Medical billing and coding are key functions for any business in the healthcare industry. Coding and billing are important because, in the US, most patients don’t pay out of pocket for their healthcare. Instead, they generally present an insurance card.
Obtaining accurate information from a patient when they first arrive at the point of service is essential. Getting the correct patient and insurance details ensures that the coding and billing process proceeds smoothly. Outdated information makes it more difficult to be paid in full and on time.
In the billing process, claims with codes are submitted to the insurer on the patient’s behalf. Then the insurer reimburses the provider. The provider and insurer typically have an agreed-upon rate per service. If there’s a remaining balance after reimbursement, the provider notifies the patient. At that point, the patient becomes the responsible party and can either pay or revisit the issue with their insurance.
The key thing to keep in mind with the actual coding is that these codes should reflect the patient’s medical record. It’s never okay to bill for a procedure that wasn’t completed or code a diagnosis or procedure that’s not supported by patient records.
The relationship between records and services is crucial. In any disputes about payment from the insurance company, providers must have accurate records to point to. This is the best way to ensure proper reimbursement. In some cases, errors can result in claim denials. In others, they can lead to accusations of fraud. So it’s important to be accurate.
Codes for diagnoses often change. They’re compiled in manuals like the ICD-10 or in the AMA’s CPT coding guidelines. CPT issues updates every year. ICD manuals are updated less frequently, sometimes not for several years.
The other important part of coding and billing is the chargemaster. This lists a physician or organization’s prices per service. Charge capture is one of the most important parts of the revenue cycle. Prices listed in the chargemaster are the starting point for negotiations about reimbursement.
Medical coding and billing can be a complicated process. Sometimes claims are resolved in a matter of days. At other times, complex claims for unusual procedures can take weeks or months to be resolved.