Medical Coding & Billing Profession
Credentials Earned Certified & Registered Medical Biller and Coder "C&RMbCT"
Delivering quality healthcare depends on capturing accurate and timely medical data.
Medical billing & Coding is the process of submitting and following up on
claims to insurance companies in order to receive payment for services rendered
by a healthcare provider. The same process is used for most insurance companies,
whether they are private companies or government-owned.
Routine and smooth reimbursement from the insurance companies depends on
capturing accurate and timely medical data.
Coding professionals fulfils and meets this need
as a critical resource in the healthcare arena.
The medical billing process is an interaction between a health care provider and
the insurance company (payer). The entirety of this interaction is known as the
billing cycle. This can take anywhere from several days to several months
to complete, and require several iterations before a resolution is reached. The
interaction begins with the office visit: a doctor or their staff will typically
create or update the patient's medical record. This record contains a summary of
treatment and demographic information including, but not limited to, the
patient's name, address, social security number, home telephone number, work
telephone number and their insurance policy identity number.
The extent of the physical examination, the complexity of the medical decision
making and the background information (history) obtained from the patient are
evaluated to determine the correct level of service that will be used to bill
the insurance. The level of service, once determined by qualified staff is
translated into a standardized five digit procedure code drawn from the Current
Procedural Terminology database. The verbal diagnosis is translated into a
numerical code as well, drawn from a similar standardized
ICD-9-CM
Once the procedure and diagnosis codes are determined, the medical biller will
transmit the claim to the insurance company (payer). This is usually done
electronically by formatting the claim as an
ANSI 837 file and
using Electronic Data Interchange to
submit the claim file to the payer directly or via a clearinghouse.
Approved claims are reimbursed for a certain percentage of the billed services.
These rates are pre-negotiated between the health care provider and the
insurance company. Failed claims are rejected and notice is sent to provider.
Most commonly, rejected claims are returned to providers in the form of
Explanation of Benefits (EOB) or
Remittance Advice.
Upon receiving the rejection message the provider must decipher the message,
reconcile it with the original claim, make required corrections and resubmit the
claim. This exchange of claims and rejections may be repeated multiple times
until a claim is paid in full, or the provider relents and accepts an incomplete
reimbursement.
The frequency of rejections, denials, and over payments is high (often reaching
50%), mainly because of high complexity of claims and/or errors due to
similarities in diagnosis' and their corresponding codes. This number may also
be high due to insurance companies denying certain services that they do not
cover (or think they can get away without covering) in which case small
adjustments are made and the claim is re-sent.
Coding professionals must possess a thorough
understanding of the health record’s content in order to find information to
support or provide specificity for coding. Certified medical coders are trained
in the anatomy and physiology of the human body and disease processes in order
to understand the etiology, pathology, symptoms, signs, diagnostic studies,
treatment modalities, and prognosis of diseases and procedures to be coded. The
job entails much more than simply locating diagnostic and procedural phrases in
the coding manuals or with encoder software. It requires knowledge of disease
processes and procedural techniques to consistently apply the correct codes. A
medical coding professional works as part of a team to achieve the best quality
patient care.
AHCA offers multiple certifications.
Medical coding professionals work in a variety of
healthcare settings, including inpatient and outpatient healthcare settings and
non-provider settings such as third-party payers.
Typical Coding job descriptions:
There is a shortage of certified medical coders
in hospitals, physician practices, and other healthcare facilities. According to
US Bureau of Labor, employment of medical record and health information
technicians is expected to grow much faster than the average field.
For employment visit
Career Assist for guidance and availability of employment
opportunities.