Combining Medical Billing and Coding to Deliver Maximum Physician Revenue

‘Medical billing’ and ‘Medical coding’ may have sometimes been used interchangeably to mean the act of claiming reimbursement from insurance payers, but essentially they are two separate and specialized jobs. Medical coding precedes medical billing, and it is irreversible. While a medical biller is entrusted with far more task than a coder, it is the quality of coding that largely decides the success of medical billing. That is why medical coding is often termed as a ‘specialty’ by itself while medical billing, its ‘sub-specialty’.

Medical coding is based on the descriptive narration of the medical services or procedures done by physicians. The coder assigns appropriate codes based on the physicians’ clinical summaries. Here, he may have to verify with diverse source points to validate the correctness of the physician summaries. Typically, he may have to rely on the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources. Such verification is necessary in avoiding denial, delay or exposure of claims to payer audit remarks.

Coder’s general responsibility is restricted to assigning CPT codes, ICD codes and HCPCS codes to both report the procedures that were performed and to provide the medical biller with the information necessary to process a claim for reimbursement by the appropriate insurance agency/s. But he may also be required to audit and re-file appeals of denied claims. In certain cases, coder may also educate providers and recommend the appropriate application of federal mandates and compliance that require providers to use specific coding and billing standards through chart audits.

Medical billing, on the other hand, is a series of activities culminating in ensuring maximum reimbursement for physicians. A medical biller job begins with filing insurance forms in the admissible formats with the payers. He may be required to clarify diagnoses or to obtain additional information so as to substantiate physician claims for reimbursement from payers. Like coder, he should also be familiar with CPT; HCPCS Level II and ICD CM codes to help him better understand the clinical summaries.

Apart from preparing invoices, medical biller may even be involved in rectifying past error on account of coding discrepancies. Collecting payments, making adjustments, interpreting Explanation of Benefits (EOBs), and handling denied claims, and processing appeals are all part and parcel of a biller’s routine.

Irrespective of whether coding and billing are done separately or by the same individual/s, the success of physician reimbursements depends on how best they complement each other. While medical practices used to manage coding and billing as a comprehensive internal function, it later started impacting their core function – clinical efficiency. Therefore, outsourced coding and billing became the accepted practice. And, with the US health care industry embracing its biggest billing and coding transition (ICD-10), along with the other reforms affecting the industry physicians’ reimbursement rates may further be impacted. Therefore, finding competent billing and RCM service providers makes much more sense than embarking on costly in-house practices, which may or may not yield the desired results. – with demonstrated ability in ensuring maximum reimbursement for a large pool of physician practices across the 50 states in the US – should be your first choice of billing and RCM services. Capable of maneuvering through multi-payer and ICD-10 environments, our billing services live up to being the most comprehensive with Patient Enrollment, Insurance Enrollment, Scheduling, Insurance Verification, Insurance Authorizations, Charge Entry, Coding, Billing and Reconciling of Accounts, Denial Management & Appeals and Physician Credentialing services.