Codes exist for all types of encounters, services, tests, treatments, and procedures provided by a healthcare provider in a medical office, hospital, or clinic. These codes are described as CPT4 codes that consist of 5 digit numbers. Even the simplest patient complaints such as headache, or nausea have codes which consist of a set of numbers and combinations of sets of numbers.
Art of Medical Coding
Medical coders are fundamental to medical record keeping. Every healthcare provider that delivers a service receives money for these services by filing a claim with the patient's health insurance provider or managed care organization.
Medical Coding Purposes
The American Medical Association (AMS) developed the CPT coding system. CPT stands for Current Procedural Terminology to tell the health insurance companies or government entities the reason why a patient was seen and what services were performed so that the provider can get paid. Codes also are implemented to gather and communicate public health statistics
Medical codes are used for a variety of purposes. Among them:
- coding diseases and procedures
- physician billing and reimbursement
- recording causes of death
When a provider sees and treats a person seeking medical advice in the medical office or practice it is referred to as an encounter. An encounter is defined as "a face-to-face contact between a healthcare professional and an eligible beneficiary."
The Medical Coder's Areas of Knowledge and Responsibility
KNOWLEDGE OF INSURANCE CLAIM AND REGULATORY CONSIDERATIONS. New patient interview and check-in procedures; established patient return visits; post-clinical check-out; computerized practice procedure methods.
COMPLETING CMS-1500 AND COMMERCIAL CLAIMS. Billing guidelines for inpatient medical, in/outpatient global surgery, minor surgery, and maintenance of a provider's claim files; setting up a filing system for completed claims; determining primary and secondary status; completing common types of claims.
KNOWLEDGE OF BLUE CROSS AND BLUE SHIELD PLANS. Features of BCBS plans; correct filing procedure; completing a BCBS claim form.
KNOWLEDGE OF MEDICARE. Parts of the Medicare program; eligibility criteria; fee schedule; supplemental plans and managed care; filling out an HCFA 1500 claim form.
KNOWLEDGE OF MEDICAID. Services covered under the federal portion of Medicaid; eligibility; services provided and paid for by state coverage; obtaining preauthorization for services.
TRICARE AND WORKERS' COMPENSATION. Health care for the military; deductibles, cost sharing and eligibility requirements for TRICARE; filing TRICARE claim forms; workers' compensation programs; classifying on-the-job injuries; preparing a First Report of Injury form; qualifying for workers¹ compensation benefits.
ICD-9-CM CODING. Using the ICD-9-CM coding system; primary vs. principal diagnosis; ICD-9-CM terms, marks, abbreviations and symbols; index tables.
CPT CODING. Basic format of CPT service and procedure codes on the CMS-1500 claim; comparing CPT with ICD-9-CM coding; modifiers; new vs. established patient; assigning emergency department and critical care codes; consultation vs. confirmatory visit; preventive medicine visits.
HCPCS CODING AND CMS REIMBURSEMENT. The HCPCS system for reporting professional services, procedures, supplies and equipment; HCPCS level II coding system; CMS reimbursement; rules of the Medicare physician fee schedule payment system.
CODING FOR MEDICAL NECESSITY. Assessment and coding from patient medical records; securing the correct physician documentation; coding an operative report; selecting and coding diagnoses and procedures from case studies and sample records.
Medical Coder's Job Security
Physicians depend on well trained, reliable medical coding and billing staff because otherwise they might not get paid for their services, or might wind up being charged large penalties due to improper coding, which could mean financial disaster, and cost them their livelihoods. Once hired, medical coders and billers hold secure jobs, with good futures. Supervisors spend weeks or months training medical billers and coders one-on-one. Once they are trained and have gained experience by participating in the daily office routine, chances are good that their positions will be long term.
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