MEDICAL BILLING

PROLOUGE
Medical Billing is the process of getting a provider paid for their
services. This is the payment from the insurance carrier and the patient
for uncovered and deductible charges .

A good medical billing specialist knows how to get their provider paid
promptly for the service they perform.

PROCEDURE
 What the billing specialist does is not easily automated much of
their task is interpreting physician notes, records and verifying
and correcting patient and insurance information, verifying
correct coding etc.
 It’s pulling all this critical information together, insuring it is
accurate and assembling into a claim that’s is just getting the
claim filed ! it still must go through the insurance paying
adjudication process.
 Once a claim is processed and paid,applying payments has
several other challenges that are not easilt automated billing
speacialist frequently interpret payer coding error messages
 and correct them or submit additional documentation to get a
claim successfully processed.
 A medical billing specialist could also be referred to as an
Insurance Billing Specialist that’s because majority of what a
billing specialist does revolves around the health insurance
health insurance can be very complex and frustrating – and it’s
always changing!
 In a smaller single physician office , the billing specialist may
handle everything.

MEDICAL CODING
INTRODUCTION
Medical billing and coding are separate but closely related
both are critical to getting the health care provider’s paid.

PROCEDURE

 The medical coder analyzes patient charts and assigns

appropriate alphanumeric and numeric codes, these medical
codes are the standard diagnosis and treatment codes used
throughout the healthcare industry
 Both coder’ and biller’s use medical records as the basis for
their work the difference is the coder used patient medical
records as the basis of their work the difference is the coder
used patient medical records determine the appropriate codes
for the medical services the biller uses medical records
necessary for payment of these services

METHODOLOGY
 In a ideal world, once he medical coder has determined and
assigned the appropriate codes, it is the medical billers
responsibility to use this information to prepare and submit a
claim.
 When the claim has been successfully paid, the medical biller’s
code posts these payments, determine what the patient is
responsible for, and reconcile the accounts.
 Most smaller practices cannot justify having both a coder and
biller since they typically use many of the same codes over and
over, it’s important for the biller have same coding knowledge
for the speciality periodically have to look up ICD and CPT
codes, understand what the modifier means, and recognize
when the codes are incorrect.
 Situations where you have a both a Medical Coder and Biller is
typically for larger healthcare providers- multi-physician
 practices, clinics, hospital-places that see a lot of patients and
have a centralized coding a billing

JACKS OF ALL
TRADES-TYPICAL
BILLING TASKS
CREATE DETERMINE> LOOK- ENTER> UNDERSTAND>
> UP>
Create Determine Look-up Enter Understand
and patient medical information manage care
maintain responsibility diagnosis from patient authorization
patient based on their and registration and coverage
account particular treatment forms and limits
ledgers health codes superbills communicate
insurance into the with insurance
plans practice payers to resolve
management rejected or
software denied claims