Medical Billing & Coding For Dummies E-Book

Karen Smiley

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 572

Veröffentlichungsjahr: 2024

Beschreibung

The essential guide for medical billing professionals, updated for ICD-11 standards

Medical Billing & Coding For Dummies will set you up for success in getting started as a medical biller and coder. To ensure data accuracy and efficient data processing, medical offices need professionally trained coders to handle records. This book provides prospective allied health professionals with everything they need to know to get started in medical billing and coding as a career. In addition to an introduction to the basics of medical coding, you'll get information on how to find a training course, meet certification requirements, and deal with government agencies and insurance companies. Learn about the standard practices in the medical billing industry and get up to speed on the ethical and legal issues you're likely to face on the job. This accessible guide is a great entry point—and a great refresher—for anyone interested in the medical billing and coding profession.

• Get a primer on your career options in the field of medical billing
• Learn coding practices for telehealth, viral outbreaks, and other emerging issues
• Update your knowledge of the changes between ICD-10 and ICD-11 coding systems
• Find training programs and explore your options for certification

This Dummies guide is an accessible entry point for prospective professionals looking get a jump on their new career, and current professionals intent on staying up-to-date in this flexible and growing field.

Leseprobe

Medical Billing & Coding For Dummies®

To view this book's Cheat Sheet, simply go to www.dummies.com and search for “Medical Billing & Coding For Dummies Cheat Sheet” in the Search box.

Table of Contents

Cover

Title Page

Copyright

Introduction

About This Book

Foolish Assumptions

Icons Used in This Book

Beyond the Book

Where to Go from Here

Part 1: Getting to Know Medical Billing and Coding

Chapter 1: Dipping Your Toes into Medical Billing and Coding

Coding versus Billing: They Really Are Two Jobs

Following a Day in the Life of a Claim

Keeping Abreast of What Every Coder Needs to Know

Deciding Which Job Is Right for You

Prepping for Your Career: Training Programs and Certifications

Planning for the Future

Chapter 2: Exploring the Billing and Coding Professions

Looking at the Medical Coding Job

In Tandem: Working Together or Doing Both Jobs Yourself?

Chapter 3: Weighing Your Employment Options

Choosing Your Environment: Doctor’s Office, Hospital, and Others

Remote Access: Setting Up Off-Site

Reviewing Other Work Options: Freelancing, Temping, and More

Heeding a Word of Advice for New Coders

Part 2: Boning Up on the Need-to-Knows of Your Profession

Chapter 4: Compliance: Understanding the Rules

You Rule! Meeting the Rule Makers

Complying with HIPAA

Unbundling the Compliance Bundle

Getting the Most out of the Dreaded Audit

Chapter 5: Not-So-Strange Bedfellows: Medical Terminology and Medical Necessity

Brushing Up on Basic Anatomy

Say What? Deciphering Medical Terminology

Understanding Medical Necessity

Connecting with the World of Evaluation and Management Codes

How COVID Drove Changes

Chapter 6: Getting to Know the Payers

Wading through the Sea of Commercial Insurance Payers

Medicare: Meeting the Chief Government Payer

Working with Other Government Payers

Part 3: Becoming a Professional: Getting Certified

Chapter 7: Your Basic Certification Options, Courtesy of the AAPC and AHIMA

Introducing the Two Main Credentialing Organizations: AAPC and AHIMA

Looking at the Basic Certifications

Choosing the Certification That’s Right for You

Examining the Exams: A Quick Review of the Main Tests

Chapter 8: The Path to Certification: Finding a Study Program

The Big Picture: Thinking about Your Degree and Career Objectives

Considering the Time Commitment

First Things First: Squaring Away Your Prerequisites

Picking a Program of Study

Caveat Emptor: Watching Out for Diploma Mills

Chapter 9: Signing Up and Preparing for the Certification Exam

Establishing a Study Routine and Strategy

Focusing on the Right Topics

Preparing Yourself for Test Day

Signing Up for and Taking the Big Test

Chapter 10: Adding Street Cred: Specialty Certifications and Continuing Ed

Introducing Specialty Certification Options

Building on Your Cred with Continuing Education

Part 4: Dealing and Succeeding with Nitty-Gritty On-the-Job Details

Chapter 11: Processing a Run-of-the-Mill Claim: An Overview

Dreaming of the Perfect Billing Scenario

Delving into the Details: Contract Specifics

Covering Your Bases: Referrals and Preauthorization

Tracking Your Claim from Submission to Payment

Fighting for Proper Payment: Filing an Appeal with the Payer

Chapter 12: Homing In on How to Prepare an Error-Free Claim

Assigning CPT and HCPCS Codes

Applying Modifiers Correctly

Looking for Money Left on the Table

Checking and Double-Checking Your Documentation

Chapter 13: From Clearinghouse to Accounts Receivable to Money in the Pocket

Spending Time in the Clearinghouse

Facing Factors Affecting Reimbursement Amounts

Payment or Denial: Being in the Hands of the Payer

Breaking Down the Remittance Advice

Chapter 14: Handling Disputes and Appeals

Dealing with Disputes Involving Contracted and Noncontracted Payers

Knowing When to File an Appeal: General Guidelines

The Art of the Appeal: Understanding the Basics before You Begin

Going through an Appeal, Step by Step

Appealing Medicare Processing

Appealing a Workers’ Comp Claim

Chapter 15: Keeping Up with the Rest of the World

WHO’s on First: Providing Data to the World Health Organization

Charting Your Course with ICD

Part 5: Working with Stakeholders

Chapter 16: Dealing with Commercial Insurance Claims

Meeting Commercial Insurance

Cashing In with Commercial Payers

Knowing What’s What: Verifying the Patient’s Plan and Coverage

Chapter 17: Caring about Medicare and Medicaid

Brushing Up on Medicare Basics

Working with Medicare Claims

Deciding What Gets Paid

Working with Medicare Contractors

Doing Business with Medicare Part C Plans

Verifying Coverage and Plan Requirements

Chapter 18: Coding Ethics: Being an Advocate for Your Employer

Playing the Part of the Professional Medical Biller/Coder

Protecting Yourself and Your Integrity

Getting the Most Bang for Your Client’s Buck — Honestly

Part 6: The Part of Tens

Chapter 19: Ten Billing and Coding Mistakes and How to Avoid Them

Being Dishonest

Shifting the Blame

Billing More than Is Documented

Unbundling Incorrectly

Ignoring an Error

Mishandling an Overpayment

Failing to Protect Patients from Out-of-Network Penalties

Failing to Verify Prior Authorization

Breaking Patient Confidentiality

Following the Lead of an Unscrupulous Manager

Chapter 20: Ten Acronyms to Burn into Your Brain

ACA: Patient Protection and Affordable Care Act

ACO: Accountable Care Organization

CDI: Clinical Documentation Improvement

CMS: Centers for Medicare and Medicaid Services

EHR: Electronic Health Record

EOB: Explanation of Benefits

HIPAA: Health Insurance Portability and Accountability Act

INN: In-Network

NCCI: National Correct Coding Initiative

OON: Out-of-Network

Chapter 21: Ten (Plus One) Tips from Billing and Coding Pros

Insist on Proper Documentation

Verify Patient Benefits

Get Vital Patient Info at Check-In

Review the Documentation ASAP

Set Up a System to Ensure Accuracy

Play Nice with Others

Follow Up on Accounts Receivable Daily

Be a Bulldog on the Phone

Know Your Payer Contracts by Heart

Create a File System That Lets You Find What You Need

Make Payers Show You the Money!

Glossary

Index

About the Author

Connect with Dummies

End User License Agreement

List of Tables

Chapter 5

TABLE 5-1 Major Body Systems

TABLE 5-2 Common Greek and Latin Prefixes

TABLE 5-3 Common Greek and Latin Suffixes

Chapter 7

TABLE 7-1 Basic AAPC Certifications

Chapter 10

TABLE 10-1 Trademark AAPC Certifications

TABLE 10-2 AAPC CEU Requirements

List of Illustrations

Chapter 2

FIGURE 2-1: The HCFA/CMS-1500 form.

FIGURE 2-2: General functions associated with billing and coding.

Chapter 9

FIGURE 9-1: The cardiovascular system, the heart of the circulatory system.

FIGURE 9-2: The lymphatic system, another part of the circulatory system.

FIGURE 9-3: The digestive system.

FIGURE 9-4: The endocrine system.

FIGURE 9-5: The respiratory system.

FIGURE 9-6: The urinary/excretory system.

Chapter 14

FIGURE 14-1: A request for reconsideration for a contracted payer.

FIGURE 14-2: A request for reconsideration for a noncontracted payer.

Guide

Cover

Table of Contents

Title Page

Copyright

Begin Reading

Glossary

Index

About the Author

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Medical Billing & Coding For Dummies®

Published by: John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030-5774, www.wiley.com

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Introduction

Welcome to Medical Billing & Coding For Dummies! Consider this your personal guided tour to the profession that all physicians, hospitals, and clinics rely on to get paid in a timely fashion. This book shows you the ins and outs of the medical billing and coding profession, from the differences between the two jobs to how to prepare for and land a billing and coding job to what to expect after you’re safely in that office chair.

As you read this book, you’ll discover that medical billing and coding is a vital cog in the healthcare wheel. After all, the medical biller and coder is the rainmaker of the healthcare industry, turning the healthcare provider’s documentation into payment.

Medical billing and coding is way more than codes and insider jargon, though. It’s also about working with people and knowing how to interact with each type of person or business you come in contact with, from patients and physicians to fellow coders and insurance reps — a virtual who’s who of the medical world — and you’ll be right in the middle of them all!

About This Book

The world of medical billing and coding, what with all the terminology you must master and the codes you need to know, can seem big and a bit daunting at times. After all, there’s a lot to remember and so, so many codes. But don’t worry: Parsing the ins and outs of all the details on how to enter the correct code is what those super-technical coding books are for. Think of this book as a friendly guide to all the twists and turns you’ll encounter in your medical billing and coding world, from taking the certification exam and finding a job to working with insurance companies and deciphering physician documentation.

Not only do I share the ins and outs of the profession itself and what to expect on the job, but I also tell you what you need to know to succeed.

What this book isn’t is a book of codes. Tons of great resources are out there that list all the codes you need to do your job properly, and I recommend that you have them handy. Instead, this book is a friendly take on the job as a whole. And, in this fourth edition, I give you all the details to get you started in this dynamic career, including what is coming in the 11th edition of the International Classification of Diseases (ICD-11). My main goal with this book is to introduce you to the wider world of medical billing and coding so that you are prepped and ready to scrub in for this challenging, evolving, and always exciting career.

Foolish Assumptions

In writing this book, I made some assumptions about you:

You’re a medically minded individual who is interested in pursuing a career in medical billing and coding and has no previous coding experience.

You’re a current medical professional who is looking to switch to the coding side of the industry.

You’re a medical billing and coding student who is looking for information on certifications, job hunting, and the career in general.

Regardless of why you picked up this book, you can find the info you need to pursue your medical billing and coding career goals with confidence.

Icons Used in This Book

As you read this book, you’ll notice icons peppered throughout the text. Consider these signposts directing you to special kinds of information. Here’s what each icon means:

This icon marks tips and tricks you can use to help you succeed in the day-to-day tasks of medical billing and coding.

This icon highlights passages that are good to keep in mind as you master the medical billing and coding profession.

This icon alerts you to common mistakes that can trip you up when you are coding or following up on a denial.

This icon indicates something cool and perhaps a little offbeat from the discussion at hand. Feel free to skip these bits.

Beyond the Book

In addition to the material in the print or e-book you’re reading right now, this book also comes with a free, access-anywhere Cheat Sheet that has all the best tips on medical billing and coding. To get this Cheat Sheet, simply go to www.dummies.com and type Medical Billing & Coding For Dummies Cheat Sheet in the Search box.

Where to Go from Here

This book is designed to be easy to navigate and easy to read, no matter what topic you’re interested in. Looking for information on certification exams? Head to Chapter 7. Want to know how to file an appeal? Chapter 14 has the information you need.

Of course, if you feel confident that you already know the basics on medical billing and coding and you want to dive into the middle of this book, feel free. That said, getting a strong idea of what the medical billing and coding job entails can be incredibly useful if you’re a bit on the fence about whether this is the job for you. If that description fits you, start in Part 1, where you can find some really useful overview-type info.

Bottom line: Go wherever you want. After all, it’s your life, it’s your future, and this profession is yours for the taking. Go for it!

Part 1

Getting to Know Medical Billing and Coding

IN THIS PART …

Getting an overview of the who, what, when, and where of the billing and coding profession

Finding out the difference between being a medical biller and being a medical coder

Examining what you need to know now to enter and succeed in this field

Chapter 1

Dipping Your Toes into Medical Billing and Coding

IN THIS CHAPTER

Getting to know the industry

Deciding whether the job is right for you

Choosing a certification

Planning your education

Welcome to the world of medical billing and coding! No other job in the medical field affects more lives than this one because everyone involved in the healthcare experience, from the patient and front office staff to providers and payers, relies on you. You are, so to speak, the touchstone in the medical industry.

A lot rests on your shoulders as the biller and coder. With this responsibility comes great power, and that power must be treated with respect and integrity. In this chapter, I take you on a very brief tour of what medical billing and coding entails. I hope you find, as I have, that working as a medical biller/coder is a challenging and rewarding job that helps you to fulfill your dreams as you become an integral cog of the medical industry.

Coding versus Billing: They Really Are Two Jobs

Although many people refer to billing and coding as if it were one job function (a convention I use in this book unless I’m referring to career-specific functions), billing and coding really are two distinct careers. In the following sections, I briefly describe the tasks and functions associated with each job and give you some things to think about to determine which path you want to pursue:

The medical coder deciphers the documentation of a patient’s interaction with a healthcare provider (physician, surgeon, nursing staff, and so on) and determines the appropriate procedure (CPT) and diagnosis code(s) (ICD) to reflect the services provided.

The medical biller then takes the assigned codes and any required insurance information, enters them into the billing software, and then submits the claim to the payer (often an insurance company) to be paid. The biller also follows up on the claim as necessary.

Both medical billers and coders are responsible for a variety of tasks, and they’re in constant interaction with a variety of people (you can read about the various stakeholders in

Part 5

). Consider these examples:

Because they’re responsible for billing insurance companies and patients correctly, medical billers have daily interaction with both patients and insurance companies to ensure that claims are paid correctly and in a reasonable time.

To ensure coding accuracy, coders often find themselves querying physicians regarding any questions they may have about the procedures that were performed during the patient encounter and educating other office staff on gathering required information.

Billers (but sometimes coders, too) have the responsibility for explaining charges to patients, particularly when patients need help understanding their payment obligations, such as coinsurance and copayments, that their insurance policies specify.

When submitting claims to the insurance company, billers are responsible for verifying the correct billing format, ensuring the correct modifiers have been appended, and submitting all required documentation with each claim.

In short, medical billers and coders together collect information and documentation, code claims accurately so that physicians get paid in a timely manner, and follow up with payers to make sure that the money finds its way to the provider’s bank account. Both jobs are crucial to the office cash flow of any healthcare provider, and they may be done by two separate people or by one individual, depending upon the size of the office.

For the complete lowdown on exactly what billers and coders do, check out Chapter 2 for general information and Part 4, which provides detailed information on claims processing.

Following a Day in the Life of a Claim

When you’re not interfacing with the three Ps — patients, providers, and payers — you’ll be doing the meat and potatoes work of your day: coding medical records to start the process of converting provider-performed services into revenue.

Claims processing refers to the overall work of submitting and following up on claims. Here in a nutshell is the general process of claims submission, which begins almost as soon as the patient enters the provider’s office:

The patient hands over their insurance card and fills out a demographic form at the time of arrival.

The demographic form includes information such as the patient’s name, date of birth, address, Social Security or driver’s license number, the name of the policyholder, and any additional information about the policyholder if the policyholder is someone other than the patient. At this time, the patient also presents a government-issued photo ID so that you can verify that they are actually the insured member.

Using someone else’s insurance coverage is fraud. So is submitting a claim that intentionally misrepresents an encounter in order to obtain payment. All providers are responsible for verifying patient identity, and they can be held liable for fraud committed in their offices.

After the initial paperwork is complete, the patient encounter with the service provider or physician occurs, followed by the provider documenting the services.

The coder abstracts the billable codes, based on the physician documentation.

The coding goes to the biller who enters the information into the appropriate claim form in the billing software.

After the biller enters the coding information into the software, the software sends the claim either directly to the payer or to a clearinghouse, a company that sends the claim to the appropriate payer on the provider’s behalf for reimbursement.

If everything goes according to plan, and all the moving parts of the billing and coding process work as they should, your claim gets paid and no follow-up is necessary. For a detailed discussion of the claims process from beginning to end, check out Chapters 11, 12, and 13.

Of course, things may not go as planned, and the claim may get hung up somewhere — often for missing or incomplete information — or it may be denied. If either of these happens, the biller/coder must follow up to discover the problem and then resolve it. Chapter 14 has all the details you need about this part of your job.

Keeping Abreast of What Every Coder Needs to Know

If you’re going to work in the medical billing and coding industry, you must familiarize yourself with three big must-know items: compliance (following laws established by federal or state governments and regulations established by the Department of Health and Human Services or HHS, or other designated agencies), medical terminology (the language healthcare providers use to describe the diagnosis and treatment they provide), and medical necessity (the diagnosis that makes the provided service necessary). In the following sections, I introduce you to these concepts. For more information, head to Part 2.

Complying with federal and state regulations

In the United States, as in many countries, healthcare is a regulated industry and you have to follow certain guidelines. In the United States, these rules are enforced by the Office of Inspector General (OIG). The regulations are designed to prevent fraud, waste, and abuse by healthcare providers, and as a medical biller or coder, you must familiarize yourself with the basics of compliance.

Being in compliance basically means an office or individual has established a program to run the practice under the regulations as set forth by federal or state governments and the department of HHS or other designated agencies.

You can thank something called HIPAA for setting the bar for compliance. The standard of securing the confidentiality of healthcare information was established by the enactment of the Health Insurance Portability and Accountability Act (HIPAA). This legislation guarantees certain rights to individuals with regard to their healthcare. Check out Chapter 4 for more info on compliance, HIPAA, and the OIG.

Learning the lingo: Medical terminology

Everyone knows that doctors speak a different language. Turns out that that language is often based on Latin or Greek. By putting together a variety of Latin and Greek prefixes and suffixes, physicians and other healthcare providers can describe any number of illnesses, injuries, conditions, and procedures.

As a coder, you need to become familiar with these prefixes and suffixes so that you can figure out precisely what procedure codes to use. By mastering the meaning of each segment of a medical term, you’ll be able to quickly make sense of the terminology that you use every day.

You can read about the most common medical prefixes and suffixes in Chapter 5.

Demonstrating medical necessity

Before a payer (such as an insurance company) will reimburse the provider, the provider must show that rendering the services was necessary. Setting a broken leg is necessary, for example, only when the leg is broken. Similarly, prenatal treatment and newborn delivery is necessary only when the patient is pregnant.

To demonstrate medical necessity, the coder must make sure that the diagnosis code supports the treatment given. Therefore, you must be familiar with diagnosis codes and their relationship to the procedure codes. You can find out more about medical necessity in Chapter 5.

Insurance companies are usually the parties responsible for paying the doctor or other medical provider for services rendered. However, they pay only for procedures that are medically necessary to the well-being of the patient, their client. Each procedure billed must be linked to a diagnosis that supports the medical necessity for the procedure. All diagnoses and procedures are worded in medical terminology.

Deciding Which Job Is Right for You

If you think the idea of working with everyone from patients to payers sounds good and working a claim through the billing and coding process seems right up your alley, then you can start to think about which particular jobs in the field may be a good fit for you. Luckily, you have lots of options. You just need to know where to look and what kind of job is right for you. I give you some things to think about in the following sections.

Examining your workplace options

Before you crack open the classifieds, give some thought to what sort of environment you want to work in. You can find billing and coding work in all sorts of places, such as

Physician offices

Hospitals

Nursing homes

Outpatient facilities

Billing companies

Home healthcare services

Durable medical good providers

Practice management companies

Federal and state government agencies

Commercial payers

Which type of facility you choose depends on the kind of environment that fits your personality. For example, you may want to work in the fast-paced, volume-heavy work that’s common in a hospital. Or maybe the controlled chaos of a smaller physician’s office is more up your alley.

Other considerations for choosing a particular area include what you can gain from working there. A larger office or a hospital setting is great for new coders because you get to work under the direct supervision of a more experienced coding staff. A billing company that specializes in specific provider types lets you become an expert in a particular area. In many physician offices, you get to develop a broader expertise because you’re not only in charge of coding, but you’re also responsible for following up on accounts receivable and chasing submitted claims.

To find out more about your workplace options and the advantages and disadvantages that come with each, head to Chapter 3.

Thinking about your dream job

Although you can’t predict the future, you can begin to put some thought into your long-term career goals and how you can reach them. Here are some factors to consider when thinking about what kind of billing/coding job you want:

The kind of job you want to do and the tasks you want to spend your time performing:

Refer to the earlier sections “

Following a Day in the Life of a Claim

” and “Keeping Abreast of What Every Biller/Coder Needs to Know” for more job-related tasks.

Chapter 2

has a complete discussion of billing and coding job functions.

Where you plan to seek employment and in what kind of setting:

The preceding section gives you a quick idea of what your options are.

Chapter 3

gives you more detail.

The type of certification potential employers prefer and the time commitment involved:

Many billing or practice management companies, for example, are contractually obligated to their clients to employ only certified medical coders to perform the coding.

The type of training program(s) available in your area:

Many reputable training programs are associated with the two main biller/coder credentialing organizations, the AAPC (American Academy of Professional Coders) and AHIMA (American Health Information Management Association), each of which tends to focus on a particular area. AAPC certification is generally associated with coding in physicians’ offices, but it has recently updated its courses and now offers certification in both hospital inpatient and outpatient coding; AHIMA certification is generally associated with hospital coding. For information about finding a training program and your options, head to

Chapter 8

.

Take a few minutes (or hours!) now to think over these points. Trust me: It’s time well spent before you jump on the billing and coding bandwagon.

Prepping for Your Career: Training Programs and Certifications

Breaking into the billing and coding industry takes more than a wink and a smile (though I’m sure yours are lovely). It takes training from reputable institutions and certification from a reputable credentialing organization. The next sections have the details.

Previewing your certification options

To score a job as a biller and coder, you should get certified by a reputable credentialing organization such as the AHIMA or the AAPC. In Chapter 7, I tell you everything you need to know about these organizations. Here’s a quick overview:

AAPC is the credentialing organization that offers Certified Professional Coder (CPC) credentials, as well as a myriad of other credentials. AAPC training focuses on physician offices, practice management, compliance, auditing, billing, and inpatient and outpatient hospital-based coding.

AHIMA coding certifications — Correct Coding Specialist (CCS) and Certified Coding Associate (CCA) — are intended to certify the coder who has demonstrated proficiency in inpatient and outpatient hospital-based coding, while the Correct Coding Specialist—Physician-based (CCS-P) is, as its name indicates, for coders who work for individual physicians.

All sorts of other specialty certifications are also available, which you can read more about in Chapter 10.

To choose which certification — AHIMA or AAPC — best fits your career goals, first think about the type of training program you want. Second, examine your long-term career goals. What kind of medical billing and coding job do you ultimately want to do, in what sort of facility do you want to work, and how do you want to spend your time each day?

To get certified, you must pass an exam administered by the credentialing organization. Head to Chapter 9 for exam details and information on how to sign up for one.

Going back to school

Sharpen your pencils, get a sweet new backpack, and shine up an apple for the teacher because you’re going back to school. That’s right, school. It’s your first stop on the way to Medical Billing and Coding Land. The good news is that medical coding or billing is one of the few medical careers with fewer education requirements. Translation: You won’t be spending decades preparing for your new career. Most billing and coding programs get you up and running in a relatively short amount of time, often less than two years.

After you successfully complete a training program, you receive a certificate of completion. Note that this is different from achieving certification. To get your certification, you still have to take certification exams offered by the credentialing bodies after graduation. Fortunately, a solid medical coding and billing program provides you with the knowledge necessary to ace the exams and gain entry-level certification. Most programs offer training in the following:

Human anatomy and physiology

Medical terminology

Medical documentation

Medical coding, including proper use of modifiers

Medical billing

Claims filing

Medical insurance, including commercial payers and government programs

You can read all about your educational options — from abbreviated study programs to more inclusive extended programs — in Chapter 8, where I highlight the advantages of some programs and the pitfalls of others.

Planning for the Future

As soon as you get your first billing and coding job — and probably even before that — you’ll start hearing about something called ICD-10, which is the tenth revision of the International Classification of Diseases (hence, the ICD), the common system of codes used by the World Health Organization (WHO) that classifies every disease or health problem you code. These diagnosis codes represent a generalized category of the disease or injury that was the catalyst for the patient/physician encounter. As a biller/coder, you use the ICD every day.

ICD codes are also used to classify diseases and other health problems that are recorded on many types of health records, including death certificates, to help provide national mortality and morbidity rates. ICD-10 went into place October 1, 2015. Before that, the ninth edition of the ICD classification (ICD-9) had been used in the United States since 1979.

The new kid in town is ICD 11. ICD 11 was released in January 2022 but has not yet been adopted by the United States. The United States faces significant issues with ICD 11 implementation. It lacks the clinical modifications required by our claims processing systems. Since ICD codes determine in-patient hospital reimbursements known as DRGs (diagnosis-related groups). Implementation will require modifications to the DRGs, payer claim processing platforms, and billing software used by facilities and professionals. Unlike ICD 10, which represented huge benefits to hospitals, ICD 11 lacks similar advantages and may not produce a return on the financial investments that will be required for its implementation.

WHO uses the data gleaned from your coding to analyze the health of large population groups and monitor diseases and other health problems for all members of the global community. For your purposes, you can think of the ICD codes as the language you speak when coding so that organizations like WHO can do the work of keeping the world healthy.

The transition to ICD-10 increased the demand for medical coders due to the increased specificity. The healthcare workforce is predicted to continue growing, which should increase the demand for billing and coding professionals for the foreseeable future. Although AI-driven coding software is available, the medical community still needs human intervention and support.

Chapter 2

Exploring the Billing and Coding Professions

IN THIS CHAPTER

Understanding how medical coding differs from medical billing

Looking at the tasks that billers and coders must perform

Determining which job is best for you

Medical billing and coding specialists are the healthcare professionals responsible for converting patient data from treatment records and insurance information into revenue. They take all that complicated information and turn it into a language of codes the insurance companies and other payers can understand. The healthcare industry depends on qualified medical billers and skilled medical coders to accurately record, register, and keep track of each patient’s account so that the docs get paid and the patients get charged only for services they receive.

Although they’re frequently clumped together, medical billing and medical coding are actually two distinct jobs. In this chapter, I discuss each separately.

Note: In this chapter, I offer a very brief overview of the tasks that billers and coders perform. For a detailed discussion of the billing and coding process, head to Part 4.

Looking at the Medical Coding Job

The coder’s job is to extract the appropriate billable services from the documentation that has been provided. The coder is given the office notes and/or the operative report as dictated by the physician. From this documentation, the coder identifies any and all billable procedures and assigns the correct diagnosis and procedure codes. The coder also identifies whether a procedure that is often included with another procedure should be billed on its own (or, in coder-speak, unbundled) to allow for additional reimbursement. To be eligible for unbundling, the documentation must indicate that extra time and effort was required or that a procedure that is normally included in the primary procedure was done at a separate site or time and was necessary to ensure a positive outcome for the patient.

That’s the nuts-and-bolts stuff. To do the job of medical coder well, however, you must be aware that medical coding requires a daily commitment to remaining high ethical standards despite pressures from employers who are looking at the bottom line and who may not always be aware of the laws and regulations that govern billing and coding. I have heard physicians tell coders to just use the code with the highest revenue potential. This philosophy may be what is best in the short term for the provider’s bottom line, but when an auditor comes around to investigate, that money is going back with interest. So the first order every day for the coder is to maintain high ethical standards.

The key to optimal reimbursement is full documentation by the provider (the physician, for example, who sees the patient and performs the procedure) coupled with full extraction, or identification, of billable procedures by the coder. Everyone — from the doc to you, the coder — has to dot every i and cross every t.

In the following sections, I take you through the different tasks you’ll perform as you prepare claims for reimbursement.

Verifying documentation

As noted earlier, the job of coder starts with the documentation provided by the physician. This documentation can take the form of an operative report or an office note.

Physicians and clinicians are trained to document their work, so consider them partners in the coding enterprise. They (or a member of their staff) note all the information needed to treat a particular patient before the paperwork hits the coder’s desk. If the documentation is incomplete, do not guess or “fill in the blanks.” Query the physician or clinician and ask them to review the transcript to ensure it includes everything that was done. Do not tell them what is missing; it is their responsibility to document. It is your responsibility to ensure that the documentation is complete. Ask yourself, “If this note were to become Exhibit A, would it hold up in court?”

Checking operative reports

An operative report is the document that is transcribed from the physician’s dictation of the patient encounter. It describes in detail exactly what was done during a surgery. Operative reports are normally set into a template, which serves as an outline that identifies the reason for the procedure, what illness or injury was confirmed during the procedure, and finally the procedure(s) that were performed.

The basic format of an operative report includes the following:

Patient name and date of birth

Operating physician

Assistant at surgery

Date of service

Preoperative diagnosis (the diagnosis based on the examination and preoperative testing)

Postoperative diagnosis (new diagnoses based on what the doctor found during the surgery)

Procedure(s) performed (an outline of the procedures done)

Body of the operative report (a description of everything that was stated in the postoperative diagnosis and procedure performed sections)

Put simply, verifying documentation is a fact-checking gig. Here’s what you need to check:

That procedures stated as performed in the heading of the operative report are substantiated in the body of the report.

The diagnosis provides medical necessity for the procedure and that the procedure(s) listed in the outline are documented in the body of the operative report.

Medical necessity

is simply the reason for the visit or surgery; it defines the disease process or injury (head to

Chapter 5

for details). Before payers reimburse the provider, they have to know why the services billed were necessary.

As a coder, you rely on the information in the body of the operative report to verify the documentation. If the body doesn’t support the rest of the operative report (the operative report doesn’t mention a procedure listed in the “procedures performed” section, for example, or the description isn’t detailed enough), then you’re responsible for asking the surgeon to clarify.

If the doctor doesn’t describe a procedure in the operative report, regardless of how obvious it seems, it is the same as if it were not done, because per coding guidelines, it cannot be coded or billed.

All physician services are coded and billed based upon physician documentation. When coding office procedures or verifying the level of evaluation and management code that is appropriate for the visit, you rely on the physician’s office notes. An office note typically documents the patient’s symptoms, the physician’s findings, and the plan for treatment, including a follow-up plan.

If you believe that a higher level of service was performed, asking a physician for clarification is certainly acceptable, but coding a procedure that’s not documented is not acceptable. Coding is not a job for those who like to second-guess. You can’t assume you know what the doctor meant or intended and append a code that is not supported by the documentation based on your assumptions. Therefore, make sure you add “clarifying information” to your list of daily jobs as a coder.

IT’S A BIRD! IT’S A PLANE! IT’S SUPER-BILL!

A super-bill is a form created specifically for an individual office or provider. It normally is prepopulated with the patient’s demographic information, including insurance copay, and contains the most common diagnosis and procedural codes used by the office. It may also have a section that indicates the need for follow-up appointments and should have a space for the physician’s signature.

The super-bill is a great tool for the provider for billing purposes and also proves helpful for keeping track of each patient’s visit. In many offices, the super-bill has been replaced by the electronic health record (EHR), an all-electronic method of patient recordkeeping.

Super-bills, wonderful as they are, can also be the bane of the coder’s existence. Although checking off billable procedures is certainly easier for the provider, they may overlook adding the detail necessary to support the procedures (and level of the visit) indicated on the bill. If the chart doesn’t match the super-bill, it’s back to square one for the coder.

Following up on unclear documentation

As I explain in the preceding sections, physicians document all procedures they perform. If they don’t state a procedure in their dictation (in their operative report) or note it in the physician’s notes, regardless of how obvious it may seem, it cannot be coded or billed.

The chant of the medical coder always comes in handy. When in doubt or faced with incomplete documentation, remember: “If the doctor didn’t document it, it wasn’t done.” Period. When the documentation is missing or ambiguous, it’s your responsibility to clarify with the physician. Although some physicians become defensive or irritated when the coder questions the documentation, those who understand that your questions can maximize their reimbursement will gladly amend the documentation to clear up the problem.

Assigning diagnosis and procedure codes

Time to play “Name that Illness!” Upon reading the operative report or office notes, you must identify the illness or injury and find the corresponding International Classification of Diseases (ICD) diagnosis code. The ICD codebook is the bible of coding, containing all the diagnosis codes.

After finding the diagnosis codes, you then look up the procedure codes that best describe the work done, using one of the following books:

The Current Procedural Terminology (CPT) codebook:

The CPT codebook contains all the procedure codes as determined by the American Medical Association (AMA) and includes the definition of each procedure. Physicians and outpatient facilities choose codes from the CPT book.

The ICD-10 Procedure Coding System (PCS) codebook:

Hospital inpatient procedures are chosen from the ICD-10-PCS reference.

Coming soon:

The next revision to the ICD codes, ICD-11, is now in place by the World Health Organization (WHO). There is no current implementation target date set in the United States. ICD-10 required a decimal in the fourth position of the diagnosis code. ICD-11 doesn’t work that way. Example: ICD 10 codes cellulitis of the left lower limb as L03.116. If the cellulitis is caused by staph, then A49.x is added (

x

being dependent upon specific location, and so forth). In ICD-11, however, cellulitis caused by staph is 1B70.2

Because so many different codes and corresponding procedures exist, you may suffer from “coding drama.” Coding a procedure with a lot of moving parts can get a bit complicated. Sure, capturing all the procedures that were performed during a surgery is important, for example, but they each must be separately billable or have involved extra work by the surgeon in order to justify unbundling them (or billing them separately). The point? Coding can get pretty complicated. Before you panic, keep this in mind: Coding a procedure is simple if you remember to break it down into small bites.

Physician coding

Physician coding is just what it sounds like: coding diagnoses and procedures representing the work performed by a physician. Under certain circumstances, work performed in an outpatient setting, such as an ambulatory surgery center (ASC), also uses physician coding.

Physician offices, ASCs, and other outpatient facilities use the CPT code set to represent the procedure performed. Physician claims are submitted on the CMS-1500 claim form (although ASCs may be required to submit the older HCFA-1500 claim forms in certain states or to certain payers). In most circumstances, facilities bill commercial carriers on the UB-04 claim form. Both of these forms are discussed later in this chapter.

Facility coding

Coding for facility reimbursement often pertains to hospital coding. Specific coding and billing guidelines exist for hospital billing. If you are working as a facility coder in a hospital, you will use the ICD-10-PCS codebook to identify surgical procedures done during an inpatient stay, and the CPT codebook for procedures done during an outpatient visit.

Basically, facility coding is for the hospital inpatient setting. Outpatient centers, including those run by the hospital, use physician coding.

Transforming visits into revenue

After the procedure codes and diagnosis codes are entered into the office billing software, the billing process officially begins.

In many offices, the claim is out of the coder’s hands at this point because the actual billing part of the process falls to the medical biller who takes the coding information and submits it for payment (you can read about that job in the next section, “Decoding the Medical Biller’s Job”). Nevertheless, the claim may return in the form of a denial from the payer.

Often, if a claim is denied for medical necessity (refer to Chapter 5), it is returned to coding for clarification or verification so that it can be corrected and or resubmitted if necessary.

Determining whether medical coding suits you

As you decide whether medical coding is a job you’d like and think you would do well at, consider these points:

As a medical coder, you’re responsible for extracting the correct procedure code from the physician’s documentation. To do this task well, you must have a strong command of the medical terminology, be a good reader, and be very detail oriented.

In fact, the job of coder is especially attractive to those who are skilled at analyzing data. Every procedure performed in a medical setting has a specific code assigned to it, and it needs to be coded properly to ensure correct billing and maximum reimbursement for the physician or facility.

You’re responsible for recognizing when information is unclear or missing from the documentation and for clarifying with the physician any ambiguous wording in the documentation.

You must stay current on correct coding guidelines and the ever-changing procedure codes as determined by the AMA and the Centers for Medicare & Medicaid Services (CMS).

Check out www.ama-assn.org and www.cms.gov for the most up-to-date coding changes. For ICD-11 coding info: https://www.who.int/news/item/11-02-2022-icd-11-2022-release For ICD-11 coding info, look to www.who.int/news/item/11-02-2022-icd-11-2022-release.

As a coder, you may not have much interaction with insurance companies and patients because you will tend to spend most of your time in the office working on coding medical records. So if you think coding is the job for you, know that you’ll have more face time with your computer than with patients.

Decoding the medical biller’s job

After the coder does their thing, it’s time for the medical biller to step up to the plate. The biller is responsible for billing insurance companies and patients.

When a medical biller submits claims to the insurance company, the biller is responsible for verifying the correct billing format, ensuring the proper modifiers (additions to the code that indicate further specificity; more on modifiers in Chapter 12) are appended, and submitting all required documentation with each claim. In most offices, claims are submitted through billing software. Learning to use the software is essential to successful billing and is a major part of on-the-job training for those seeking that profession. In the following sections, I highlight the key parts of the role of a medical biller.

A claim that has been well-documented and correctly coded and billed should generate a timely payment for the physician from the insurance company, which is the goal of both the medical coder and biller.

Knowing the payers and keeping up with their peculiarities

Most providers have contracts with multiple commercial payers (basically insurance companies), as well as government payers, such as Medicare. Here’s a very brief overview of the kinds of payers and organizations with whom medical billers work:

Commercial insurance:

These are private insurance carriers, and they fall into a variety of categories, each of which has particular rules regarding what’s covered, when, and how providers get reimbursed. Preferred provider organizations (PPOs), health maintenance organizations (HMOs), and point-of-service plans (POSs) are just a few categories medical billers deal with. You can discover further details in

Chapter 6

.

Networks:

Some commercial payers and providers participate in networks. A

network

is essentially a middleman who functions as an agent for commercial payers by negotiating contracts with providers and pricing claims (that is, determining the fees for procedures) according to the terms of those contracts.

Third-party administrators:

These intermediaries either operate as a network or access networks to price claims, and they often handle claims processing for employers who self-insure their employees rather than use a traditional group health plan.

Government payers:

These include governmental insurance programs that offer benefits to particular groups. Examples of government payers include Medicare (the elderly and qualifying disabled people), Medicaid (low-income individuals), Tricare (military members and their families), and so on.

The Patient Protection and Affordable Care Act:

The Affordable Care Act (ACA for short) is the healthcare reform act signed into law in America in 2010. Plans that became available with the passage of the ACA can be purchased through open exchanges that are different in every state. As a result, a medical biller must verify the actual payer as identified on the patient’s insurance card. ACA cards usually indicate that the plan is noncommercial and that provider commercial contracts may not be applicable. But to be sure, the front office must verify coverage type prior to seeing the patient. In most states, only providers who have enrolled with the specific plan will receive payment for services.

Chapter 6 goes into a great deal of detail on all the things you need to know about these payers. What you need to know now is that each has its own rules and guidelines that must be followed to secure reimbursement. Medical billers must be familiar with the eccentricities of each payer. You never know what you may need to know about a payer, such as which modifiers are accepted, how the payer views bilateral procedures (procedures performed on both sides of the body at the same time) and what kind of documentation the payer requires. Most workers’ compensation carriers, for example, require that procedural notes be included with all claims, even if doing so means they get the same operative report from the facility and the surgeon.

Taking the time upfront to learn what each payer requires can save medical billers a lot of time. Who wants to get tripped up by not knowing a payer’s documentation needs? Not the savvy medical biller! So bone up on this information early and then hit your mental refresh button often by staying abreast of the latest payer information. You can read about the different payers in Chapter 6.

Billing each payer correctly

As with just about everything else in life, billing and coding are going paperless. Remember those giant sliding file cabinets in the doctor’s office? They’re either gone or are being used to store the office holiday decorations. The Health Insurance Portability and Accountability Act (HIPAA) now makes it necessary to bill most claims electronically.

Most payers accept electronic claims, although some still require paper claims. It’s the medical biller’s responsibility to know which method will be accepted. This information is contained in the payer contract, but sometimes you need to call and ask how to submit the claim.

Medical billers encounter various formats or platforms of electronic claim submissions. For that reason, the biller also needs to make sure that the correct format is linked to each individual payer. Fortunately, this information isn’t too difficult to find: The patient’s insurance card normally has claim submission information on it, and of course, you can always call the payer to check prior to submitting a claim if there is any uncertainty.

For several decades, medical billing was entirely on paper. Then medical practice management software was developed and made claim processing more efficient. Although paper claims may soon be extinct due to the introduction of the HIPAA (covered in Chapter 4), certain payers are exempt and will continue to accept and possibly require paper claims.

In the following sections, I introduce you to the forms medical billers use routinely.

The CMS-1500 form

The Centers for Medicare & Medicaid Services 1500 (CMS-1500) form, formerly known as a Health Care Financing Administration-1500 (HCFA-1500) form, is the paper form used to submit claims for professional services (see Figure 2-1). Physicians and clinical practitioners submit their claims on this form, which is printed in red ink and contains spaces for all the necessary information. Directions for completing the form are printed on the back of each one.

FIGURE 2-1: The HCFA/CMS-1500 form.

Various forms have been used in the past, and it’s essential that medical billers use the most current, or correct, edition when submitting a claim via a paper form.

The HCFA/CMS-1500 form is split into three sections. Section One is patient information. All this information should be in the patient’s registration form. Section Two is for procedural and diagnostic information, which should be on the super-bill or coding form. Section Three is for the provider information. See? Easy as 1-2-3.

The UB-04/CMS-1450 form

The Uniform Bill 04 (UB-04) claim form, also called the CMS-1450 or just plain UB in some circles, is used by facilities for health insurance billing. Hospitals, rehabilitation centers, ambulatory surgery centers (usually, but not always) skilled nursing facilities, hospices, and others must bill their services on the UB-04 form in order to get paid by commercial payers. There are 84 boxes on the UB-04. Required fields on the UB include revenue codes, bill type, and sometimes value codes in addition to much of the same information required in the HCFA. Just as with the HCFA/CMS-1500, the directions are printed on the back of the form. Payer contracts will specify which billing format to use.

Checking over the claim prior to submission

As I mention previously, the biller receives the claim form from the coder and then prepares it for submission. In addition to knowing which submittal method to use — paper or electronic — the biller also needs to check over the claim to make sure all the necessary information is included. This is one of the reasons why medical billers need to understand the medical codes used.

In addition, billers also need to know how to use modifiers correctly. The coder may be responsible for assigning modifiers based on correct coding edits, but the biller is ultimately responsible for making sure that payer-specific (or provider-specific) modifiers are on the claim prior to submission. For information on modifiers and checking the claim over before submitting, head to Chapter 12.

Assessing whether medical billing is the right choice for you