Medical Billing and Coding
What is Medical Coding? In short, a Coder is someone who has a thorough understanding of the ICD-9 codes, Modifiers, and CPT codes and uses this knowledge to ensure the proper application. Coders most often review the work of the physician, apply modifiers, and check for errors in CPT code bundling or ICD-9(Diagnosis Code) appendage. For each procedure that the physician or NPP(non-physician provider performs, there is an applicable CPT code and associated Diagnosis code.
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The CPT code is what and the ICD-9 represents the why behind the what. Medical coding is the most difficult job in a billing office because it requires constant learning and is highly detailed oriented. Many offices also use their coder to perform routine coding audits for the practice. These audits come in many different forms but the primary role of all audits is to ensure that all procedures billed for are properly substantiated and paid for. Many time audits are performed to ensure compliance with the documentation in the chart.
These audits are performed done to safeguard the practice from owing Medicare or other payers, refunds because of inadequate documentation and over billing. Many times, audits find that physicians are under billing for most services because they do not fully understand the way to code or they are afraid of being audited. There are different types of Coders and some are specialized in Hospitals, Private Practices or particular specialties. There a few different options when it comes to becoming certified and we have links to the different options on this site.
Certification does not guarantee you a place in the coding workforce but it does place you above much of your competition. Medical Coding as defined by the American Association of Professional Coders is: Medical coding is a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must code and create a claim to be paid, whether by a commercial payer, the patient or CMS.
While the medical coder and medical biller may be the same person or may work closely together to make sure all invoices are paid properly, the medical coder is primarily responsible for accurately coding the claims. To do so, he/she checks a variety of sources within the patient’s medical record, such as the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources, to verify the work that was done. To make sense of it all, a thorough knowledge of anatomy and medical terminology is essential.
It is also important that the medical coder is familiar with different types of insurance plans, regulations and, of course, CPT®, HCPCS Level II and ICD-9-CM codes and guidelines. This enables the coder to assign correct codes and service levels for the procedures performed and supplies used to treat the patient during an encounter as well as properly identify the physician’s diagnoses. The medical coder also serves to help document frequency of diagnoses and utilization of particular services and procedures associated with those diagnoses.
The coder may audit and re-file appeals of denied claims. The medical coder educates and recommends federal mandates requiring providers use specific coding and billing standards through chart audits, and he/she may act as an advocate for the provider and patient in issues of coverage and medical necessity. Certified Professional Coders, or CPCs®, are in high demand because employers know that these individuals can perform the job of medical coder with the utmost proficiency.