- Delisa M
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Fundamentals of Medical Billing and Coding
Medical billing and coding interpret a patient history into the languages used for claims submission and reimbursement. Billing and Coding are different processes, but both are critical to receive payment for healthcare services.
Medical coding is the alteration of healthcare diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes. The diagnoses and procedures codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory and radiologic results.
The medical billing and coding cycle can take anywhere from a few days to several months, depending on the services, management of any claim denials, and how organizations collect a patient’s financial responsibility.
Make sure provider understand the fundamentals of Medical Billing and Coding can help providers and other employees to operate an error free revenue cycle and compensate all of the reimbursement allowable for the delivery of quality care.
Medical coding starts with a patient meeting in a physician’s clinic, hospital or other care delivery centers. When a patient meeting occurs, providers describe the services in the patient’s record and explain why they are providing these services, items or procedures.
Absolute and precise clinical documentation during the patient meeting is important for Medical billing and coding. The main and very important rule of healthcare billing and coding department is, “Do not code it or bill for it if it’s not documented in the medical record.”
When a conflict arises regarding reimbursement, provider will justify it by using clinical documentation. The organization will face a claim denial, if a service is not sufficiently documented in the medical record by providers or their employees.
A professional medical coder review and inspect clinical documentation to connect services with billing codes related to diagnosis, procedure, charge and professional or facility code, when a provider discharges a patient from hospital or the patient leaves the office.
ICD-10 Diagnosis Codes
Diagnosis codes are a source to determine patient’s condition or injury, as well as social encouragement of health and other patient characteristics. The industry uses the International Statistical Classification of Diseases and related health problems, tenth revision (ICD-10) to capture diagnosis codes for billing purposes.
The ICD-10 code set has two components: the ICD-10-CM (clinical modification) codes for diagnostic coding, and the ICD-10-PCS (procedure coding system) for inpatient procedures performed in the hospital.
There are more than 70,000 unique identifiers in the ICD-10-CM code set alone. The ICD coding system is maintained by the World Health Organization, and is used internationally in modified formats.
The code indicate patient’s condition or injury, where an injury or symptom is located, and if the visit is related to an initial or subsequent encounter.
CPT and HCPCS Procedure Codes
Procedure codes praise diagnosis codes by specifying what providers did during a meeting. The two main procedure coding systems are the Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS).
The American Medical Association (AMA) maintains the CPT coding system, which is used to describe the services provided to a patient during meeting. Medical Coders should know the fact that CPT codes have modifiers that describe the services in greater specificity. CPT modifiers indicate if providers performed multiple tasks, why a medical service was compulsory, and where the procedure required for patient.
Many HCPCS and CPT codes overlie, but HCPCS codes describe non-physician services, such as ambulance rides, durable medical equipment use, and prescription drugs use. CPT codes do not indicate the type of products used during meeting.
Coders also define physician order entries, clinical items and patient care services with a charge code. These codes are a list of the organizations prices for the services provided by organizations. This is also known as charge capture. Revenue cycle management leaders use these prices to reduce claims reimbursement rates with payers and bill patients for the remaining balance.
Professional and Facility Codes
Medical Coders also translate the medical record into professional and facility codes, when needed, describes the AAPC, known as American Academy of Professional Coders. Physicians and other clinical services delivered and also connect the services with a code for billing caused by professional codes.
On the other hand, facility codes are used by hospitals to manage account and overhead of providing healthcare services. These codes capture the charges for using space, equipment, supplies, prescription drugs, and other technical components of care.
Medical Billing has two kinds, front-end Medical Billing and Back-end Medical Billing. Medical coders translate medical records, the front-end billing process has already started.
Front-end Medical Billing
Medical Billing begins when a patient register at the clinic or hospital and schedules an appointment.
When a patient check-in, billers and financial services staff ensure patients complete required forms and they confirm patient information, including home address and current insurance coverage. During check-in or check-outs, billers or other staff should also collect copayments, when required. Provider organizations should collect copayments while a patient is in the clinic or hospital to make sure collection of patient payments.
Front-end Medical Billing also involves confirmed information about patient payments. Medical Billers and patient financial staff prove that services are according to a patient health plan and submit required details when necessary.
Back-end Medical Billing
Back-end medical billers and medical coders use codes and patient information to create a bill. These bills contain itemized form that provider use to create claims. The form includes
Provider name, location, and signature as well as National Provider Identifier (NPI) of ordering, referring, and consulting physicians.
Patient name, date of birth, insurance information, date of first symptom, and other data.
Date of service, procedure codes, diagnosis codes, code modifiers, time, units, quantity of items used, and authorization information.
Provider opinions and notes also include in these bills to verify medically special care.