Medical Billing and Coding

1 January 2017

Medical Billing and Coding Medical billing and coding is the process of receiving and submitting error free claims to insurance companies to receive payment for services by a health care provider. Billing and coding is almost like story telling. Attention to detail and familiarity with anatomy, medical terminology and diseases enhance the coder’s ability to retell the events during a patient’s encounter by using diagnosis codes.

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The medical billing process is the interaction between health care providers and the insurance companies. The entire process is known as the billing cycle. It can take anywhere from several days to several months to complete and require several interactions until a resolution is reached. Billing and coding is not a new IT field and has been around for many decades. For several decades medical billing was done almost entirely on paper. The need for standardized information has grown since the beginning of the Medicare program in 1965.

As new systems for reimbursement were developed, a need for specialized information grew and several types of coding methods were created, in addition to one that was already in existence. The International Classification of Disease (ICD) was developed and published by the World Health Organization (WHO) about seventy-five years ago to classify disease and diagnoses. This is currently used throughout the world and has been through 10 different modifications. The U. S. is now using the ICD 9-CM (ninth clinical modification), while many thers countries have switched to ICD 10.

Other coding systems used with ICD 9-CM are CPT 4 (Current Procedural Terminology, 4th Revision) which is used for coding operations and diagnostics procedures and HCPS(Healthcare Common Procedural Coding Systems), used for coding medication, supplies and other services not covered by CPT. Additional coding systems exist in the U. S. and are used for research, mental health and pathology. The basic ICD 9 system was adapted for the use by hospitals, physicians and insurance companies.

The ICD 9 system was revised in 1993 to allow better reporting and classifying of diseases. A medical biller or coder is also known as a diagnostic coder, medical records tech or medical coder-they are responsible for analyzing clinical statement of events and diagnosis entered by the attending provider and assigning the correct diagnosis code to the greatest specificity. Medical coders work in hospitals, clinics, surgery centers, long-term care facilities, insurance companies, dental offices, some health care agencies, consulting firms coding, billing services and government agencies.

They typically work under the supervision of the Health Information Manager or chief Financial Officer. They must carefully review the medical documentation from the physicians so they can obtain detailed information regarding the disease, injuries, surgical operations and other procedures. That information is then translated into numeric codes. The coding specialist assigns diagnostic and procedural codes using a universally recognized coding system. They must pay careful attention for correct code selection so it is compliance with federal regulation and insurance requirements.

The medical codes are used for reimbursement of hospital and physician claims for Medicare, Medicaid, and insurance payments. Students interested in pursuing a career in medical coding should take high school courses in algebra, biology, computer skills, English, typing, offices procedures, data processing, and health occupation. They should have a high school diploma or equivalent. An Associate’s Degree is recommended but training may be available on the job as well as through continuing education classes offered by state associations.

They must pass an examination offered by the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders. Medical coding has impacted businesses and society in a necessary way. A patient’s record is a medico legal document, and information contained within it is expected to be timely and accurate. In addition, the medical record verifies that the claim submitted for reimbursement is indeed accurate. Services provided must be supported by documentation in the record, which is the responsibility of each caregiver.

CMS (federal agency/Center for Medicare and Medicaid Services) states, “Medical record documentation serves to facilitate high quality patient care…. verifies and documents precisely what services were actually provided. The medical record may be used to validate: (a) The site of the service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the care giver (service provider)” The diagnosis codes must justify any diagnostic or therapeutic procedures as well as supplies or injectables medications (HCPC code).

When a medical encounter is coded correctly, there is a smooth transfer of coded data in exchange for reimbursement. This is called a clean claim. If there is insufficient documentation or an error in coding, the claim can be denied for lack of medical necessity. If document is not found within the record, then it is impossible to substantiate services or procedures that are done. If it is not documented it is not done. In 1989, HCFA (Health Care Financing Administration) required physicians to use an ICD 9-CM diagnosis code on their claim forms for reimbursement purposes.

Prior to this, only hospitals were required to report a diagnosis code. and physicians could be reimbursed for their services by submitting only a procedure code. Regulations and compliance has also impacted the ability to recognized fraud and abuse, for inappropriate reimbursement has soared over the past twenty –five years and has been partly responsible for the increased costs of healthcare. In addition, the medical billing field has been challenged in recent years due to the introduction of Health Insurance Portability and Accountability Act (HIPPA).

This is a set of rules and regulations that hospitals, doctors, health care providers and health plans must follow in order to provide their services and insure that there is no breach of confidence while maintaining patient record. Since 2005, medical providers have been urged to electronically send their claims in compliance with HIPPA to receive payment. In ten years I believe that this IT field will grow and expand but there may be a possibility where human personnel is replaced by computer coding application systems.

There is an outstanding future for medical coding specialists. New technologies and medical tests, an increase in the number of elderly and their medical needs, and state and federal laws requiring more precision, all contributes to the increase in medical coding jobs. Because of the increased scrutiny over medical records by the government and insurance companies and an effort to control costs, complete and accurate records are becoming a necessity on order for hospitals and clinics to receive money from increased need for coders with the most current knowledge of new technologies.

A medical coding specialist that takes the time to stay up-to-date with the constant changing and updating of medical codes will acquire a job with more ease than those who do not make the effort to advance their training. As in most occupations, many openings will result from the need to replace employees who transfer to other companies, retire, or stop working for various reasons. However, there are computer application companies currently working on programs that may eliminate the need for manual entry of diagnosis code.

They may be creating program that will phase out coders all together, but I feel that the programs will be really costly and not all companies may be able to afford to purchase them. We will just have to wait and see. Being a biller and coder I, I know, with technology the capabilities is limitless Therefore, being a medical biller and coder myself, I have taken steps to help secure my future by attempting to obtain a degree in computer information. Just in case. In the next ten years I think the IT field will be headed towards, the constantly evolving cloud computing.

Cloud computing refers to resources and applications that are available on the internet from just about any internet device. It allows customers to store data and access software or platforms through a third party managed network. Its greatest advantage is it allows businesses to scale their IT Infrastructure to meet the changing needs without making capital investments in new applications and hardware and cloud computing vendors will make it possible by charging customers on a per use basis, that will manage all hardware maintenance and software upgrades for the client.

It is said to be more economical for users and companies. Because of the cloud some IT positions and job titles may be outsourced or eliminated. There will be new job titles like cloud architects, cloud capacity planner and cloud infrastructure administrator and integration architects. According, to the experts cloud computing will be the wave of computing for the future.

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