October 5, 2025 • 9 mins
How is the government shutdown affecting the medical coding industry? Reimbursement of claims?
I'm seeing an influx of new coders and coding roles.
Let's talk about it!
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I'm seeing an influx of new coders and coding roles.
Let's talk about it!
Become a supporter of this podcast: https://www.spreaker.com/podcast/coding-break-with-tam-talk-podcast--4244224/support.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:03):
Time to take a coding break, how they coded pros
and welcome back to another episode of the Coding Break
podcast which your favorite medical coding coach Tam talked here
to talk about all things related to the medical coding
industry and this will include the good, the bed, and
the ohso ugly details of the industry. So on today's
(00:24):
Coding Break, I want to briefly jump on the subject
of the government shut down and how it plays a
role in medical coding. So one incident that I noticed
last week, I was perusing a a payer's website and
a pop up appeared and it stated that there will
(00:47):
be a temporary hold on making payments, but the providers
or the healthcare organizations are to continue to submit claims,
but the claims won't be paid until further notice. So
I started to crushing my head like, wow, that's that's weird.
So again, it was a federal uh insurre insurance. So
(01:10):
I went down the rabbit hole to research to see
what other payers are also placing a hold on claims.
And based on my research, and again I went to
my friendly friend Google AI to figure out like to
give me a quick insight into some of the you know,
(01:33):
insurance companies or information I need that needed to do
the podcast right, So it stated that as long as
an insurance company is like a private insurance carrier, the
process is going to be satis quo. So what they
were doing before the shutdown, they will continue to do it.
You know, we shouldn't see any signs or of shift
(01:54):
or decline in reimbursement. However, we will see some some
shifting or changes when it comes to our federal federal
payers such as Medicare, Medicaid, and that will include Trycare
again because these are all federal UH payers. So again,
if you are contracted with a private insurance company or
(02:17):
it's a private insurance health insurances, then it should be satisquo.
You really, we really shouldn't see any impact as it
relates to how they reimburse claims health care claims. But
again with Medicare, Medicaid and and Trycare, we may we
will definitely see some sort of shift in how they
are reimbursing. And so that also brings me to the
(02:40):
topic of just making sure when you submit your claim
that you're submitting a clean claim. And what I mean
by that is as relates to coding. You want to
make sure you're coding is coded to the highest specificities
such as your ic d T and codes. And then
also you want to make sure you're you're it's definitely
definitely medical necessary, right. You want to make sure that
(03:04):
your your provider is providing services based upon medical medical
necessity and not just because you know it's a quick reminbursement.
You want to make sure the documentation supports the codes
that are being submitted to these insurance companies. And you
should do that whether we're in like a government shutdown
or not. You want to make sure that your coding
(03:25):
is pristine, right, whether it be flaws there. You know
you may have some flaws here and there, but for
the most part, you want to make sure it's not
an every day or a consistent practice where you're submitting
I wanna say, false claims that you're being they're not
medically necessary. And if you're unsure, you should make sure
(03:48):
you're looking at the national coverage determination or the local
coverage determinations set up by these insurance companies to ensure
that this is this is what this is what are
the diagnosis of Excuse me, let me write this correctly.
You want to make sure that the diagnosis that are
listed on the NCDs or LCDs or what that particular
(04:09):
insurance carriers deemed to be medically necessary. Now we know
Medicare is our ultimate go to, you know, when it
comes to certain guidelines. You know, we always reference back
to what the government says or what Medicare is saying
as it relates to how, uh, how I want to say,
how we code, but how claims are to be submitted, right,
(04:31):
so you want to make sure that that we're following
the NCDs or LSD's. Again, n CD represents national coverage
determinations and LCD represents local coverage determinations. And many payers
do have their own specific policies as it relates to
the LCDs and n CDs, and so you want to
reference that or peruse that to ensure that when you're
(04:55):
coding services that are in the payer is for that
particular payer that you're meeting medical medical meeting it for
medical necessity. Now you're not coding to code to the
liking of a specific payer. You want to code based
on medical necessity. Like so if a doctor says that
patient needs to live or transplant, and you know you
(05:17):
want to make sure that your diagnosis is related to
some type of disorder or dysfunction of the liver, and
hopefully that dysfunctional disorder is considered medically necessary with that
particular insurance plan. So again you want to make sure
is you're coding based on documentation and is medically necessary
(05:39):
for that particular service or that encounter that the patient
has or has experienced. And so again you want to
make sure you're following the protocol for for that when
it comes to medical necessity. And again this is what
you can do prior to the claim be insmitted. Now
(05:59):
the claim is say the claim is denied because there
are several denal codes that are used. Some are coding related,
some are billing related, summerges, it could just be the
specific payer related. And so I won't go into detail
what those codes are, our denal codes are, but there
(06:19):
should be a process in your organization that will that
should help you decipher and how to resolve those denals. Again,
some of them may be coding, some of them may
not even be coding related. But when it's coding, you
want to make sure that you're looking at everything. It's
almost like you're doing another audit of the work or
(06:41):
the coding that was submitted, and then you're hopefully you're
able to find your issue and resolve it and refoul
and get the claim reimbursed. But again there are denal
colds that we must that are associated with the denal
from the insurance companies, and so it's up to the
person who's even that claim that to the somewhat bill
(07:03):
into differ different excuse me, differentiate where it should go,
whether it be a coding now D coding denal or
a payer of specific denal or some other denal like
it could be like an issue with the patient demographics,
you know, but again that's not in a coding issue.
Coding is like again the diagnosis code, the procedural code,
(07:25):
the drug code, whatever it is that you know that
doesn't make sense, or the payer of deems to be
non medically necessary or it's not covered. Those are things
you wanna look at. And again each organization has a
process in which they resolve those UH denials to get
(07:46):
the claims reimbursed in the proper process. So yeah, so
again will the government shut down effect mad coding, Yes,
and no, we will see a shift in reimbursement as
it relates to the federal payers again Medicare, Medicaid and Trycare,
(08:07):
But as far as like the commercial or private payers,
it may be status quo. And this again, this is
as of today, the research that I've done. I'm not
saying that it will remain the same or will change again.
If so, I will keep you up to date on that.
But as far as roles, medical coding, roles, jobs, excuse me,
(08:33):
I do notice there are more individuals who are coming
to the side of medical coding, such as those who
are who have been in a clinical capacities such as nurses.
They're transitioning into a medical coding role. I see people
coming from other industries come uh again, coming into the
medical coding role. And I'll do it a podcast as
(08:54):
it relates to anybody can code, but not everybody's a
colder and yeah, but that's for another time. But again
we we will see some some some disruption and reimbursement
as it relates to healthcare claims. So yeah, so, as
I mentioned, that's what I have up to date, and
(09:15):
if anything should change, I will definitely bring it bring
it to your attention. But right now, just suspect some
type of uh dysfunction. I don't say dysfunction, but uh
changes as it relates to your federal government payers. So
that's all that I have for this code and break
and as always, until next time, Code on toodles.
Time to take a coding break, how they coded pros
and welcome back to another episode of the Coding Break
podcast which your favorite medical coding coach Tam talked here
to talk about all things related to the medical coding
industry and this will include the good, the bed, and
the ohso ugly details of the industry. So on today's
(00:24):
Coding Break, I want to briefly jump on the subject
of the government shut down and how it plays a
role in medical coding. So one incident that I noticed
last week, I was perusing a a payer's website and
a pop up appeared and it stated that there will
(00:47):
be a temporary hold on making payments, but the providers
or the healthcare organizations are to continue to submit claims,
but the claims won't be paid until further notice. So
I started to crushing my head like, wow, that's that's weird.
So again, it was a federal uh insurre insurance. So
(01:10):
I went down the rabbit hole to research to see
what other payers are also placing a hold on claims.
And based on my research, and again I went to
my friendly friend Google AI to figure out like to
give me a quick insight into some of the you know,
(01:33):
insurance companies or information I need that needed to do
the podcast right, So it stated that as long as
an insurance company is like a private insurance carrier, the
process is going to be satis quo. So what they
were doing before the shutdown, they will continue to do it.
You know, we shouldn't see any signs or of shift
(01:54):
or decline in reimbursement. However, we will see some some
shifting or changes when it comes to our federal federal
payers such as Medicare, Medicaid, and that will include Trycare
again because these are all federal UH payers. So again,
if you are contracted with a private insurance company or
(02:17):
it's a private insurance health insurances, then it should be satisquo.
You really, we really shouldn't see any impact as it
relates to how they reimburse claims health care claims. But
again with Medicare, Medicaid and and Trycare, we may we
will definitely see some sort of shift in how they
are reimbursing. And so that also brings me to the
(02:40):
topic of just making sure when you submit your claim
that you're submitting a clean claim. And what I mean
by that is as relates to coding. You want to
make sure you're coding is coded to the highest specificities
such as your ic d T and codes. And then
also you want to make sure you're you're it's definitely
definitely medical necessary, right. You want to make sure that
(03:04):
your your provider is providing services based upon medical medical
necessity and not just because you know it's a quick reminbursement.
You want to make sure the documentation supports the codes
that are being submitted to these insurance companies. And you
should do that whether we're in like a government shutdown
or not. You want to make sure that your coding
(03:25):
is pristine, right, whether it be flaws there. You know
you may have some flaws here and there, but for
the most part, you want to make sure it's not
an every day or a consistent practice where you're submitting
I wanna say, false claims that you're being they're not
medically necessary. And if you're unsure, you should make sure
(03:48):
you're looking at the national coverage determination or the local
coverage determinations set up by these insurance companies to ensure
that this is this is what this is what are
the diagnosis of Excuse me, let me write this correctly.
You want to make sure that the diagnosis that are
listed on the NCDs or LCDs or what that particular
(04:09):
insurance carriers deemed to be medically necessary. Now we know
Medicare is our ultimate go to, you know, when it
comes to certain guidelines. You know, we always reference back
to what the government says or what Medicare is saying
as it relates to how, uh, how I want to say,
how we code, but how claims are to be submitted, right,
(04:31):
so you want to make sure that that we're following
the NCDs or LSD's. Again, n CD represents national coverage
determinations and LCD represents local coverage determinations. And many payers
do have their own specific policies as it relates to
the LCDs and n CDs, and so you want to
reference that or peruse that to ensure that when you're
(04:55):
coding services that are in the payer is for that
particular payer that you're meeting medical medical meeting it for
medical necessity. Now you're not coding to code to the
liking of a specific payer. You want to code based
on medical necessity. Like so if a doctor says that
patient needs to live or transplant, and you know you
(05:17):
want to make sure that your diagnosis is related to
some type of disorder or dysfunction of the liver, and
hopefully that dysfunctional disorder is considered medically necessary with that
particular insurance plan. So again you want to make sure
is you're coding based on documentation and is medically necessary
(05:39):
for that particular service or that encounter that the patient
has or has experienced. And so again you want to
make sure you're following the protocol for for that when
it comes to medical necessity. And again this is what
you can do prior to the claim be insmitted. Now
(05:59):
the claim is say the claim is denied because there
are several denal codes that are used. Some are coding related,
some are billing related, summerges, it could just be the
specific payer related. And so I won't go into detail
what those codes are, our denal codes are, but there
(06:19):
should be a process in your organization that will that
should help you decipher and how to resolve those denals. Again,
some of them may be coding, some of them may
not even be coding related. But when it's coding, you
want to make sure that you're looking at everything. It's
almost like you're doing another audit of the work or
(06:41):
the coding that was submitted, and then you're hopefully you're
able to find your issue and resolve it and refoul
and get the claim reimbursed. But again there are denal
colds that we must that are associated with the denal
from the insurance companies, and so it's up to the
person who's even that claim that to the somewhat bill
(07:03):
into differ different excuse me, differentiate where it should go,
whether it be a coding now D coding denal or
a payer of specific denal or some other denal like
it could be like an issue with the patient demographics,
you know, but again that's not in a coding issue.
Coding is like again the diagnosis code, the procedural code,
(07:25):
the drug code, whatever it is that you know that
doesn't make sense, or the payer of deems to be
non medically necessary or it's not covered. Those are things
you wanna look at. And again each organization has a
process in which they resolve those UH denials to get
(07:46):
the claims reimbursed in the proper process. So yeah, so
again will the government shut down effect mad coding, Yes,
and no, we will see a shift in reimbursement as
it relates to the federal payers again Medicare, Medicaid and Trycare,
(08:07):
But as far as like the commercial or private payers,
it may be status quo. And this again, this is
as of today, the research that I've done. I'm not
saying that it will remain the same or will change again.
If so, I will keep you up to date on that.
But as far as roles, medical coding, roles, jobs, excuse me,
(08:33):
I do notice there are more individuals who are coming
to the side of medical coding, such as those who
are who have been in a clinical capacities such as nurses.
They're transitioning into a medical coding role. I see people
coming from other industries come uh again, coming into the
medical coding role. And I'll do it a podcast as
(08:54):
it relates to anybody can code, but not everybody's a
colder and yeah, but that's for another time. But again
we we will see some some some disruption and reimbursement
as it relates to healthcare claims. So yeah, so, as
I mentioned, that's what I have up to date, and
(09:15):
if anything should change, I will definitely bring it bring
it to your attention. But right now, just suspect some
type of uh dysfunction. I don't say dysfunction, but uh
changes as it relates to your federal government payers. So
that's all that I have for this code and break
and as always, until next time, Code on toodles.
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