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INTRODUCTION

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While most physicians know that payment for their services must usually be coded and billed for monetary reimbursement to happen, their traditional medical education and training has not provided them much information on how this is actually accomplished. And, while it is true that most physician practice groups have employed personnel trained in medical professional coding and billing, those personnel are completely dependent on the quality of physician documentation in the medical record. The rules for coders usually dictate the specific requirements that must be in the medical record to enable them to code appropriately for any given service. Therefore, physicians who are knowledgeable about the documentation requirements will likely see better reimbursement for their services than those who are not by making it easier for their coders to apply the correct codes. The purpose of this chapter is to provide the information and guidance for trauma surgeons to optimize their professional reimbursement as a result of a better understanding of documentation, coding, and billing rules.

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HISTORICAL BACKGROUND

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Prior to the 20th century, physicians in the United States were paid for their services directly by the patient. Because of new developments and discoveries, the ability to provide lifesaving remedies became increasingly available, but was accompanied by increasing costs. The concept of using an insurance model (designed to pay for catastrophic events that were unlikely to occur) first evolved in the private sector in the late 1920s.1 Initially limited, private health care insurance received a significant boost during World War II, when a restrictive wage freeze forced industries to compete with other options for the scarce able-bodied men who were present stateside. Employer-based health care insurance ultimately became the norm in American society with extremely few exceptions.

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Upon retirement, however, such employer-based health care insurance was no longer available to retirees, who were now forced to pay for their increasingly expensive health care needs out of their fixed social security income. Throughout the 20th century, there was a progressive movement to socialize American medicine and provide health care benefits for all citizens. A major milestone in this effort was the implementation of Medicare in 1965, which provided health care benefits to social security beneficiaries. Given the huge population of individuals covered by Medicare, it became an essential monopoly governing the provision of health care for previously employed individuals over the age of 65.

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Initially, patients submitted health care claims to Medicare and then received payments from Medicare to turn over to their physicians. Because many patients did not transfer that claim payment to their physicians, Medicare began to offer physicians the option of accepting “assignment.” This meant that physicians would accept payment directly from Medicare instead of directly from the patient. With this benefit came the requirement that the physician would agree to accept Medicare’s allowed amount as payment in full. Ultimately, private insurers followed suit, with actual payments ...

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