What Does a Medical Coder Do?
While the economy remains tough for so many others, the healthcare industry is
booming and the demand for medical coders is on the rise.
In a nutshell, medical coders use encounter forms attached to the patient's medical record
after the medical exam, or consultation is over to assess the procedures and associated charges. They often have to
double check notes written into a patient's record to identify procedures, tratment methods used, and at what level
of skill (low, moderate, or high complexity) the service was provided to properly prepare a claim to be submitted
to the appropriate health insurance carrier.
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Medical coders identify specific diagnoses and medical procedures that were rendered from the
patient's medical records and translate this information into standardized numeric codes. To find the codes, they
use standard industry codes, i.e. ICD for diagnoses codes, CPT for procedure codes and HCPCS for Medicare
claims. The finished work will then be submitted electronically, or on paper by the in form of a claim to health
care insurance companies (Kaiser, Blue Cross, Blue Shield, Aetna, Humana, Unicare, Anthem, Carefirst, etc.), or
Medicare, and Medicaid by the medical biller.
Difference Between Medical Coding and Medical Billing
When comparing health insurance medical coding with medical billing there are profound differences. Yet, the two
disciplines are so closely related that one couldn't be without the other! While medical billers make sure the
health care provider gets paid for their services, there are many types of medical coding specialties, that also
play an important role for reimbursement. Some coders are specialty coders, they code nothing but anesthesia,
cardiology, emergency, hospital, or physician based claims (to name just a few!). However, if you are working in a
small doctor's office you probably are doing both, greeting and rooming patients, and billing and coding from start
Steve Verno, Certified Biller Gives Us the Daily Grind:
Average Percentage of Pay to Biller «
on: February 21, 2009, 09:39:17 PM
» (Reprinted with
The managed care industry covers nearly 200 million people in the USA alone. And while almost
everywhere the medical billing routines are becoming automated, such as generating invoices, reminders, and
statements, it continues to be the medical biller's job to oversee this process. Also, there are countless office
managers, medical office staff, and health care facility assistants, not to mention lawyers, pharmacies, building
owners, equipment rental companies, and health insurance companies that also benefit indirectly from the vast
services offered by medical coding and billing professionals.
Before I look at an
account I need to know:
(a) Was the provider contracted, or not
(b) If contracted, what does the contract say
I look at:
(1) Claim submission time frames
(2) Claim payment time frames
(3) Amount to be paid on the claim
(4) Penalties for not paying the correct amount or on time
(5) Did the provider agree to carrier policies and procedures
When I look at an account:
(1) I look at see when the claim was sent
(2) If sent electronically, is there a report showing receipt
(3) Was there a payment, denial or request for information
(4) Was the information sent and how?
If the account shows the claim was sent for reimbursement on X date I resubmit the claim just in case the
original shows NOF (Not on File).
The insurance company says the claim was
I want to know
(a) When was it paid
(b) What address was the payment sent to
(c) To whom was the check, or payment addressed to
(d) What was the check number, and check date
(e) Was the check cashed, and if so by whom
I ask for a copy of the cashed check. I do NOT pay for check copies. If the insurance company insists that I
pay, I suggest they can explain this to the Office of Insurance Regulation, or the State Banking Commission for
a possible check cashing fraud investigation.
If they say they sent the payment to the member, I also want to know
(a) When the payment was sent
(b) What was the check number
(c) When was the check cashed
I want this info so I can pass it onto the patient so the patient can pay their bill. If the check to the
provider was never cashed, I request it be reissued to the provider. Lets say the check was never cashed, I
make a request to have the check reissued.
If the provider is contracted, I inform the insurance company of the contract requirement. If the provider is
not contracted, I have the following tools I can use to proceed:
(1) State statutes, Federal laws, or
(2) The patient's benefit contract
-- Steve Verno, Certified Biller
Steve is a Certified Master Medical Coder and Certified Master Medical Biller and
Medical Coding/Billing Instructor. He also is the co-owner of Lucrum Consulting, LLC, which provides training
in medical coding and billing issues, and helps physician's practices in areas such as A/R recovery, appeals, and