What is medical billing and coding

Medical Billing
Is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider. The medical biller is the conduit between the healthcare providers and insurance companies. The medical biller is in charge of making sure the healthcare provider is properly reimbursed for their services. The medical billing process starts when a patient calls the doctor and makes an appointment.

Medical Coding
For every injury, diagnosis, and medical procedure, there is a corresponding code. Medical coding reports what the diagnosis and treatment were, and prices are applied accordingly. There are a number of sets and subsets of code that a medical coder must be familiar with, including the International Classification of Diseases (ICD) codes, which correspond to a patient’s injury or sickness, and Current Procedure Terminology (CPT) codes, which relate to what functions and services the healthcare provider performed on or for the patient. These codes act as the universal language between doctors, hospitals, insurance companies and other health-specific organizations.

Medical Billing Process
The medical billing process is an interaction between a health care provider and the insurance company (payer). The medical billing process is also referred to as Revenue Cycle Management (RCM). Revenue Cycle Management involves managing claims, payment and billing.

  • After the doctor sees the patient, the diagnosis and procedure codes are assigned.
  • Once the procedure and diagnosis codes are determined, the medical biller will transmit the claim to the insurance company (payer)
  • The insurance company (payer) processes the claims by medical claims examiners or adjusters
  • Approved claims are reimbursed for a certain percentage of the billed services.
  • Failed claims are denied or rejected and notice is sent to provider.

o   Denied or rejected claims are usually returned in the form of Explanation of Benefits (EOB) or Electronic Remittance Advice

o   Upon receiving the denial message the provider must decipher the message, reconcile it with the original claim, make required corrections & resubmit the claim

o   The exchange of claims and denials may be repeated multiple times until a claim is paid in full, or the provider accepts an incomplete reimbursement

Medical Billing Services
As a medical practice grows they may outsource their medical billing to a medical billing service provider. The goal is to increase profitability of the health centers by providing medical billing services that include setup, implementation and work process integration with their practice management software. The medical billing service uses their coding expertise and knowledge to maximize insurance payments and reduce denials. Medical billing regulations are complex and often change and take time away from staff that could be helping patients.

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