Medical Billing and Coding

Medical Billing and Coding:

  • Patient
  • Pre-Registration/Data Entry
  • Encounter/ Provider
  • Medical Transcription
  • Coding
  • Charge Entry/ Billing
  • Clearing House
  • Insurance
  • Cash Posting/Correspondence
  • Accounts Receivable(AR)

Patient

  • A person who visits a doctor with ailment or health related issue to take the treatment from a physician.

Pre-Registration / Data Entry

  • The Patient submits Insurance card copy and his demographic details.
  • As per card copy Pre-Registration counter manager needs to verify if a referral or Pre-Authorization needs to be obtained.
  • Patient will be asked to contact the respective Primary care physician (Gatekeeper) and get his documentation.
  • The person in this department has major responsibility in collecting the maximum information about the patient details in forwarding clean claim to insurance

 

Insurance Eligibility will be checked in Pre-Registration counter

  • In Pre-Registration counter the role of PCP in case of MCO Plans (HMO and POS) will be shared.
  • A minimum amount that patient needs to pay to provider as Co-pay.
  • Once after completing all the above , entire Patient medical records, procedure templates, insurance card copy and Patient demographics copies will be forwarded to concerned department

Encounter / Provider

Doctors Office: A Patient visits a doctor and explains his / her problem. The doctor then diagnoses what could be the ailment and then draws a chart as to what treatment needs to be rendered.

  • Patient meeting a provider to take the treatment is called as “Encounter”
  • Treatment given to Patient by Physician is called as “Procedure/Service

Medical Transcription

  • The conversation between Patient and Provider will be recorded in Dicta Phone and same recorded data will be forwarded to the Medical Transcription departments.
  • MT department will analyze the overall conversation then the same reports will be converted to a word format or a file.

Coding:

Coding team will assign the Alpha and Numerical codes for treatment called CPT (Current procedural terminology) and Diagnosis codes based on the description given by the provider.

Considering the entire patient Diagnosis and Procedure is called “Coding”

  • CPT/ HCPCS – the treatment given by the physician to patient will be denoted in the format of codes called as CPT Codes or Procedure or Service Codes.

Below are few Examples:

  • 99201 – Initial visit of a new out patient
  • 99281 – Initial or Established visit on Emergency cases

Diagnosis Codes or ICD-9 Codes

Diagnosis codes are coded by reviewing the Patient medical diagnosis descriptions in the format of ICD-9 Codes.

Below are few Examples:

  • 0 – Headache
  • 5 – Speech disturbance

ICD-9 –CM INTERNATIONAL CLASIFICATION OF DISEASE – 9th Revision-CLINICAL MODIFICATION.

Charge Entry/ Billing

Entering the basic Patient Demographic information in format designed by the software, this process captures the details of Patient.

Details of Patient while entering the Charge Entry.

  • Patient Name (Last Name, First Name and Middle initial)
  • Age
  • Sex
  • Gender
  • Guarantor
  • Insurance Details (Primary , Secondary and Tertiary Insurance)
  • Subscriber Details
  • Policy ID
  • Group Numbers
  • Insurance Plan Types
  • Patient Employer Details
  • DOS
  • Procedure Codes
  • Diagnosis Codes
  • Additional Diagnosis
  • Place of service
  • Location
  • Admit Date
  • Discharge Date
  • DOJ
  • Number of units billed
  • Referring Physician and Rendering Physician and their ID’s
  • Finally a Charge entry associate will be applying charges & creating a claim and claim is also known as Bill or Invoice.
  • Billed amount for the procedure (CPT) will be inbuilt through “Charge Description Master” software.
  • In Medical Billing we have two types of claims which are billed for Individual Providers and for Facility Providers.
  • Individual Providers – CMS 1500 (Which has 33 Fields)
  • Facility Providers – UB04 ( Which has 81 Fields)

Clearing House

  • Clearing house acts as a scrubber, in which all the basic required data’s will be checked in all the claims.
  • Filled claims will be sent to the Transmission department.
  • This process starts after completing entry of Patient demographics and charges.

Process of Clearing House

  • Transmission department prepares a list of claims that go out on paper and through electronic media. Claims are successfully transmitted to carriers by following each carrier’s instructions and policy.
  • If the claims clean in all the respects, the same may get forwarded electronically in 14 days, if the same has any minor defects such as if the Patients address is incorrect or the zip code is not correct, then claim will be printed at vendor’s office with a warning and will be forwarded to the carrier via paper mode in 28 days.
  • Once the claims are transmitted electronically, conformation reports are obtained which will clearly state how the claim had traveled to the Insurance Electronically or by paper.
  • Claims with attachments are printed in paper only Manual Submission, if necessary, put into envelopes and sent to the US for postage and mailing. Transmission rejections are analyzed and appropriate corrective action is taken.
  • A Claim which passes through all front and edits is called “Clean Claim”

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