Medical billing and coding is the procedure of following up on claims to insurance companies
for the purpose of collecting payments for services provided by a healthcare provider. Private and
government owned insurance companies generally use the same process of medical billing. The medical billing process involves both the health care provider and the insurance company who is
the entity responsible for making payments.
It is encouraged, but optional for medical billing professionals to become certified as a medical biller by taking an exam, i.e. the CMRS or RHIA exam. There are many medical billing certification schools that provide training for those types of tests.
The process of medical billing falls into a billing cycle which can take between a few days and a few months to complete. The cycle begins when a physician or medical staff members updates a patient's
medical record. There needs to be a documented reason for the visit. The health provider will usually give a patient a diagnosis or reason for the visit(s). A physical examination will result in a medical decision
that determines the correct level of service that can be used to bill the insurance company.
CTP and Codes
There is a standardized five digit procedure code drawn from the current procedural terminology database. Additionally, the verbal diagnosis is converted into a numerical code based on a standardized
ICD-9-CM or ICD-10-CM database. The CPT and ICD-9/10-CM codes are both important codes involved in claims processing.
The medical billing staff will transmit the claim to the insurance company. This procedure is generally done electronically using an ANSI 837 file using Electronic Data Internchange. The submission
can be done directly or through a clearinghouse.
Paying the Bill
The insurance company normally processes the claims using medical claims examiners or adjusters.For the most expensive claims, a medical director will often get involved. The point of the examination process is to verify the validity and medical necessity of the claim before payment is made.
If a claim is rejected, it can be resubmitted, or if there are errors, the errors can be corrected,and then resubmitted. Claims are frequently rejected due to the complexity of the claims in addition to diagnostic and clerical errors.
Through use of the electronic billing process, medical care providers can use software to check the elegibility of the patient for the services they are considering offering.
The initial transaction for a claim for services is called an X12-37 or ANSI-837. This form contains a lot of information about
the provider interaction as well as general background information about the patient. After that submission, the insurance company will respond with an X12-997 to acknowledge that the claim was
received and accepted for processing. When the claim is finally reviewed, the insurance company willan X12-835 transaction which shows line by line which items on the claim that will be paid or denied and the reasons why.
The medical biller must be very acquainted with all of the various medical plans from the large insurance companies. Providers will normally charge more for a service than what the insurance company
will pay. Patients will often pay a co-payment which reduces the insurance payment