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.
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.
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.
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.
Medical coders receive training in :
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:
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.
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.
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.
Not only do medical coders and billers have to contend with the thousands and thousands of pages of information on the current medical code sets, but beginning in October of 2014, two new code sets will be introduced to professionals that will increase the number of procedure and diagnosis codes by 10 times the current code sets contain.
The ICD tracking system is the oldest method of tracking mortality and diseases in the world. Each code correctly identifies standard diagnostic classifications for all illnesses and conditions. ICD-9-CM has been used in the United States since about 1977 with minor updates annually. However, due to many constraints in the current system and obvious medical advancements and discoveries, a complete overhaul was needed.
ICD-10 was introduced in foreign countries back in 1992. As the United States has a very complex healthcare system special modifications had to be made to ICD-10 to make it usable here. It has been announced that ICD-10-CM will be incorporated into the United States healthcare system in October 2014.
The new ICD-10 code sets will replace the ICD-9-CM diagnosis codes and will include all procedure codes for use within all hospital facilities. CPT/HCPCS codes will still be used for reporting services performed in doctor's offices and outpatient facilities.
ICD-10-CM codes will follow the patient from diagnosis through treatment phases. Changes will effect the entire health care industry and the implementation of the ICD-10 PCS, or Procedural Coding System, will be a challenging transition for coders.
The number of diagnostic codes included in the ICD-10 will increase from 13,500 to more than 69,000. For all inpatients procedures, numbers will increase from 4,000 to 71,000 codes.
Most coders have undergone extensive training to acquire the knowledge required to be professional medical coders, but new training for all current and aspiring medical coders will have to be done to fully understand how to use the newest code set, ICD-10-CM. The ability for coders and providers to transition from ICD-9-CM to ICD-10-CM will depend heavily on the resources available to them.
Findacode.com has the resources available to medical coders and providers to aid in this transition.
According to Centers for Medicare & Medicaid Services' GEMs (General Equivalence Mappings), comparable codes listed below are examples of how different the ICD-9-CM and the ICD-10-CM code will be.For example, the ICD-9-CM code, 851.42, is the code for cerebellar or brain stem contusion without mention of open intracranial wound, with brief loss of consciousness.
The comparable ICD-10-CM codes that will be required are:
Another example of an ICD-9-CM Volume 3 code (procedure codes) and how the correct codes compare to the new ICD-10-PCS codes are:
ICD-9 code, 01.59, represents the designation of other excision or destruction of lesion or tissue of brain.
The comparable ICD-10-PCS codes that will be required are:
With the great expansion in the number of medical codes in ICD-10 vs. ICD-9 as well as the accompanying code information, usage notes and coding and billing instructions technological tools become a necessary part of any professional coder's toolbox. The computer (as well as tablets, ipads , etc.) is an ideal tool for helping medical coders and billers look up, compare, determine and research the codes necessary for filling out the medical records and claim forms.
Tools like the FindACode.com service can help medical billers and coders keep on top of all the changes and stay productive as they incorporate the new ICD-10 code sets into their work processes. Because billing and reimbursement is such a critical part of the health care industry, coders and billers will continue to play a crucial role. Keeping the coders and billers effective, efficient and always up to date will be a major challenge with the change in code sets from ICD-9 to ICD-10
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.
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