In order to be paid by insurance companies for providing healthcare, medical coders must assign numeric codes to diagnoses and procedures.
There are three primary coding manuals that include all of the codes that a physician’s coding professional may use to submit a claim for payment. These items are:
Diagnosis codes may be found in the International Classifier of Conditions 10th Revision, which is or ICD-10.
Procedures and services provided to a patient are referred to by the abbreviation CPT, which stands for Current Procedural Terminology.
- HCPCS, or the Healthcare Common Operational Coding System, which describes the remaining non-prescription medications and supplies used to treat the patient.
Coders add all three sets for codes to insurance claims before sending them on to be paid. Their applications are as follows:
- The insurance company needs to know the reason the patient is receiving medical treatment, and the ICD-10 diagnostic codes provide that information.
Pharyngitis, often known as a painful throat, is represented by the code J02.9. The insurance company will know that the patient was examined for a sore throat if the code J02.9 is included on the medical claim.
Insurance companies need to know what was done to a person on the day of their visit, and CPT codes (which stand for Current Procedural Terminology) provide that information.
The number 99213, for instance, is used to indicate a common doctor’s appointment. The number 99213 indicates to the insurance firm that a moderate office visit was done by the medical practitioner.
- HCPCS, also known as supply codes, denote any additional supplies or services provided to a patient upon the same day they were visited by a doctor.
Because they include items and services not found in the CPT manual, for example ambulance transportation and long-term medical equipment, these codes are not typically included on a claim form.
Only CPT and HCPCS codes, which correspond to the services and materials actually provided to the patient, are billed for.
The insurance company pays out their portion of the cost according to the specific code used. As a result, medical professionals cannot request reimbursement for, and insurers refuse to cover, diagnostic codes.
It’s simple to inadvertently (or maliciously) assign the incorrect codes while working with medical records. This is an extremely severe infraction that may lead to penalties and possibly prison time since it is deemed fraud or abuse.
This is why it’s crucial for coders to establish measures to prevent waste, fraud, and abuse in the healthcare coding industry.
The coding process may be sped up significantly and more clients can be managed if coders have a solid foundation in medical language and accurate coding.
Typically, clinicians are responsible for coding their own claims; however, medical coders must double-check all codes to ensure accurate billing. Medical coders may need to interpret records for patients and assign codes.
The insurance claim is based on the facts documented in the patient’s medical records. Since everything is presumed to have never occurred if it is not documented in the patient’s file by the treating physician, this emphasizes the need of thorough documentation.
In addition, the insurer may ask for this information as verification that the treatment was necessary and reasonable before making a payment.
Superbills, also known as encounter forms, are often used by doctors and hospitals because they include a predetermined list of regularly reported codes. All of the most frequently reported diagnostic and operation codes used in the practice are included on this form for billing purposes.
Both the doctor and the medical coder will benefit from this information. The medical biller may bypass the intermediary and submit the claims to the insurance company with the help of this sophisticated piece of software.
Payment to the medical practitioner is based on the codes sent to the insurance company.
The insurance company will know exactly what services were rendered on the day of service, or the day the doctor visited the patient, according to the codes that were recorded. The payment amount is decided by the insurance company after reviewing the codes plus the client’s benefits.