What You Need to Know Before Getting into Medical Billing and Coding
This comprehensive guide outlines the essentials needed to optimize accuracy and reimbursement in medical billing and coding, such as ICD-10 codes, Pseudo, HCPCS codes, RCM, Medicare billing, and HIPAA compliance. We will explore healthcare information traffic implications and initiatives for improved efficiency. This resource serves to inform those unfamiliar with the complexities of medical coding and medical billing. Medical billing and Coding are integral components of the healthcare industry. It provides the framework for accurate reporting of diagnosis and services, ensuring proper reimbursement is received.
Table of Contents
What are the 4 types of medical billing and coding systems
ICD-10 codes provide the standardized language used to uniformly report and document medical services, while CPT codes and HCPCS codes are used to accurately identify and code treatments performed (Cantor & Lapin, 2019). E/M is used for physician services.
ICD-10, the International Classification of Diseases, 10th Edition
A medical billing and coding system is used globally by healthcare providers to assign codes to diagnoses (Riedinger & Santa Maria, 2019). Developed by the World Health Organization, the ICD-10 is the primary tool to allow healthcare providers to diagnose and track patients’ health conditions and ensure that they are getting the best possible treatments (Riedinger & Santa Maria, 2019). The code system consists of a codebook, an alphanumeric code, and five characters (Riedinger & Santa Maria, 2019). The ICD-10 is constantly being updated to reflect the most current medical billing and coding services, which helps ensure that healthcare providers use the most accurate diagnoses when treating patients (Riedinger & Santa Maria, 2019).
CPT, Current Procedural Terminology
A medical billing and coding system is used by healthcare providers to assign specific codes to procedures and services (Riedinger & Santa Maria, 2019). Developed by the American Medical Association, the CPT is the industry-leading system used to accurately document patient care regarding services provided (Riedinger & Santa Maria, 2019). The code system consists of four numbers followed by letters that detail the services provided (Riedinger & Santa Maria, 2019). With thousands of codes assigned to different medical and surgical procedures and services, the CPT is the most comprehensive medical billing and coding system currently available (Riedinger & Santa Maria, 2019)
HCPCS, Health Care Common Procedure Coding System
A medical billing and coding system is used to assign codes to medical supplies, durable medical equipment, and other medical-related services (Riedinger & Santa Maria, 2019). Developed by the Centers for Medicare and Medicaid Services, the HCPCS is a tool to ensure that healthcare providers use the proper coding identifiers for medical supplies and services provided to patients (Riedinger & Santa Maria, 2019). The code system consists of two parts, with the first part using single-letter alphabetical codes, and the second part using either a five-digit numeric code or an alphabetic code (Riedinger & Santa Maria, 2019). This coding system is updated annually to reflect the current medical supplies and services that are provided to patients (Riedinger & Santa Maria, 2019).
E/M, Evaluation, and Management
Used to assign codes to physician services (Riedinger & Santa Maria, 2019). Developed by the Centers for Medicare and Medicaid Services, the E/M system is a tool to ensure that healthcare providers document their medical services accurately and properly bill for their services (Riedinger & Santa Maria, 2019). The code system consists of several components and modifiers to accurately reflect the complexity of patient care and the extent of services provided (Riedinger & Santa Maria, 2019). By assigning codes to medical services, the E/M system is helping to ensure that physicians are properly compensated for the services they provide while still delivering the highest quality of care possible (Riedinger & Santa Maria, 2019).
Why is it important to update codes?
Medical billing and coding require accurate coding of covered services and procedures to ensure the accuracy of claims processing. Improper coding can lead to denied claims, billing errors, and government auditing. To address the problem, medical coders must keep current with coding updates, maintain knowledge of the codes used by their organization, and review coding for accuracy as needed.
From reliable sources such as the Centers for Medicare and Medicaid Services, coding panels, and industry associations, medical billing and coding professionals should keep abreast of any coding updates and incorporate them into their systems. In addition, coders should be aware of any coding or reimbursement changes that might apply to their organization, since coding previously established may require updates due to changes in regulations or procedures. The importance of updating coding regularly cannot be overstated, as even minor errors in coding can lead to major billing problems and denials of claims.
Efficient medical billing and coding practices require knowledge of current coding and procedures. Medical coder’s must stay informed and up-to-date with current coding rules and regulations. Furthermore, they must ensure their coding and billing systems are accurate and updated. Any discrepancies with coding should be flagged as soon as they are identified, and coding should be adjusted as necessary.
Updating coding as needed is an essential part of medical billing and coding processes. Inaccurately coding services and procedures can result in serious complications for the organization, from stolen patient data to denied claims. Therefore, coders must be vigilant to ensure coding remains current and accurate. With diligence and accuracy, a medical coder can help ensure accuracy and streamline the coding and billing process.
The successful management of the revenue cycle within the healthcare industry is contingent on the efficient and effective distribution of information. Revenue cycle management (RCM) is employed to organize and report data on patient claims, diagnoses, payments, and services. Quality assurance measures must be taken and analytics must be closely monitored in order to validate their efficiency (Macroberts & Zang, 2018).
Medicare billing must also be taken into account and a capable accounting staff should be assigned, who can submit invoices to insurance companies properly and record payments of reimbursements. Apart from accurate record-keeping and invoicing, software programs must be employed to assess related metrics (Benjamin, 2017). According to an article published in the Journal of Medical Imaging and Health Informatics, the implementation of data analysis procedures has the ability to impact the performance of the RCM system.
Software programs are employed to access reports and accurately measure the system’s metrics, allowing for the identification of trends that may improve or impede the system (Ahuja et al., 2017). To supplement the use of software programs, alerts, and reminders should be issued in the event of any inaccuracies or delays. Regular assessments are also necessary to reduce errors, verify data accuracy, and track trends in the reporting. By incorporating these practices, the RCM system can be successful
Guide to Medicare Billing
Medicare billing is the process of submitting medical claims to the Centers for Medicare and Medicaid Services (CMS) for reimbursement. Medicare is a national health insurance program for people aged 65 and older, as well as certain disabled individuals. It is funded by taxpayer dollars and covers medical services such as hospital stays, doctor’s visits, and home healthcare.
The process for submitting Medicare claims begins with obtaining a Medicare healthcare provider number and completing administrative paperwork. The provider number is used to identify a healthcare provider in Medicare billing. The required paperwork includes standard forms and information like a beneficiary’s name, address, and personal identifying information, as well as the provider’s name, address, and NPI number. This information is important to ensure accurate payments and to later verify that Medicare paid the appropriate provider.
Once the administrative paperwork is completed, the medical process starts. Beneficiaries can receive Medicare coverage for medical services, including doctor visits, tests, treatments, and medications. All services must be medically necessary and ordered by the health care provider.
When filing a Medicare claim, documented services must be correctly coded using ICD-10, CPT, HCPCS, and E/M codes. These codes provide information on diagnosis, procedures, supplies, and services so that claims can be processed quickly and accurately. The amount of reimbursement depends on the type of service, the geographic location of the provider, and the Medicare fee schedule.
Depending on how a provider files the claim, Medicare will either directly pay the patient’s bill, or reimburse the provider after the services are received. The provider can then bill the beneficiary for the remaining amount if there are deductibles, copays, or coinsurance.
In order to stay up to date with the latest Medicare regulations, providers should regularly review the CMS website for new billing codes and any changes to existing codes. Understanding the Medicare billing process and staying up to date are essential for accurate reimbursement and compliance with Medicare regulations. With the proper utilization of ICD-10, CPT codes, and HCPCS codes, medical billing professionals ensure that patient care is accurately documented and reimbursement is efficiently collected (Cantor & Lapin, 2019). Organizations must ensure that all processes are compliant with HIPAA regulations to maintain legal and ethical standards.
What Are HIPAA Guidelines for Medical Billing and Coding?
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was established to protect the privacy and security of personal health information. These guidelines are in place to ensure the confidentiality, integrity, and availability of all protected health information, including information received and transmitted through the use of electronic media. HIPAA has implemented a number of technical, physical, and administrative protocols to secure your medical records and ensure they aren’t inappropriately accessed or used without your permission.
When it comes to medical billing and coding, organizations must take extra care to protect their personal health information and meet the requirements of HIPAA. Companies providing medical billing and coding services must develop and implement administrative, technical, and physical safeguards to protect PHI and maintain its integrity, availability, and confidentiality. This includes using system security measures such as encryption and authentication, in addition to training employees and designating a privacy officer to initiate, oversee, and monitor the organization’s HIPAA compliance activities.
Organizations must establish and follow policies and procedures to ensure use, disclosure, access, and disposal of PHI is restricted to authorized personnel only. They must obtain a valid authorization, signed by you, to release your PHI and meet record-keeping requirements regarding the collection and use of PHI. Additionally, they must maintain patient records in a secure environment to protect against unauthorized access, improper distribution, and misuse of records.
Apart from these rules, HIPAA requires companies to notify patients when their information has been inappropriately accessed or released. If a breach of unsecured protected health information occurs, the organization must provide you with written notification within 60 days of discovering the breach.
HIPAA guarantees the privacy of your confidential medical information. Medical billing and coding companies must adhere to the rules and regulations of HIPAA to protect your data from unauthorized access and use. By taking the extra measure to comply with these regulations, these companies help keep your personal health information secure.
Become a Medical Biller
Medical billing and coding is a vital and exciting field at the forefront of the healthcare industry. With your knowledge and expertise, you can make a difference in someone’s life by helping ensure accurate reimbursement for medical services. Through the use of ICD-10, CPT, HCPCS, and E/M codes, along with the understanding of Revenue Cycle Management (RCM) and Medicare billing, you can make sure healthcare providers are getting the reimbursement they deserve. Plus, due to HIPAA guidelines, you will be on the front lines making sure confidential medical information is protected and secured. With a thorough understanding of the coding procedures and regulations, medical coders can help ensure accuracy and reimbursement efficiently and securely.
So if you’re looking to get into the healthcare field and make a difference, medical billing and coding may be the way to go.
- Cantor, P., & Lapin, J. (2019). Coding and Reimbursement for Long-Term Care. In The Encyclopedia of Health Services Management.
- Macroberts, J., & Zang, K. (2018). Revenue Cycle Management—Implications for Healthcare Information Traffic. Online Journal of Nursing Informatics, 22(1).
- Riedinger, P. J., & Santa Maria, G. (2019). Coding and Documentation from Anesthesia Care. Anesthesiology Clinics, 37(4), 719–737
- Riedinger, M. R., & Santa Maria, M. (2019). Medical Insurance Handbook (3rd ed.). Clifton Park, NY
- Ahuja, P., South, S., Cheek, A., Monroe, R., Masino, C., & Rivin, R. (2017). Use of Data Analysis Procedures To Impact Performance of a Health Information Management Revenue Cycle. Journal of Medical Imaging and Health Informatics, 7(5), 889–894.
- “Health Insurance Portability and Accountability Act (HIPAA) and Electronic Records.” Centers for Medicare & Medicaid Services. Centers for Medicare & Medicaid. Services, 8 Apr. 2021, http://www.cms.gov/Regulations-and-Guidance/Administrative Simplification/HIPAA-ACA/HIPAA.
- Debra G. Anderson, and Mark J. Anderson. Medical Coding & Billing, Expert Consult – Online and Print. Elsevier, 2008.
- David J. Pugsley, and Frances M. Wehr. Medical Coding for Physicians for ICD-10-CM and ICD-10-PCS. Jones & Bartlett Learning, 2016.