• ✓ 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) to reflect the services provided. • ✓ The 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 V). 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 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, assigning the proper • modifier(s), and submitting all required documentation with each • claim. • The patient hands over her insurance card and fills out a demographic • form at the time of arrival. • The demographic form includes info such as patient 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, patient also • presents a government-issued photo ID so that you can verify that she is • actually the insured member. • To score a job as a biller and coder, you must get certified by a reputable • credentialing organization such as the American Health Information • Management Association (AHIMA) or the AAPC (formerly known as the • American Academy of Professional Coders). In Chapter 7, I tell you everything • you need to know about these organization. Here’s a quick overview: • ✓ The AAPC is the credentialing organization that offers Certified • Professional Coder (CPC) credentials. The AAPC training focuses on • physician offices and outpatient hospital-based coding. • The 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. 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 info on how to sign up • for one. • 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’ll start hearing about something called ICD-10, which is the • 10th edition of the International Classification of Diseases (hence, the ICD), • the common system of codes that classifies every disease or health problem • you code. These diagnosis codes represent a generalized description 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-9 is the old-school coding classification system, while ICD-10 is the new • kid in town, and the differences between the two are fairly significant. For • starters, ICD-9 has just over 14,000 diagnosis codes and almost 4,000 procedural • codes. In contrast, ICD-10 contains more than 68,000 diagnosis codes • (clinical modification codes) and more than 72,000 procedural codes. Other • differences involve how the codes are presented (the number of characters, • for example) • 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) book: The CPT book 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 a code from the CPT book. • 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 you’ll • work with as a medical biller: • ✓ 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 plans (PPOs), health maintenance plans (HMOs), and • point of service plans (POSs) are just a few you’ll deal with. • ✓ Networks: Some commercial payers and providers participate in networks. • A network is essentially a middle man who functions as an agent • for commercial payers by pricing claims (that is, setting the fees associated • with medical procedures) for them. • ✓ 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 • (the poor), Tricare (military members and their families), and so on. • The CMS-1500 form • The Centers for Medicare & Medicaid 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 . • 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.