The medical billing and coding, whose direct translation would be “medical billing and coding”, translate a patient’s encounter with the doctor into the languages used for claim submission and bill reimbursement. Although they are separate processes, both are crucial for providers to receive payment for the services they have provided.
Medical coding involves extracting billable information from medical records and clinical documentation, while medical billing uses these codes to create insurance claims and medical bills for patients. Claim creation is where medical billing and coding intersect to form the backbone of the healthcare revenue cycle..
In this sense, the process begins with the registration of the patient and ends when the provider receives full payment for all services provided to patients.
The billing cycle and medical coding can last from a few days to several months, depending on factors such as the complexity of the services provided, the handling of claim denials, and the manner in which organizations charge the financial responsibility of the patient.
Ensuring that provider organizations understand the fundamentals of medical billing and coding can help providers and other staff run a smooth revenue cycle, as well as recover all allowable reimbursements for the delivery of quality care. .
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What exactly is medical coding?
Medical coding, at its most basic, is a bit like translation. The encoder’s job is to take something that is written in one way (a doctor’s diagnosis, for example, or a prescription for a certain drug), and translate it as accurately as possible into a numeric or alphanumeric code. For each injury, diagnosis, and medical procedure, there is a corresponding code.
There are thousands upon thousands of codes for medical procedures, outpatient procedures, and diagnoses. Let’s start with a quick example of medical coding in action.
A patient comes into the doctor’s office with a dry cough, high mucus or sputum production, and a fever. A nurse asks the patient about their symptoms and performs some initial tests, and then the doctor examines the patient and diagnoses bronchitis. The doctor then prescribes the medication to the patient.
Each part of this visit is recorded by the doctor or someone in the health provider’s office. The medical coder’s job is to translate every bit of relevant information from that patient’s visit into numeric and alphanumeric codes., which can then be used in the billing process.
And how exactly does this encoding work?
There are a number of code sets and subsets that a medical coder should be familiar with, but for this example we will focus on two: the codes of the International Classification of Diseases, or CDI, that correspond to a patient’s injury or illness, and codes from the Terminology of Current Procedures, or CPT, that relate to the functions and services that the health care provider performed on or for the patient. These codes act as the universal language among physicians, hospitals, insurance companies, insurance clearinghouses, government agencies, and other health-specific organizations..
Well, the encoder reads the doctor’s report about the patient’s visit and then translates each bit of information into a code. There is a specific code for the type of visit, the symptoms the patient shows, the tests the doctor does, and what the doctor diagnosed.
Each set of codes has its own set of guidelines and rules. In the case of certain codes, such as those that signify a pre-existing condition, they must be placed in a very particular order. In the end, coding accurately and within the specific guidelines of each code will affect the status of a claim.
The coding process ends when the medical coder enters the appropriate codes into a form or software program. Once the report is coded, it is passed on to the medical biller.
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And what about medical billing?
Medical billing is as simple as it sounds: medical billers take information from the medical coder and bill the insurance company, called a “claim.” Of course, Like everything related to the health system, this process is not as simple as it seems.
To better look at medical billing, let’s rewind the example we used earlier. Our same patient has a cough, fever and produces a lot of mucus. This patient calls the doctor and makes an appointment. This is where the medical billing process begins.
The medical biller takes the codes, which show what type of visit it is, what symptoms the patient is exhibiting, what the doctor’s diagnosis is, and what the doctor prescribes, and creates a claim from these using a form or some type of software . The biller then sends this claim to the insurance company, which evaluates and returns it. The biller then reevaluates this claim, which is returned by the company, and calculates how much of the bill the patient owes, after the insurance has paid its share.
How does medical billing work?
If our patient with bronchitis has an insurance plan that covers this type of visit and the treatment of this condition, his bill will be relatively low.. The patient may have a co-pay, or have some other form of arrangement with their insurance company. The biller takes all this into account and creates a medical bill accurate, which is then passed on to the patient.
In the event that a patient is delinquent or unwilling to pay the bill, the medical biller may have to contract with a collection agency to ensure that the health care provider is properly compensated.
Therefore, in the medical billing and coding process, the medical biller acts as a kind of pass-through point between patients, health care providers, and insurance companies.. You can think of the biller, like the coder, as a kind of translator, where the coder translates medical procedures into code, while the biller translates the codes into a financial report.
The biller has other responsibilities, but for now just know that the biller is in charge of making sure the health care provider is properly reimbursed for their services.