INTRODUCTION TO REIMBURSEMENT AND CODING

Fundamentals of Medical Billing and Coding

The backbone of the healthcare revenue cycle is medical billing and coding, which ensures that payers and patients repay providers for services rendered. Medical billing and coding convert patient encounters into claim submission and reimbursement languages. Although billing and coding are two distinct processes, they are both necessary for collecting payment for healthcare services. Medical billing employs those codes to establish insurance claims and bills for patients, whereas medical coding extracts billable information from the medical record and clinical documentation. Medical billing and coding collide in claim creation to create the backbone of the healthcare revenue cycle.

The procedure begins with patient registration and concludes with full payment for all services rendered to patients. Depending on the complexity of the services performed, the management of any claim denials, and how organisations collect a patient's financial responsibilities, the medical billing and coding cycle can take anywhere from a few days to many months. Having a basic understanding of medical billing and coding can assist doctors and other staff in running a seamless revenue cycle and recouping all of the reimbursements available for providing high-quality treatment.

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MEDICAL CODING

A patient encounter in a doctor's office, hospital, or other care delivery venue is the starting point for medical coding. When a patient encounter happens, clinicians document the visit or treatment in the patient's medical record and explain why certain services, materials, or procedures were provided. According to the American Health Information Management Association (AHIMA), accurate and full clinical documentation throughout the patient contact is crucial for medical billing and coding. "Do not code it or bill for it if it is not documented in the medical record," is the golden rule in healthcare billing and coding departments.

When there is a problem with a claim, providers use clinical documentation to explain reimbursements to payers. The organisation could suffer a claim denial and possibly a write-off if a service is not adequately documented in the medical record by providers or their personnel. If providers attempt to bill payers and patients for treatments that are erroneously reported in the medical record or are missing from the patient's data entirely, they may face a healthcare fraud or liability inquiry.

A professional medical coder evaluates and analyses clinical paperwork after a patient is discharged from the hospital or leaves the office to connect services with billing codes relating to a diagnosis, procedure, fee, and professional and/or facility code.

During this procedure, a variety of code sets are employed for various goals, including:

DIAGNOSIS CODES ON CD-10: Diagnosis codes are important for characterising a patient's ailment or damage, as well as social determinants of health and other patient characteristics. For billing purposes, the sector employs the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) system. The ICD-10 code set consists of two parts: ICD-10-CM (clinical modification) codes for diagnostic coding and ICD-10-PCS (procedure coding system) codes for hospital inpatient operations.

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CPT AND HCPCS CODES: Procedure codes are used in conjunction with diagnosis codes to describe what physicians did during an interaction. The Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System are the two main procedure coding systems (HCPCS). The CPT coding system is maintained by the American Medical Association (AMA), and it is used to characterise the services provided to a patient during a private payer interaction. They use ICD-10 numbers to complete the picture of what happened and why it happened. Every year, the American Medical Association (AMA) issues CPT coding standards to assist medical coders in categorising certain operations and services.

CHARGE CAPTURE CODES: A chargemaster code also connects physician order entries, patient care services, and other clinical data. Chargemasters are a list of the provider organization's rates for each service it provides. Charge capture is the term for this procedure. These pricing are used by revenue cycle management leaders to negotiate claim reimbursement rates with payers and bill patients for the balance.

CODES FOR PROFESSIONALS AND FACILITIES: The AAPC, formerly known as the American Academy of Professional Coders, says that medical coders also transform the medical record into professional and facility codes, as relevant. Professional codes document physician and other healthcare services provided and link them to a billing code. These codes are derived from a patient's medical record documents. Hospitals, on the other hand, employ facility codes to account for the costs and overhead associated with providing healthcare services. Charges for the use of space, equipment, supplies, prescription medications, and other technical components of care are captured by these codes. When a hospital-employed provider offers clinical services, professional codes can be included on claims. However, if a provider is not under contract and uses the hospital's space and resources, the facility cannot use a professional code. Integrating professional and facility coding is a best practise for hospitals. Single-path coding, which united professional and facility coders into one platform, was recently introduced at the University of California (UC) San Diego Health.

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