Medical billing and coding professionals ensure health care providers get paid or reimbursed for their services. Billing and coding are two sides of the same coin, both essential for smooth business operations.
Medical billing professionals act as the go-between for health care providers, insurance companies, and patients. Health care providers can essentially be thought of as sub-contractors for insurance companies, while patients can be thought of as the customers of the insurance companies. Once the health care provider provides its service to a patient, it will then submit a bill for services to the insurance company. The insurance company – which can be in the form of a government entity such as Medicare or Medicaid, or an altogether private company – looks at the bill of specific services provided and, in an ideal situation, pays the health care provider.
The medical billing professional will submit a bill to the insurance company that contains the accurate codes for all health care services provided. Patients using the services of the health care provider have a variety of different insurance plans and coverage, and medical billing professionals must understand these. They must obtain insurance information from patients, confirm that billed procedures are covered by the insurance company, and explain any lack of coverage or patient liability to the health care users.
Medical coding professionals, on the other hand, do more technical work and act less like a go-between. Professional coders are the ones who essentially write the bill which medical billing professionals will submit to the insurance company.
Billing codes are based on several factors, chief among them are a patient’s prior medical history and the severity of the procedure or health care service the patient has received. This means billing professionals must make a careful review of a patient’s medical history and previous procedures when formulating the proper billing code. The billing professional must also review any notes provided by the health care provider which may provide justification for more specific or severe codes.
There are two widely used code sources for procedures recognized by most insurance companies and health care providers: Current Procedural Terminology (CPT) and the International Statistical Classification of Diseases and Related Health Problems (ICD).
The CPT is developed and maintained by the American Medical Association and provides a coding system for patient procedures. These can include vaccinations, patient examinations, mental evaluations, screenings, and procedures carried out with emerging technologies. Virtually all procedures can be classified with the CPT.
The ICD is, as its name suggests, the coding system for diseases and health problems. This is maintained by the World Health Organization, and in the United States the Department of Health and Human Services has developed a version of this which is used in the US health care system. The tenth version of this – ICD-10 – is scheduled to come into use in the US towards the end of 2014, with significantly expanded codes allowing for more specific diagnoses.
Medical billing and coding professionals are each responsible in their own way of insuring their employing health care provider receives the accurate amount of reimbursement from insurance companies and liable patients in an efficient fashion. With a top-notch team of billing and coding professionals, a health care provider can expect to maximize revenues in the quickest amount of time.