In my work as an expert witness regarding medical billing and coding, I provide opinions on Usual Customary and Reasonable cost of care. I receive questions on the difference between different types of care, codes and billing and the role of various entities in health care revenue cycle management and claims management. It is important to take into account inpatient and outpatient payment rules, federal and state statutes and industry best practices and guidelines. The privacy and security of patient records being evaluated as prescribed under the HITECH Act or HIPAA must be considered including safeguards, policies and procedures to ensure the privacy and security of protected health information (PHI).
Also, the timing of expenditures in relation to inpatient care may be important. Diagnosis codes including ICD-9 and ICD-10 CM as well as procedure codes, ICD-9 and ICD-10 PCS as well as outpatient procedures using the AMA standard Current Procedural Terminology (CPT®) or dental CDT codes may be factors. Inpatient stays may require review of Diagnosis Related Groupings (DRGs). Additionally, payments via various payors whether private insurance, Medicare and Medicaid via the Centers for Medicare and Medicaid may be factors. Medical codes are determined by coders who rely on physician or physician assistant diagnosis and prescribed procedures. Additionally, diagnostic imaging, pharmaceuticals and durable medical equipment costs (DME) may be factors.
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