Describe procedures you might enact in your facility to avoid violating this law.

The U.S. health care system relies heavily on third-party payers, and therefore, patients are often

not the ones who pay most of their medical bills. Third-party payers include commercial insurers

and the Federal and State Governments. When the Federal Government covers items or services

rendered to Medicare beneficiaries, Federal fraud and abuse laws apply.

Explain the roles of the physician, the nurse, the coder, and billing professionals in the

process of reporting healthcare encounters.

The provider is responsible to document about that service rendered then the record is given to

the medical billing and coding specialist. The biller and coder must then translate the

documentation into the proper code. Medical billing and coding specialists are responsible for

correctly coding the diagnoses and procedures performed by the healthcare provider. This

requires a thorough knowledge of both ICD-9- CM codes and ICD-10-CM codes for diagnostics,

and CPT codes for procedures. A procedure document includes relevant information like the date

of the procedure, the patient’s name, and his or her date of birth. More importantly, a procedure

document includes the doctor’s diagnosis and the procedure performed. The medical biller and

coder would look at the procedure documentation and decide which codes correspond to the

diagnosis and procedure listed. The bulk of the medical coding portion of the billing process

involves turning procedure reports into correct medical code, then entering it into the system for

the claims process. Medical coders spend their day taking procedure documentation, looking up

the proper codes, and entering that information into their claims software.
References

Halabi, S. F. (2016). Collective Corporate Knowledge and the Federal False Claims Act. Baylor

L. Rev., 68, 265.

Martel, M. L., Imdieke, B. H., Holm, K. M., Poplau, S., Heegaard, W. G., Pryor, J. L., & Linzer,

M. (2018). Developing a medical scribe program at an academic hospital: the Hennepin

County Medical Center experience. The Joint Commission Journal on Quality and Patient

Safety, 44(5), 238-249.