Beginner’s Guide to Medical Billing and Coding imageThe U.S. Bureau of Labor Statistics, in its recent report, predicts that by 2026, the Medical Billing and Coding industry will expand up to 22%.This industry is responsible to protect the confidentiality of patient information while ensuring that healthcare professionals receive adequate reimbursement for their services.

It is safe to say that Medical Billing and coding has safeguarded the healthcare sector and become the real hero of today’s time. This blog article will delve deeply into the area of medical billing and coding, demystifying what these processes involve, key responsibilities of Medical biller and Coder, and why medical coding and billing is important in the healthcare industry?

What is Medical Billing?

Medical billing, in simple words, is the process of generating health insurance claims on the patient’s behalf with different health insurance payers in order to get payment for services provided by a medical facility. In order to make sure that the  organization receives reimbursement,the medical biller tracks the claim after converting a healthcare service into a billing claim.

The main purpose of Medical billing is to assure that the services of providers must be adequately rewarded.Payment must be exact, made on schedule, and proportional to the cost of work performed.

Medical Bill Types

Front-End Medical Billing

In Front-End billing, claims are produced using patient data by entering into the provider’s practice management system. The procedure assesses whether a claim has all the information required to be handled correctly.

Back- End Medical Billing 

Back-End Medical billing includes Processing appeals, denials, and other interactions with insurance companies. An internal employee or a biller representative at the provider’s office is capable of  handling this. 

Medical Billing Process

The process of Medical billing starts the moment a patient enters a facility for care. The following guide illustrates how the medical billing procedure is carried out, along with a brief explanation of  what happens at each step.

Step 1 Patient check-in and registration 

The first step is Patient’s registration , also known as check-in. A medical biller gathers data such as the patient’s name, address, and other contact details and also inquires about the patient’s insurance details. This insurance data is gathered in advance so that it can be validated.

Step 2 Verifying Insurance and Eligibility

After the registration of a patient, the medical biller validates the accuracy of the insurance information. They next evaluate whether or not the patient’s operation is eligible for insurance coverage.

Step 3  PMS receives Patient Demographic Information

In step 3, the Demographic data such as age, sex, race, and any other pertinent details  about the patient is  gathered throughout the intake procedure. This information can be used for statistical analysis by the healthcare facility, insurance companies, or government agencies.Some of this patient data can also be related to the procedure in issue. 

STEP 4 Sending Charge Entry Documents for Medical Coding

The procedure of entering charges starts once all the patient-related data has been gathered. Charge entry includes allocating money to the patient’s account in accordance with the services rendered throughout their stay at the care facility. As a consequence, the insurance provider receives a claim.

STEP 5 Insurance Claim Submission

After being examined for inaccuracies to see what would be covered by each party, the claim is finally submitted to the insurance company. In case the claim is rejected for any reason,the duty of medical biller entails the updation of the file and include a remark. 

 STEP 6 Payments Posting

After the claim has been filed and paid, the medical biller fulfills its duty by  posting those payments. Medical billing software is used to record the payments. This step  helps in the detection of  any medical error.

STEP 7 Follow-up on Receivables

To Guarantee accurate payment, Medical billers make contact with paying parties to collect any unpaid balances (also known as accounts receivable).This might require asking the patient for payment  or contacting the insurance company to confirm receipt.

STEP 8 Denial Management

The procedure enters into the denial management phase if a payer, such as a patient or insurance company, refuses to pay for any reason. During this phase of the process, the biller conducts a root cause analysis to determine the accuracy of the payment refusal and submits an appeal of the denial.

STEP 9 Sending the Client a Report

The last step is preparing a report. The biller prepares a report that includes vital information for the care facility such as  the amount of money collected, the actions taken, and the overall number of adjustments made during the claims processing.

Responsibilities of Medical Biller

  • Assembles and transmits medical claims and billing information from insurance companies.
  • Maintains each patient’s medical record.
  • Prepare bills, documents, and invoices to demonstrate the amounts payable for medical services and treatments.
  • Monitor payments and validate patient coverage information by contacting insurance company representatives.
  • Ensure that the provider is compensated through digging into rejected claims and unpaid patient bills .
  • Responsible to securely handle patient payments and information updates over the phone and in person

What is Medical Coding?

Medical coding, in simple words, is the conversion of data  regarding diagnoses, therapies, services, and equipment into standardized alphanumeric codes that are utilized for the patient billing procedure.Codes make it easy for health professionals to understand and work is a smooth pattern. All the documented Medical records, such as the transcription of the doctor’s notes, the laboratory and radiologic test results, etc uses these procedural codes.

The role of a Medical Professional is to make sure that all  the codes are accurately applied during the medical billing process. 

They are responsible for: 

  • gathering the required information from the supporting documentation
  • assigning the appropriate codes
  •  generating a claim, reimbursed by insurance companies.

Whenever you visit any healthcare professional, medical coding takes place. The healthcare professional is responsible for overviewing your complaint and medical history, determines the possible cause and effects of the issue and also records your appointment. 

Important Code Types

The International Classification of Diseases (ICD), is the standard classification, used for medical coding all around the world. It is maintained by the World Health Organization and each member nation modifies it to its own standards.In the US, a total of six official HIPAA-mandated codes are used for various purposes.

CPT® (Current Procedure Terminology)

The American Medical Association maintains CPT which  consists of more than 8,000 five-character alphanumeric codes.All the services that doctors,  healthcare professionals, therapists, and others deliver to patients are described by these codes.

The 10th edition of the International Classification of Diseases, Clinical Modified (ICD-10-CM)

ICD-10-CM, also known as smart codes,  contains codes  up to seven alphanumeric characters and provides a detailed analysis of the patient’s complaint. This 69,000-code collection is used for everything that can harm, make you ill, or kill you. It includes codes for ailments, wounds, poisons, neoplasms, and their causes.

The 10th edition of the ICD-10-PCS (International Classification of Diseases, Procedural Coding System)

A total set of 130,000-character ICD-10-PCS code sets is used by hospitals to define surgical procedures carried out in operation rooms, emergency rooms, and other settings. By approaching ICD-10-PCS coding correctly, you can avoid being intimidated by the procedural coding.

Dental Procedures and Nomenclature Code, or CDT®

 CDT® codes are maintained by  The American Dental Association (ADA). Almost all the dental and oral procedures  are bound to use CDT® codes for billing. A five-character code,  beginning with the letter D, was originally used by the HCPCS Level II dental section .  

Health Care Procedural Coding System, Level II (HCPCS Level II) 

HCPCS Level II is a family of more than 7,000 alphanumeric codes. These  were initially used to report procedures and bill for supplies by Medicaid, Medicare, Blue Cross/Blue Shield, and other providers. Now it has broadened its range and includes other purposes such as academic studies, quality measure tracking, and outpatient surgery billing. 

National Drug Codes (NDC)

The Federal Drug Administration’s (FDA) code set comprises 10–13 alphanumeric smart codes.This code set is basically used to report and track every packet of medication.Providers, suppliers, and federal agencies can easily identify pharmaceuticals prescribed, sold, and utilized.

Responsibilities of Medical Coder

  • Ensures that codes are generated and sequenced correctly in compliance with government and insurance regulations.
  • Adheres to medical coding rules and guidelines.
  • Receives  and checks the documents in patient records for  precision and accuracy.
  • Clarify to other staff members any information that is unclear or ambiguous.
  • Create monthly reports by gathering the data the doctors generate from multiple sources.
  • Implements strategic processes into practice and chooses techniques and evaluation procedures that yield reliable results.
  • Examines and identifies any cases of medical malpractice that have been recorded and reported. 

Why are Medical Billing and Coding Crucial in the Healthcare Industry?

These are just a few explanations for why  medical billing and coding so important to the healthcare sector:

Billing is Accurate and Prompt

A wide range  of medical codes and the complex billing processes guarantee the accuracy of each claim submitted. It increases the likelihood that the clinic or healthcare facility gets  the payment necessary to remain in operation. Together,as a team, medical billing and coding provides an effective billing procedure where claims are submitted promptly, and patients are subsequently billed on time.

 Patient Information is accurately transmitted

Coding is a worldwide language.Codes make it easy to gather and send patient data accurately when all practices use the same codes to bill their treatments and services. Cause of the disease can be different and the course of  treatment for that particular cause can also differ but in both cases,doctors use the same medical code.  

Meets Regulatory Requirements

Medical billing and coding makes it simpler for healthcare organizations to fulfill regulatory requirements and stay in compliance. Any minor mistake can put the institution in great trouble. Heavy fines and penalties can be imposed by these regulators. This can only be avoided if the medical and billing programs are effectively implemented.

Bridges the Gap between Healthcare Providers and Payers

Medical billing and coding bridges up the gap between patients, insurance companies, and healthcare providers. It makes the whole process easy to understand by all the parties by answering the following questions:

  • How much expenditures are incurred?
  • How much insurance coverage is  offered?
  • What is the patient’s out-of-pocket expense?

Final Thought

In conclusion,it is safe to say that  medical billing and coding are vital components of the healthcare ecosystem as they are the heroes responsible to protect patient’s data and  link payers and providers of healthcare facilities. The future of this industry  appears bright, with promises of technological inventions, rising automation, flexibility to changing healthcare contexts, and the increased automation. As there is a continuous change in this field, it is essential that the professionals must play a crucial role to stabilize the industry financially. 

Are you Ready to optimize your healthcare facility’s revenue cycle management? If yes then Contact MedHeave Medical billing Experts today to handle your medical billing and coding needs. Ensure accurate billing, prompt payments, and compliance with industry standards. Contact us for more details.

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