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Medical Coding and Technology Come Together

Medical coding is the process of matching specific services and diagnoses to numeric or alphanumeric codes and submitting these codes to insurance companies for payment.

When you visit the doctor’s office or medical facility you meet many medical personnel who are there to assist you in your care. Among these you may meet receptionists, nurses, medical assistants, radiology technicians, doctors and more. These are highly trained individuals who know just what to do to care for your medical needs. Who you don’t usually meet are the medical coders and billers. These highly trained individuals also work in the medical office and facility but usually in the background. They are the ones who make sure the services provided to you are paid for by your insurance.

What does a Medical Coder do?

Let's say you have a sore throat and fever. You go see your doctor, who does an evaluation and then orders his medical assistant do a strep test to see if you have strep throat. The test comes back positive so the doctor has an official diagnosis of strep throat. He prescribes bed rest for three days and an antibiotic for a week.

The medical coder reviews the doctor’s note to locate and report the diagnoses and services to the insurance company. The diagnoses and services are then translated from a description or word format to a numeric code.

DIAGNOSIS:

We know from the note above the patient has a sore throat and fever and a positive strep test confirmed a diagnosis of strep throat. When there is a confirmed diagnosis (strep throat confirmed by a test) you don’t need to report the symptoms so only the strep throat (034.0) diagnosis would be reported. If the test came back negative, you would report the symptoms of sore throat (784.1) and the fever (780.60) unless the provider was able to confirm another diagnosis.

SERVICES:

The examination the doctor performed would be reported using evaluation and management codes and are based on time and detail documented. A low complexity, approximately 15-minute, visit would be coded 99213 and the strep test 87880.

These codes, along with the prices and patient, physician, and insurance information would be entered onto the claim form and submitted to the insurance company for reimbursement.

Unlike grocery shopping where you pay for what you get at the time it is given to you, the insurance company payment to a healthcare provider usually comes anywhere from two weeks to three months after the service has been rendered. This can take longer, depending upon insurance requests for additional information, pre-existing issues, clarification of information, or coding errors. It is important to get it right the first time.

Generally, a medical coder’s job is done once the service has been coded and billed. Medical billers then take over with submission of the claim and following up on it until payment is received from the insurance company and any remaining balance collected from the patient. Some medical coders are also trained in billing and perform both tasks, which makes them even more valuable to those they work for.

What Kind of Training Does A Medical Coder Need?

Medical coders receive training in :

• Medical terminology
• Anatomy
• Disease processes
• HIPAA (Health Insurance Portability and Accountability Act), which governs the privacy, confidentiality, and reporting laws of our nation with regard to medical information.
• ICD-9-CM diagnostic coding set
• CPT procedural coding set
• HCPCS medications, durable equipment, etc., code set

Software and other tools available to medical coders to aid in code selection and reporting.

It is imperative that coders have training on how to use the following code sets:

• 1. ICD-9-CM (International Classification of Diseases): Diagnoses or medical conditions are represented by three to five digit numeric or alpha-numeric codes.
• 2. CPT (Current Procedural Terminology): Medical services or procedures are represented by five-digit numeric codes.
• 3. HCPCS (Healthcare Common Procedural Coding System): Five-digit alphanumeric codes used to describe medical supplies and drugs (as well as some services not included in the other codebooks). These are referred to as hick-picks codes.

Each of these code sets are updated annually and are expected to be implemented by the first of each year. Once a medical coder has been trained on the process of code selection they can continue to train themselves on any new updates as they come.

Regulations

Medical coders are held to a high standard due to their certified training. Once certified, a medical coder can be held liable for fraudulent coding practices they are involved in.

In the past, medical providers and employers have been solely held responsible for any miscoding or fraudulent coding that has occurred within their practice or facility. However, medical coding training and certification includes training on the laws and regulations of correct coding as well as the penalties, fines, and legal issues related to fraudulent coding.

If you work for someone who is fraudulently billing and do not put a stop to it, you too may be prosecuted. It is expected that you, as a medical coder, will report the fraud and remove yourself from any job in which fraudulent coding practices exist.

Tools of the Trade

As you can see, medical coders need to be on top of ever changing regulations and increasing codes and code sets, in order to perform their job well. The main code sets by themselves are incredibly large, but once you add all the reference materials, dictionaries, etc., you could easily find a dozen or more books located at any coder’s work station.

All of this information can create an enormous library and make coding more cumbersome and less efficient. It has finally reached the point where a professional coder needs the assistance of technology to maintain their effectiveness and accuracy.

FindACode.com, http://FindACode.com, is one of a handful of companies that have risen to meet this need for enhanced medical coding and billing technology.