagnosis, Coding, and Ethics

This report provides a comprehensive overview of medical billing and coding, emphasizing the importance of accurate diagnosis and coding for effective healthcare reimbursement. It explores diagnostic procedures, the significance of a complete patient history, and the role of medical codes in translating patient documentation into standardized codes. The report discusses the impact of pre-existing conditions on coding and insurance coverage, as well as the steps required for accurate medical coding and the implications of unbundling. Furthermore, it presents and analyzes several coding scenarios, including cases involving expressive language disorders, sensory hearing loss, and insurance claim denials, providing insights into ethical considerations and best practices for handling such situations. References from various authors are also included to support the content and the ideas presented in the report.

Running head: MEDICAL BILLING AND CODING
MEDICAL BILLING AND CODING
Name of the Student
Name of the University
Author Note

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What does a diagnosis or diagnostic statement tells us?
Diagnosis is the detection of any medical condition that needs treatment. It is a process of
determining the disease that is explained by the person’s symptoms and condition. Diagnosis of a
disease is important to begin treatment. The information or medical data that are required for
diagnosis are generally collected from patient’s medical history and through physical
examinations. When a diagnosis is exact and created in time, a person has the greatest chance for
promoting wellness since the decision-making process is designed to ensure improved outcome
of the patient (Hoeppner and Marilu). There are a variety of diagnostic procedures like medical
tests such as blood test, ECG, X-ray, ultrasonography and others. Depending on the type of
illness the patient is seeking medical help, different approaches of diagnosis are applied. Patients
are treated based on the diagnosis data and doctors plan treatment strategies from these data.
Diagnostic process requires medical information of the patient including history,
condition and symptoms the patient is having. To start the treatment based on the diagnostic
results it is very important to know the whole story including medical history. Medical
conditions and past history gives us information about what and how to treat the patient against
the particular disease.
Why is it important to tell the “whole story” of the encounter?
Medical codes are required in order to convert patient’s documentation into standardized
codes that gives information of the patient’s diagnosis, medical requirements for the treatment
and services and facilities. Health codes must tell the entire history of a patient's meeting with
the doctor and must be as specific as possible to collect reimbursement for services rendered
(Whitmer and Elizabeth). The primary task of a medical coder is to review and assign standard

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codes on the clinical statements of the patient using different classification systems. Medical
accountants handle and track allegations for the reimbursement of facilities provided by a
medical supplier that are forwarded to insurance undertakings. It is important to know the whole
story of the encounter as it helps to understand patient’s documentation and the diagnosis
assigned to the patient and also helps to determine the procedures performed when they visited
the physician (Ansah and Evelyn).
Pre-existing condition and its importance to the professional coder
In the US, a pre-existing health condition is a medical condition which has begun before
the health benefits of an individual have come into effect. When an individual requests for health
insurance, he or she will complete a medical history questionnaire on their medical history. An
authorized healthcare supplier may also have to undergo a physical exam to determine their
health status (Whitmer and Elizabeth). The insurance companies may choose with this data to
exclude coverage on certain terms while still offering complete protection of the pre-existing
conditions for regular or acute care.
Conditions affecting commercial health insurance are circumstances which continue
when an insurance plan is implemented. There are no previous circumstances for which patients
have not been treated any more. The patient's diagnosis is reported by professional medical
healthcare providers and certified medical coders in accordance with universal medical code.
The right code will allow patients to get advantage fully from their health benefits. Medical
codes are allocated on the basis of the available information documented in the medical history
of the patient. Without definite diagnosis, medicine coders and billers do not attribute final
diagnostic codes (Deverka et al.,). If the person is not yet affected by any disease, the reasons for
the arranged tests are the signs justifying the tests to be performed. The licensed medical coders

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and billers translate their medical interactions into uniform codes and are responsible for
carrying out their tasks in depth so that medical facilities are described as precisely as feasible
not only because the patients can get benefit from their complete insurance benefits, but also to
maintain a transparent and efficient healthcare reimbursement scheme.
The steps to be followed for accurate medical coding
 The whole super bill should be read along with all the doctor's records.
 Instructions from the doctor should be carefully read. A duplicate of the patient's note and
superbill should be made, so that they can be accessed without marking the originals.
Enhance the variety of diagnosis and procedure codes with significant phrases.
 Check or discuss any vague, incompatible or lacking data with the health care provider.
Never took or conjecture. Code only the paperwork that is understandable and
comprehensible. The contents cannot be coded if the doctor doesn't record or document
it.
 Code each diagnosis that is verified and/or indications and/or symptoms explaining the
reason why, as per doctors ' instructions, the healthcare professionals supplied the
facilities requested for this meeting. Use the documentation's most particular code
accessible.
 Coding should be done in accordance with the documentation, procedures, services and
treatment provided by the doctors and staff.
 Check medical requirement by connecting at least one diagnostic code for each method
sequence with the same statement.
 Codes should be cross checked. The details of the allocated sections should be read again
and combine with the notes and documentations to double check the codes of assigned.

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What is unbundling?
Mis-coding may also happen through "unbundling" or "fragmentation." Medicare and
Medicaid often have reduced levels of reimbursement for common operation types, such as
surgery incisions and closures (Lifchez and Scott). Unbundling or fragmentation of accounting
systems raises the earnings of a provider illegal through separate payment processes, resulting in
greater Medicare and Medicaid reimbursements (Lifchez). The use of electronic health records
(EHR) software can facilitate upcoding and unbundling. The application of software for
Electronic Health Checks (EHR) can make upcoding and unbundling easier. EHR technology
enables suppliers to download and paste records from a prior patient encounter into each present
therapy record so that it can show that each disease has been identified and handled by the
supplier. Providers may also limit their EHR software menu options to display only the
maximum reimbursement diagnosis and instructions (Clack and Crystal).
The steps that I would follow to handle the scenarios:
Considering the first scenario, the 3 year old girl Juliana is diagnosed with F80.1
Expressive language disorder and development aphasia. It is associated with mental, behavioural
and neurodevelopmental disorders. She is also diagnosed with F 90.1 sensory hearing loss,
bilateral. It is natural for Sarah, the victim’s mother, to get stressed out knowing the fact that her
child is suffering from mental disorder that can affect her life and career in long run. However,
being a medical healthcare professional it is my primary responsibility to not break ethical
standards associated with my profession. In addition to that, if I hide or change her medical code
that would depict some other disease and other treatment plan irrelevant to her medical state that

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might have a bad impact on her and moreover, if healthcare suppliers and facilities miscode their
medical services to obtain greater refunds, copying fraud takes place, that is against my ethics.
In the second scenario, the aim is to crack down a patient's account in order to enable the
insurance company to check, handle and screen allegations correctly. A superbill can also
include further data about a trip (e.g. a disease) that can be warranted by an insurance supplier
for a particular operation or activity, as opposed to an periodic invoice which can be forwarded
to a health insurance firm or customer. Superbills thus save suppliers money by offering a
predefined roster of instructions they can use for a customer trip merely to find out.
In the third scenario, since the insurance company knows that this disease has been
identified earlier, it can be drawn on to exclude obesity and to exclude the fee for medicines and
hypertension management services. I will prepare a claim against her diabetes issue so that she
gets insurance coverage.
Considering the last case, since the codes represent similar diseases and identical
treatment, I will consider this as a unique case and get the codes changed so that the family gets
treated without facing problem in terms of money.

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References:
Ansah, Evelyn K., et al. "“Even if the test result is negative, they should be able to tell us what is
wrong with us”: a qualitative study of patient expectations of rapid diagnostic tests for
malaria." Malaria journal 12.1 (2013): 258.
Clack, Crystal. "Don’t Let Preventable CPT Coding Mistakes Cause Heartburn." Journal of
AHIMA 86.11 (2015): 60-61.
Deverka, Patricia A., David Kaufman, and Amy L. McGuire. "Overcoming the
reimbursement barriers for clinical sequencing." JAMA 312.18 (2014): 1857-1858.
Hoeppner, Marilu A. "NCBI Bookshelf: books and documents in life sciences and health
care". Nucleic Acids Research 41.D1 (2012): D1251-D1260.
Lifchez, Scott D., et al. "Ethical and educational considerations in coding hand surgeries."
The Journal of hand surgery 39.7 (2014): 1370-1377.
Rimmerman, Curtis M., and Arnette Colbert. "Standardizing electronic medical record
documentation." Physician executive 40.4 (2014): 44.
Spitznagel, Regina, and Debjani Sarkar. "Medical coding system with integrated codebook
interface." U.S. Patent Application No. 14/296,214.

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Tang, Karen L., Kelsey Lucyk, and Hude Quan. "Coder perspectives on physician-related
barriers to producing high-quality administrative data: a qualitative study". CMAJ
Open 5.3 (2017): E617-E622. Online. Internet. 5 Jul. 2019.
Tasker, Robert C. "Why Everyone Should Care About “Computable Phenotypes”*".
Pediatric Critical Care Medicine 18.5 (2017): 489-490. Online. Internet. 5 Jul. 2019.
Whitmer, Elizabeth. "Medical coding keyboard." U.S. Patent Application No. 10/139,923.