Medical Coding and Billing


Medical coding is among the most in demand professions in the USA and around the world. If you ever had, and still have an interest in the industry of healthcare then the best time to get started is NOW.

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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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Getting Your Medical Coding Right

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.

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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 to finish.

Steve Verno, Certified Biller Gives Us the Daily Grind:

Calculating Average Percentage of Pay to Biller «
on: February 21, 2009, 09:39:17 PM »
(Reprinted with permission)

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?
(5) Notes

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 paid:

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 staff training.