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What Is Medical Coding?

medical coding professionalMedical coders are fundamental to medical record keeping and essential to the medical practice's existence. A healthcare provider who delivered a medical service to a patient or client is entitled to receive money for these services. Accurate medical coding is just as critical to get paid as timely filing a claim with the patient's health insurance, or managed care organization.

Medical coding involves identifying a medical service that was provided from the patient's medical record, or the superbill, and assigning a numerical code that corresponds with this service. Coders need to know how to code for specific insurance companies within their established policies and applicable laws and regulations. It is a systematic process that can get complicated.

What Medical Coders Do

Many see medical billing and medical coding as two distinct disciplines, however, both embrace so many facets that overlap, or go hand-in-hand, that one couldn't exist without the other. The art of medical coding cannot be learned through using software, it is learned by listening to the instructor, taking notes, opening the CPT/ICD-10 books and using your mind to code through practice, practice, and practice. You don't succeed by using software as your main tool. You learn and succeed through hard work.

Although the medical coding process somewhat resembles looking up a name and phone number in a telephone book it is not as simple as it may sound. And although medical coders work hand-in-hand with medical billers, the experts in the field feel strongly that medical billers should not code unless trained to do so and with proper professional liability insurance in place.

medical coding bullets KNOWLEDGE OF INSURANCE CLAIM AND REGULATORY CONSIDERATIONS. New patient interview and check-in procedures; established patient return visits; post-clinical check-out; computerized practice procedure methods.

medical coding bullets ICD-10-CM CODING. Using the ICD-10-CM coding system; primary vs. principal diagnosis; ICD-10-CM terms, marks, abbreviations and symbols; index tables.

medical coding bullets CPT CODING. Basic format of CPT service and procedure codes on the CMS-1500 claim; comparing CPT with ICD-10-CM coding; modifiers; new vs. established patient; assigning emergency department and critical care codes; consultation vs. confirmatory visit; preventive medicine visits.

medical coding bullets HCPCS CODING AND CMS REIMBURSEMENT. The HCPCS system for reporting professional services, procedures, supplies and equipment; HCPCS level II coding system; CMS reimbursement; rules of the Medicare physician fee schedule payment system.

medical coding bullets CODING FOR MEDICAL NECESSITY. Assessment and coding from patient medical records; securing the correct physician documentation; coding an operative report; selecting and coding diagnoses and procedures from case studies and sample records.

Special codes exist for all types of encounters, services, tests, treatments, and procedures provided by a healthcare provider in a medical office, hospital, or clinic. These codes are described as CPT4 codes that consist of 5 digit numbers. Even the simplest patient complaints such as headache, or nausea have codes which consist of a set of numbers and combinations of sets of numbers. Software is NO guarantee of 100% accuracy.

The Encounter

When a provider sees and treats a person seeking medical advice in the medical office or practice it is referred to as an encounter. An encounter is defined as "a face-to-face contact between a healthcare professional and an eligible beneficiary."

Medical Coding Purpose

The American Medical Association (AMS) developed the CPT coding system. CPT stands for Current Procedural Terminology to tell the health insurance companies or government entities the reason why a patient was seen and what services were performed so that the provider can get paid. Codes also are implemented to gather and communicate public health statistics. Medical codes are used for a variety of purposes.

Among them:

  • Coding diseases and procedures
  • Physician billing and reimbursement
  • Recording causes of death

Surveys show that MANY medical coding positions remain unfilled due to a lack of qualified candidates! The US Bureau of Labor Statistics states coding (as well as billing) is one of the ten fastest growing allied health occupations. Physicians depend on well trained, reliable medical coding and billing staff because otherwise they might not get paid for their services, or might wind up being charged large penalties due to improper coding, which could mean financial disaster, and cost them their livelihoods. Once hired, medical coders and billers hold secure jobs, with good futures. Supervisors spend weeks or months training medical billers and coders one-on-one. Once they are trained and have gained experience by participating in the daily office routine, chances are good that their positions will be long term.

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