Medical coding and medical billing are two distinct roles in the billing and coding process. Medical coders assign alphanumeric codes to diagnoses, procedures, and treatments based on notes and communication from the medical provider. Medical billers take the codes and create, format, scrub, and submit reimbursement claims to insurance payers on behalf of the healthcare provider. These are two complementary roles that play a crucial role in the revenue cycle of the healthcare system.
Why is Medical Coding Important?
When you go to an appointment at a medical office, and they bill your insurance, what really happens is a medical coder tells the story of your doctor’s visit by selecting universally-used alphanumeric codes, and the medical biller prepares a claim using these codes. The claim is sent to the insurance payer - an insurance company or a government program - and the claim is processed and approved (paid), adjusted (paid, but not at the requested rate), or denied (not paid).
If the coding is done correctly, with the most accurate and specific codes matching the procedures, with substantive documentation to show those procedures were necessary and done by the provider, the claim will likely be approved. This means the medical office will be fully reimbursed for their services, and the patient will not have to pay extra for their portion of the bill. The revenue cycle works as it is supposed to, with the healthcare facility getting paid, and the patient getting the medical services they need.
When the medical coding is done hastily, or inaccurately, or proper documentation is not included, then the claim may be adjusted or even denied. This means the medical office will not make enough money to cover their costs, affecting payroll and overhead. Too many claim denials can lead to the medical practice having issues with their revenue flow.
A medical coder must have extensive knowledge of medical procedures, all the current codes, modifiers, and prefixes, and how to select the most specific codes to match each diagnosis, treatment, and procedures. The included documentation must be correct and match the codes, this helps ensure the reimbursement claim will be clean before it is submitted to the payer.
Typical Day of a Medical Coder
When a medical coder gets information on a patient appointment or procedure from a healthcare provider, they must check all the information for accuracy. They look at the notes and documentation from the provider and see if the treatment matches the diagnosis. Based on this information, they will select the codes that describe the patient appointment with the most specific degree of accuracy.
If the healthcare provider has already provided the codes, the medical coder will review the codes for quality assurance. This is to make sure the claim is not upcoded or downcoded. When looking at the provider notes, if any information is conflicting, the medical coder must figure out what the correct code is for the procedure or treatment. In addition to checking the codes for the best possible match, they will check the insurance information and make sure it matches the patient information.
Medical coders may also need to get clarification with the provider if there is a discrepancy between their diagnosis and treatment in their notes. This prevents coders from sending the incorrect code and causing issues on the reimbursement claim when the medical biller submits it to the payer.
If there is vague language in the notes, or if the provider copied the notes from last time, but did not state what happened in this patient appointment, the medical coder must also get clarification so they can select the correct codes. Medical coding software may alert the coder if the notes for an appointment are exactly the same word for word as another claim from the same provider.
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Communication with Healthcare Providers
Medical coders also play a vital role in helping to educate healthcare providers. They can provide valuable insights on how to document their notes to improve accuracy. Documentation from the provider has a great deal to do with how medical coders prepare their report to send to the medical billing team. The more accurately the healthcare provider creates their notes, the more accurate the medical coding will be, meaning the more accurately the reimbursement claim will be when it’s submitted.
Before Sending the Coding to the Medical Billers
Medical coders will double check the report for the correct patient name, date of birth, and details, place of service and address. They will also check the insurance payer – each one has their own idiosyncrasies and internal rules. The medical coders will also make sure the documentation supports the codes they select with the highest possible specificity, and all the codes are in the correct sequence.
One last check to verify the healthcare procedure is linked to the appropriate diagnosis, with no mismatches. Then the information can be sent to the next stage.
Once the claim is submitted to the medical billing clearinghouse, the claim moves to the insurance payer for processing. They will check for medical necessity, patient insurance policy and coverage, and if codes match the documentation.
Become a Certified Medical Coder With Our Online Program
If you’ve been considering becoming a medical coder, Campus has an Online Medical Billing and Coding program that will help train you and get certified. You’ll learn all about ICD codes, CPT® codes, HCPCS codes, procedural coding, medical billing, and claim submissions. In less than ten months, you’ll be ready to be certified in both medical coding and medical billing. This program is entirely online for your convenience. For more information on eligibility, start dates, and financial aid, contact our Admissions department or call 888-675-2460.