• ✓ The medical coder deciphers the documentation of a patient’s interaction

• with a healthcare provider (physician, surgeon, nursing staff, and

• so on) and determines the appropriate procedure (CPT) and diagnosis
• code(s) to reflect the services provided.
• ✓ The biller then takes the assigned codes and any required insurance
• information, enters them into the billing software, and then submits the
• claim to the payer (often an insurance company) to be paid. The biller
• also follows up on the claim as necessary.
• ✓ Both medical billers and coders are responsible for a variety of tasks,
• and they’re in constant interaction with a variety of people (you can read
• about the various stakeholders in Part V). Consider these examples:
• • Because they’re responsible for billing insurance companies and
• patients correctly, medical billers have daily interaction with both
• patients and insurance companies to ensure that claims are paid in
• a reasonable time.
• • To ensure coding accuracy, coders often find themselves querying
• physicians regarding any questions they may have about the
• procedures that were performed during the patient encounter and
• educating other office staff on gathering required information.
• • Billers (but sometimes coders, too) have the responsibility
• for explaining charges to patients, particularly when patients
• need help understanding their payment obligations, such as coinsurance
• and copayments, that their insurance policies specify.
• ✓ When submitting claims to the insurance company, billers are responsible
• for verifying the correct billing format, assigning the proper
• modifier(s), and submitting all required documentation with each
• claim.
• The patient hands over her insurance card and fills out a demographic
• form at the time of arrival.
• The demographic form includes info such as patient name, date of birth,
• address, Social Security or driver’s license number, the name of the
policyholder,
• and any additional information about the policyholder if the
• policyholder is someone other than the patient. At this time, patient also
• presents a government-issued photo ID so that you can verify that she is
• actually the insured member.
• To score a job as a biller and coder, you must get certified by a reputable
• credentialing organization such as the American Health Information
• Management Association (AHIMA) or the AAPC (formerly known as the
• American Academy of Professional Coders). In Chapter 7, I tell you
everything
• you need to know about these organization. Here’s a quick overview:
• ✓ The AAPC is the credentialing organization that offers Certified
• Professional Coder (CPC) credentials. The AAPC training focuses on
• physician offices and outpatient hospital-based coding.
• The AHIMA coding certifications — Correct Coding Specialist (CCS) and
• Certified Coding Associate (CCA) — are intended to certify the coder who
• has demonstrated proficiency in inpatient and outpatient hospital-based
• coding, while the Correct Coding Specialist Physician-Based (CCS-P) is, as
• its name indicates, for coders who work for individual physicians. goals, first think about the type of
training program you want. Second, examine
• your long-term career goals. What kind of medical billing and coding job
• do you ultimately want to do, in what sort of facility do you want to work, and
• how do you want to spend your time each day?
• To get certified, you must pass an exam administered by the credentialing
• organization. Head to Chapter 9 for exam details and info on how to sign up
• for one.
• Fortunately, a solid medical coding and billing
• program provides you with the knowledge necessary to ace the exams and
• gain entry-level certification. Most programs offer training in the following:
• ✓ Human anatomy and physiology
• ✓ Medical terminology
• ✓ Medical documentation
• ✓ Medical coding, including proper use of modifiers
• ✓ Medical billing
• ✓ Claims filing
• ✓ Medical insurance, including commercial payers and government programs
• you’ll start hearing about something called ICD-10, which is the
• 10th edition of the International Classification of Diseases (hence, the ICD),
• the common system of codes that classifies every disease or health problem
• you code. These diagnosis codes represent a generalized description of the
• disease or injury that was the catalyst for the patient/physician encounter.
• As a biller/coder, you use the ICD every day.
• ICD codes are also used to classify diseases and other health problems that
• are recorded on many types of health records, including death certificates,
• to help provide national mortality and morbidity rates.
• ICD-9 is the old-school coding classification system, while ICD-10 is the new
• kid in town, and the differences between the two are fairly significant. For
• starters, ICD-9 has just over 14,000 diagnosis codes and almost 4,000
procedural
• codes. In contrast, ICD-10 contains more than 68,000 diagnosis codes
• (clinical modification codes) and more than 72,000 procedural codes. Other
• differences involve how the codes are presented (the number of characters,
• for example)
• After finding the diagnosis codes, you then look up the procedure
codes that
• best describe the work done, using one of the following books:
• ✓ The Current Procedural Terminology (CPT) book: The CPT book
contains
• all the procedure codes as determined by the American Medical
• Association (AMA) and includes the definition of each procedure.
• Physicians and outpatient facilities choose a code from the CPT book.
• Most providers have contracts with multiple commercial payers (basically
• insurance companies), as well as government payers, such as Medicare.
• Here’s a very brief overview of the kinds of payers and organizations you’ll
• work with as a medical biller:
• ✓ Commercial insurance: These are private insurance carriers, and
• they fall into a variety of categories, each of which has particular rules
• regarding what’s covered, when, and how providers get reimbursed.
• Preferred provider plans (PPOs), health maintenance plans (HMOs), and
• point of service plans (POSs) are just a few you’ll deal with.
• ✓ Networks: Some commercial payers and providers participate in networks.
• A network is essentially a middle man who functions as an agent
• for commercial payers by pricing claims (that is, setting the fees associated
• with medical procedures) for them.
• ✓ Third-party administrators: These intermediaries either operate as
• a network or access networks to price claims, and they often handle
• claims processing for employers who self-insure their employees rather
• than use a traditional group health plan.
• ✓ Government payers: These include governmental insurance programs
• that offer benefits to particular groups. Examples of government payers
• include Medicare (the elderly and qualifying disabled people), Medicaid
• (the poor), Tricare (military members and their families), and so on.
• The CMS-1500 form
• The Centers for Medicare & Medicaid 1500 (CMS-1500) form, formerly known
• as a Health Care Financing Administration-1500 (HCFA-1500) form, is the
• paper form used to submit claims for professional services .
• The HCFA/CMS-1500 form is split into three sections. Section one is patient
• information. All this information should be in the patient’s registration form.
• Section two is for procedural and diagnostic information, which should be on
• the super-bill or coding form. Section three is for the provider information.