Medical Billing and Coding in Revenue Cycle Services
Medical billing and coding are important components of the healthcare revenue cycle management cycle. They involve two main processes: the translation of healthcare services into billable codes and the preparation and submission of claims to insurance companies for reimbursement.
Medical Coding
Medical coding is the process of converting healthcare diagnoses, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc. This coding helps in accurately describing the patient's diagnosis and the procedures performed to treat these diagnoses. Coders use classification systems like:
the International Classification of Diseases or ICD,
the Current Procedural Terminology or CPT, and
the Healthcare Common Procedure Coding System or HCPCS to assign these codes.
Medical Billing
Medical billing is the process of submitting and following up on claims with health insurance payers in order to receive reimbursement for medical services rendered by a healthcare provider. The payers can include:
Commercial insurance companies like Regence or Premera
Regulatory payers like Medicare and Medicaid
This involves billing the health insurance companies or Medicare and Medicaid and patients for procedures and treatments. The medical biller takes the codes processed by the medical coder and submits claims to insurance payers and follows up on claims to oversee the settlement of all accounts. This role requires an understanding of health insurance policies, patient billing practices, and compliance with federal and state regulations. It also means having the patience to follow up and address any claim denials by the payers. Often there can be a requirement to submit more documentation or adjust the code used to get reimbursement for the provider.
Who Performs Medical Billing Work?
Usually, there is a department at a hospital or clinic that is responsible for this work and sometimes the work is outsourced to specialists. Either way, it’s a job that requires an understanding of health insurance policies, including co-pays, co-insurance, and deductibles, to accurately bill patients and insurance companies. It also requires knowledge of Medicare, Medicaid, and CHIPS especially in rural health settings. Medical billers must follow up on claims to ensure that they are processed and paid by payers. They also handle disputes or rejections of claims by providing additional information or clarification on services rendered. Medical billers often interact with patients and insurance companies, making customer service skills important for their role. Typically, the people working in these roles are those who like medical billing remote jobs. It is becoming more and more of a priority for this workforce.
Who Performs Medical Coding Work?
Like medical billers, medical coding specialists can be in-house or be part of a company the work is outsourced to. They must have a comprehensive understanding of medical terminology, anatomy, and physiology to accurately code a patient's diagnosis and the procedures performed. Coders usually work behind the scenes in healthcare settings such as hospitals, clinics, and sometimes in remote positions. They play a crucial role in ensuring that healthcare providers are reimbursed for their services.
Increasingly AI technology is being used to do the job of medical coders and has really begun to change the industry. However, the expertise of senior medical coders is still needed to help resolve denials.
Medical Billing and Coding Job Certification Requirements
To perform these roles, individuals typically undergo specialized training through certificate programs, diploma programs, or associate degree programs in medical billing and coding. Additionally, certification from organizations such as the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) can enhance a professional's qualifications and may be required by some employers. Medical billers and coders can be remote jobs as long as they have the technology equipment needed.
Why are Medical Billing and Coding Jobs So Important?
Medical billing and coding professionals are essential to the healthcare industry, ensuring that services are accurately documented and that healthcare providers receive timely payment from insurance companies, regulatory payers and patients.
Where Do Medical Billing and Coding Fit into the Revenue Cycle Management Process?
Medical billing and coding are integral components of the Revenue Cycle Management (RCM) process in healthcare. RCM encompasses all the financial processes involved in managing the administrative and clinical functions associated with claims processing, payment, and revenue generation. The goal of RCM is to streamline these processes to ensure that healthcare providers are paid timely and fully for the services they provide. Here’s how medical billing and coding fit into the RCM process:
1. Patient Registration and Insurance Verification
The RCM process begins with patient registration and insurance verification before any medical services are provided. This step involves collecting patient demographic and insurance information to ensure accurate billing and coding later in the process.
2. Medical Coding
After the patient receives medical services, medical coders translate the services, procedures, diagnoses, and equipment used into standardized codes. These codes are essential for the billing process as they describe what treatments and services were provided. Accurate coding is crucial for ensuring that claims are correctly processed by insurance companies and that healthcare providers are reimbursed for the right services.
3. Charge Capture and Claim Submission
Charge capture is the process of recording and categorizing all the services provided to a patient. The medical codes are used to create a claim, which is then submitted to the patient’s insurance company for reimbursement. This step is where the detailed work of medical coders directly impacts the financial flow of the healthcare provider.
4. Claims Management
Once a claim is submitted, it undergoes processing by the insurance company, which involves verifying coverage and assessing the claim based on the provided codes. Claims may be accepted, denied, or rejected based on this review. Effective medical billing and coding help minimize denials and rejections by ensuring that claims accurately reflect the services provided.
5. Payment Processing
After a claim is approved, the insurance company processes payment based on the agreed-upon rates and policies. The medical biller posts these payments to the patient’s account and manages any discrepancies or denials.
6. Patient Billing
If there’s a balance after the insurance payment, such as a copay, deductible, or non-covered service, the medical biller generates a bill for the patient. Clear, accurate coding and billing are crucial to correctly inform patients of their financial responsibility.
7. Follow-up and Collections
The final step involves following up on unpaid claims with insurance companies and pursuing outstanding patient balances. Effective coding and billing practices are essential for resolving any issues that may arise during this phase, such as disputes over coded services or coverage.
In summary, medical billing and coding are foundational to the RCM process, ensuring that healthcare services are accurately documented, claims are properly submitted and followed up on, and healthcare providers receive appropriate compensation. These processes directly impact the financial health of healthcare organizations and require a high level of precision and expertise to manage effectively.
At InlandRCM we have 10 years of expertise delivering medical billing services to our clients as part of revenue cycle management services. Read more about our services at https://www.inlandrcm.com/services.
If you want to find out more please email us at start@inlandrcm.com to request more information.