Medical billing and coding serve as the foundation of the healthcare revenue cycle, ensuring that payers and patients repay providers for services rendered.
Medical billing and coding are the processes that convert a patient encounter into the languages used by healthcare institutions for claim submission and payment.
Billing and coding are distinct procedures, yet both are required for providers to get paid for healthcare services.
Medical coding is the process of collecting billable information from the medical record and clinical paperwork, whereas medical billing is the process of using such codes to establish insurance claims and invoices for patients. Creating claims is the moment at which medical billing and coding come together to form the backbone of the healthcare revenue cycle.
The procedure begins with patient registration and concludes when the provider receives complete payment for all services provided to patients.
Depending on the complexity of services performed, claim denial handling, and how organizations collect a patient’s financial responsibilities, the medical billing and coding cycle can take anywhere from a few days to many months.
Ensuring that healthcare organizations understand the fundamentals of medical billing services can assist physicians and other employees in maintaining a smooth revenue cycle and recovering all allowable reimbursement for quality care delivery.
WHAT IS MEDICAL CODING?
The process of medical coding services begins with a patient visit at a doctor’s office, hospital, or other healthcare institution. When a patient interaction happens, clinicians document the visit or treatment in the patient’s medical record and explain why certain services, materials, or procedures were provided.
Accurate and thorough clinical recording throughout the patient visit is crucial for medical billing and coding. “Do not code or bill for anything if it is not documented in the medical record,” is the golden rule of healthcare billing and coding departments.
When a claim controversy emerges, providers use clinical documentation to explain reimbursements to payers. If a provider fails to adequately document service in the medical record, the organization may suffer a claim denial and/or a write-off.
If providers attempt to bill payers and patients for treatments that are erroneously documented in the medical record. Or are missing entirely from the patient’s data, they may face a healthcare fraud or liability inquiry.
Once a patient has been discharged from a healthcare institution, a professional medical coder reads and analyzes their clinical data to match services. With billing codes associated with a diagnosis, procedure, charge, and professional and/or facility code.
CODES FOR PROFESSIONAL AND FACILITY
Medical coders also transform medical records into professional and facility codes where applicable.
Professional codes identify physicians and other healthcare services provided and link them to a billing code. These codes are derived from information in a patient’s medical record.
Hospitals, on the other hand, employ facility codes to account for the costs and overhead associated with delivering healthcare services. Charges for medical equipment, supplies, medicine, nursing personnel, and other technical care components are captured by these codes.
When a hospital-employed provider offers clinical services, hospitals can put professional codes on claims. However, if a non-hospital practitioner uses the hospital’s premises and resources. The professional code of ethics cannot include.
WHAT IS MEDICAL BILLING?
The process through which healthcare institutions submit claims to payers and bill patients for their own financial responsibilities is known as medical billing. The front-end billing process has already begun while coders are busy deciphering medical information.
FRONT-END MEDICAL BILLING
Medical billing starts when a patient schedules an appointment and registers at the clinic or hospital.
Administrative staff workers evaluate patient information and ensure that patients complete necessary paperwork. during pre-registration, such as a home address and insurance coverage. Staff should confirm the patient’s financial responsibility after confirming that the patient’s health plan will cover the requested treatments and filing any prior authorizations.
The staff advises patients of any expenditures they are accountable for throughout the front-end medical billing process. The clinic should ideally be able to collect copayments from the patient throughout the appointment.
When a patient leaves the hospital, medical coders obtain the patient’s medical records and begin the process of translating the information into billable codes.
BACK-END MEDICAL BILLING
Medical coders and back-end medical billers collaborate to build a superbill by combining codes and patient information.
The superbill is a list of everything you need to provide your patients with, and it’s a great way for providers to generate claims. Typically, the form includes:
- Provider details include the name, location, and signature of the rendering provider, along with the name and National Provider Identifier (NPI) of the ordering, referring, and attending physicians.
- Name, date of birth, insurance details, date of the first symptom, and any patient information.
- Date of service(s), procedure codes, diagnostic codes, code modifiers, time, units, number of goods utilized, and authorization information are all included in the visit information.
Notes or remarks on the superbill may also include by providers to substantiate medically essential care. Billers construct claims using information from the superbill.
Billers often deal with two kinds of claim forms. The CMS-1500 form was developed by Medicare to allow non-institutional healthcare institutions, such as medical offices, to file claims. The CMS-1450, or UB-04, form is also used by the federal program for claims from institutional institutions such as hospitals.
Private payers, Medicaid, and other third-party payers may use multiple claim forms depending on their individual claim reimbursement needs. Some payers have used CMS-generated forms, while others have created their own forms based on the CMS framework.
Billers scrub claims during claim preparation to ensure that procedure, diagnostic, and modifier codes are present and accurate, as well as that all relevant patient, provider, and visit information is complete and right.
Back-end Medical billing and HIPAA
The claim is then transmit to payers via back-end medical billers. HIPAA requires providers to electronically transmit Medicare Part A and B claims using the ASC X12 standard transmission format, often known as HIPAA 5010.
Other payers have followed Medicare’s lead and mandated electronic claim transmission. According to CAQH, adopting electronic claims administration may save providers $9.5 billion each year.
Because of the move to remote labor during the COVID-19 epidemic, more payers and providers have adopted electronic claims management systems.
Medical billers can submit claims directly to payers or through a third-party entity like a clearinghouse. A clearinghouse sends provider claims to payers. In order to secure compensation, these businesses scrub claims and check facts.
Clearinghouses may assist providers who may not have access to a full practice management system in editing and electronically submitting claims. Clearinghouses can assist in reducing potential errors caused by manual operations.
Adjudication commences after a claim reaches the payer. The payer will evaluate a provider’s claim and determine how much it will pay the provider during adjudication. Payers further have the authority to accept, deny, or reject claims.
Payers return Electronic Remittance Advice (ERA) forms to provider organizations. If more information is required, specify why the claim was rejected or denied. Billers can revise and resubmit claims for reimbursement for a variety of reasons.
Medical billers generate statements for patients after getting compensation for a successful claim. Typically, providers would charge patients the difference between the rate on their chargemaster and the amount paid by the payer.
Final phase
Patient collections are the final stage of medical billing.
They are responsible for receiving payments from patients. Recording them in their records, and sending them on their way to A/R Administration where they can be utilized by other departments within the hospital. The medical biller plays a vital role in ensuring that all financial transactions involving patients record accurately.
Some patient accounts may be classified as “aged A/R,” indicating that the patients have failed to pay their patient financial responsibility after 30 days. Medical billers should contact patients in aging A/R batches to remind them to pay their invoices and guarantee the organization obtains the income.
Further, read about Medical Billing and coding
