Ethics of Maximizing Reimbursement

Behind every instance of your patients flashing their Medicare or Medicaid card is a three-step process for filing your reimbursement. Proper coding comprises two-thirds of the task, which is why it's important to get the codes right. Aside from the ICD-9 (soon to be phased out in favor of the ICD-10), practitioners have their own local codes.

Physicians use the current procedural terminology (CPT®), a coding system maintained by the American Medical Association developed in 1966. The CPT® is updated yearly to include as many treatments and diagnoses as possible. The codes evolve along with the evolution of medical technology and recent discoveries in the field.

Since 1992, the codes—both local and ICD—correspond to a specific fee schedule published by Medicare or Medicaid. The fee schedules emerged as a result of the vulnerabilities of doctors setting the price tag themselves. Some may justify above-average fees, stating that it's the so-called "usual, customary, and reasonable charge."

While this will increase your profit margin, as health professionals, it's important to conform to ethics. Proper coding ensures just, maximized reimbursement without delay. What good would proper coding serve if patients, existing and prospective, turn away from your facility due to bad practices? If you want to raise your profit margin, do it ethically.