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When a patient visits a healthcare provider, the provider documents the visit, including the patient’s symptoms, diagnosis, treatments, and any procedures performed. This medical record forms the basis for billing and coding.
Medical coders analyze the medical record and assign diagnosis codes using the ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification). These codes specify the patient’s condition or illness.
If any treatments, surgeries, or procedures were performed, the coder uses CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) codes to describe the services provided. CPT codes cover medical procedures and services, while HCPCS codes include equipment and services not covered by CPT, such as ambulance rides and medical equipment.
After coding, the coder or a billing specialist creates a medical claim using the codes and relevant patient and provider information. This claim is submitted to the patient’s insurance company or payer for reimbursement. The claim details the services rendered, diagnoses, procedures, and related costs.
The insurance company reviews the submitted claim and determines whether the services are covered under the patient’s policy. If approved, the insurance pays the provider based on the patient’s coverage plan. The claim may be denied or require additional information if issues arise.
If a claim is denied, the medical billing coder may investigate the cause and make corrections or appeal the decision. This often involves updating codes, providing more documentation, or ensuring compliance with payer policies.
After insurance payments are processed, any remaining balance not covered by the insurance is billed to the patient. This may include co-pays, deductibles, or services not covered by their plan.
Medical billing and coding professionals must stay up-to-date with changes in coding guidelines, healthcare regulations, and payer rules to ensure accurate and compliant claims processing.