Medical billing and coding are the fundamental pillars of any established healthcare practice or facility. A provider may excel with the provision of their services to their patients, but if they don’t strengthen their foundation, i.e., the billing and coding, there would remain no use of their proficiency, as they will struggle with collecting the revenue, which would ultimately put a profound impact on their healthcare centers.
To put it simply, poor medical billing and coding would instigate you on letting go of your practice and move in as a consultant in a hospital. However, when it comes to their immaculate implementation, you’d pay no heed to those thoughts. Instead, you will start loving your healthcare facility even more, for it’d be generating more revenue—faster, which will keep you satisfied, leading to the satisfaction of your customers.
The above two stanzas draw a concrete idea of the importance of medical billing and coding. With that said, as we explore the fundamentals of medical billing and coding below, you’ll know more about enhancing their standards in your practice, and if you should be handling them yourself or outsource them to a company offering personalized medical billing and credentialing services for your practice.
What is Medical Coding?
The process of translating the treatment of a patient into standardized industry codes is known as medical coding. The treatment could be anything, from diagnosis to applied procedures, a medical coder would translate all of them into uniform codes that allow the insurers or payers to understand what they are paying for, and eventually pay if the coding turns out downright accurate.
The process generally starts with the patient registration at the healthcare facility, when they make them fill out a form or two to obtain their personal and insurance information, and figure out what payments would be made by the insurer directly, and what would have to be paid by the patient themselves.
The practice then charges the patient for anything they have to pay, and the rest of the expenses are coded in a form of an insurance claim, which is later submitted to the insurance providers, third-party payers, or agencies and companies alike. It depends mostly on how many insurance providers have credentialed the practice for their services and the frequency of interaction.
Now, to code everything with utter precision, there are, as we said, standardized industrial codes that the coder allots to the procedure or treatment accordingly, which allows the practice to file a claim. If the claim aligns with the patient’s data received by the payer, it wouldn’t take much time for them to accept the claim.
However, in case of incorrect information or fraudulent documentation, your practice wouldn’t only have a denied claim, but could also get its license with the insurance provider canceled without any warning.
Following are the tools/code standards that go down into filing a truly collectible claim.
- ICD-10 Diagnosis Codes
- HCPCS and CPT Procedure Codes
- ICD-10 Diagnosis Codes
As conveyed by its name, the ICD-10 is a diagnostic tool that healthcare practices use to code the diagnosis of a patient into a submittable insurance claim. These codes are of two types, the ICD-10 CM and ICD-10 PCS. The former is an abbreviation of the International Classification of Diseases for Clinical Modification (ICD-10-CM), while the latter elaborates as the International Classification of Disease for Procedure Coding System (ICD-10-PCS).
A healthcare practice codes all the diagnoses of a patient using these codes, if it deals with the clinical visit, it would fall into the ICD-10-CM category. However, if it is the inpatient diagnosis, it would fall into the category of ICD-10-PCS. This coding standard is controlled by WHO (World Health Organization) and is recognized by every practice and provider in the USA.
- HCPCS and CPT Procedure Codes
They are, as you have read, procedure codes, the HCPCS (Healthcare Common Procedure Coding System) and CPT (Current Procedural Terminology) are the code sets dedicated to their respective specialties.
The CPT is used to code the medical procedures only, while the HCPCS is the code set that the practices use while coding other than procedural operations such as equipment, ambulance rides, drug prescription, and more.
These two are the most commonly implemented coding standards that healthcare practices leverage to charge patients for their services and make the revenue cycle management more flawless.
Apart from them, there are two more coding standards including Charge Capture Codes and Professional and Facility Codes, the former is used to code the billable items consumed while treating the patient, it could be supplies and equipment, procedure descriptions, and time reference codes.
The latter, however, codes for the reimbursement of the healthcare professionals working in healthcare practice, and how much of the resources the practice consumed.
What is Medical Billing?
One part of the medical billing has already started with medical coding, as the healthcare practice has obtained everything from the patient they need to file an eligible claim, which will have higher chances of getting accepted than being denied. This part is known as the front-end medical billing.
The back-end billing, however, is the process of preparing a claim, issuing it, submitting it to the provider, and following up for its completion or collection. This process typically takes place after the discharge of the patient or when the patient has returned home from the clinic, whether outpatient.
The authorized personnel fills out all the forms with adequate information as well as codes so that when the provider goes through the claim, they have a complete comprehension of what they are paying against, and if the patient has actually been rendered with the services the claim says they have.
The ultimate aim of any billing department with back-end billing is to minimize claim rejection rate or claim denial, which is the only way a practice can have enhanced revenue generation and can keep up with the expenses ahead. The overall process of medical billing and coding isn’t as quick as we have described, the practice has to wait for up to 6 weeks to collect a claim, only if doesn’t end up rejected.
For a healthcare provider or practice to thrive, aggressive implementation of the best practices of medical billing and coding becomes imperative. Most of the time, many providers opt for hosting an in-house team of billers and coders, which doesn’t turn out very effective, and ultimately directs them towards outsourcing their billing department.
As a result, they let go of the stress they were accumulating by impunctual submission and follow-up on claims and invest that time into treating their patients with more care and satisfaction. It eventually accounts for the name of their practice while keeping the revenue maintained and thriving.