Why is Insurance Billing and Coding important in the medical field?

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To understand how critical these two practices are to the medical profession, we will examine what each involves. By elaborating on their responsibilities, it becomes evident why the billing and coding specialists are crucial to the medical field.

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Medical Coding

Coding usually refers to an alphanumeric code applied to a specific diagnosis, prescription, or medical procedure. There are thousands of codes. The following is one example to illustrate the coder’s function.

A patient visits a doctor’s office with a persistent cough, mucous production, and a fever. A nurse or the doctor’s assistant would likely begin asking the patient questions about when the cough started and how long has he/she had a fever. After vital signs and preliminary information is obtained, the doctor examines the patient and formulates a diagnosis. In this case, the physician determines the patient has bronchitis and prescribes a medication for the symptoms. The nurse or doctor enters all of the details regarding the patient’s visits into his/her medical records.

The pertinent information documented during the patient’s visit makes its way to the office medical coder. The next step involves translating all the medical services into numeric and alphanumeric codes, which are entered into a software program. This step is vital to the billing process.

Where does the coder look for the appropriate codes? One source is the World Health Organization International Classification of Diseases or ICD. The ICD is the standard used in health care and related fields. Diseases of the respiratory system, for example, range from J00 to J99 – lung diseases from external agents are in the J60-J70 Category. J68 is the code for respiratory conditions caused by the inhalation of chemicals, gasses, solids, fumes, and vapors.

There is also a CDT for Dental Procedures, the NDC for National Drug Codes, HCPCS Level II for Health Care Procedural Coding System, APC for Ambulatory Payment Categories.

Another set of codes is the American Medical Association (AMA) Current Procedural Terminology (CPT). These codes report medical, surgical, radiology, laboratory, anesthesiology, and diagnostic procedures to health insurance companies. In 1966, the AMA standardized the codes for physicians, health professionals, hospitals, outpatient facilities, labs, and non-physician practitioners.

There are three types or categories of CPT codes:

Category I:  These codes, which range from 00100 to 99499, correspond to a specific procedure or medical service.

Category II:  This group refers to alphanumeric supplemental codes to measure performance. They are optional.

Category III:  Temporary alphanumeric codes for developing technology, procedures, and services. Medical coders typically use this Category for those that do not exist or meet the classification of Category I.

Both the CPT and IDC code books may apply to one procedure. During an office visit, a patient needs a pigmented mole removed via cryoablation or freezing. The doctor disinfects the mole, injects lidocaine to numb the area, and then removes the mole with liquid nitrogen. To record this procedure for billing purposes, the coder would use CPT 17110 for the destruction or removal of a benign lesion and ICD-9 CM Code D22.5. The latter refers to, in medical terms, melanocytic nevi of the trunk. A melanocytic nevus is a mole, in this case, located on the patient’s trunk region of the body.

Medical Billing

Coding and billing is a two-step process. First, the coder enters the pertinent codes for the procedure and therapeutic services performed on the patient. The medical biller takes the coded information to bill the patient’s insurance company. In addition to the medical procedure, the biller takes into account the person’s co-pay or required payment for the office visit. Consequently, the biller creates an accurate invoice, which he/she enters into a computer program to remit to the insurer for payment.

Therefore, the biller’s critical role in the process is to file a claim with the payer. Most often, this is a health insurance company, which could be a private enterprise or government, such as Medicare or Medicaid. The biller must be familiar with each company’s practices and policies, to ensure the hospital or physician’s office receives payment promptly.

The role of the medical biller is more akin to accounting than the computer-input work of the coder. The former must be familiar with finance, accounting, insurance terminology, and computer software. The coder needs to be knowledgeable of medical terms and procedures. If the medical facility separates these two jobs into separate positions, then the two will have frequent communication.

Both the coder and biller are essential to the viability of the medical office or facility. Without a steady stream of revenue, the operation would soon come to a halt. As with any profitable entity, funding is paramount. It is the medical coding and billing positions that generate these funds – to pay salaries, buy equipment, pay rent, cover utilities, and related expenses.

Becoming a Medical Coder or Biller

The AAPC for Advancing the Business of Healthcare offers training, examination, and certification for both professions. Interested students in coding can take their education online with AAPC-approved staff that uses the Professional Medical Coding Curriculum (PMCC). The organization also has an online billing program that you can finish within four months.

You may opt, instead, to enroll in an Associate of Applied Science degree in Insurance Billing and Coding Specialist. Most programs at this level bundle the two into the same degree curriculum. By combining these two, students can expect courses covering medicine, for example, anatomy, physiology, pharmacology, and medical terminology. Other coursework may include claim procedures, coding classifications, accounting, and insurance claim procedures.

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