Jan 28, 2023

Medical Billing and Coding: What You Need To Know Today

  • By Eva Johnson,

Medical billing and coding are two meticulously allied aspects of the modern health care segment. It forms the backbone of the medical revenue, and involves in the vastly crucial reimbursement cycle, ensuring health care providers are paid appropriately for their services.

Although billing and coding are distinct processes, creating claims is where both intersect to receiving payment for healthcare-related services.

Medical Coding

Medical coding is a process of pulling out billable data from the clinical and medical documents. In simple terms, it involves translating what’s written in a doctor’s diagnosis or a prescription for medication into a numeric or alphanumeric code. There are several codes for medical procedures, injury, diagnosis, outpatient trials, and more.

Some of the standard codes used during the medical process comprises:

  • ICD-10 Diagnosis Codes – It indicates injury details or a patient’s current state, along with the social factors of health and other patient’s individualities.
  • Procedure Codes – It describes the steps taken by the providers during any encounter. Healthcare Common Procedure Coding System and Current Procedural Terminology are the two principal procedure codes.
  • Professional Codes – It includes both the clinical and physician services delivered and associates it with a particular code for billing process.
  • Facility Codes – Hospitals use it to account for the price and overhead of delivering healthcare services.
  • Chargemaster Code – It is a list consisting of service prices by a provider organization.

Medical Billing

Medical billing uses the above generated codes to build coverage claims as well as patient bills. This claim is sent to the insurance firm, which evaluates and returns it. The biller’s job is to assess this returned claim to identify the amount of bill the patient owes. The medical biller acts as the central point of connection between healthcare providers, insurance firms, and patients.

A clean and error-free medical claim meets the following criteria:

  • The claim must be submitted on a given time.
  • The claim form must consist of all the necessary information of a patient, such as their name, date of birth, address, group number, and identification number.
  • The form must appropriately detect the payer with the payer identification number and their mailing address.
  • The form should not include any expired or deleted codes.
  • The healthcare provider should be licensed to practice on the right date of service and must not be under any investigation for fraud.
  • The patient’s insurance must cover the service provided, and it must be in effect on the date of service.

Medical billing and coding are essential for any healthcare service procedures. Therefore, it’s necessary for the hospitals and the healthcare services to ensure that the medical billing and coding cycle runs smoothly, and the providers get paid for their services.

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