Medical Billing & Coding Process

Medical billing and coding are the systematic process of translating healthcare services into universal codes for accurate billing and reimbursement, ensuring financial transactions between healthcare providers and insurance companies run smoothly.

What is Medical Billing?

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

Patient Visit: This is the initial step where a patient seeks medical attention from a healthcare provider.

Get Patient and Insurance Info and Collect Co-pay: During the patient visit, the medical staff collects necessary personal and insurance information from the patient. They may also collect any applicable co-payments required by the patient’s insurance plan.

Provider Encounter and Documentation: The healthcare provider evaluates the patient’s condition, provides necessary treatment, and documents all services rendered during the encounter. This documentation is crucial for accurately coding the services later.

Assigning ICD & CPTs: Once the encounter is complete, medical coders review the provider’s documentation and assign appropriate diagnostic (ICD) and procedural (CPT) codes to represent the services provided during the visit. These codes are standardized and used for billing purposes.

Claim Preparation: Based on the assigned codes, a medical biller prepares a claim form that includes all necessary information about the patient, provider, services rendered, and associated codes. This claim serves as a request for reimbursement from the patient’s insurance company.

Claim Submission (Paper/Payer ID): The prepared claim is submitted to the patient’s insurance company for processing. This can be done electronically through a clearinghouse or directly to the payer using their specific identification (Payer ID) for electronic submissions.

Claim Rejected or Denied > Re-submitted after Correction: Sometimes, claims are rejected or denied by the insurance company for various reasons such as missing information, coding errors, or lack of medical necessity. In such cases, the medical billing staff identifies the reason for rejection or denial, makes necessary corrections or additions, and resubmits the claim for reconsideration.

Provider Paid: Once the insurance company approves the claim, they provide reimbursement to the healthcare provider for the services rendered. The amount paid may vary depending on the patient’s insurance coverage, deductibles, co-insurance, and any contractual agreements between the provider and the payer.

Payment Posting: Finally, the payment received from the insurance company is posted to the patient’s account in the provider’s billing system. Any remaining balance after insurance payment, such as co-insurance or deductible amounts, is then billed to the patient for payment.

This cycle repeats for each patient encounter, ensuring that healthcare providers receive appropriate reimbursement for the services they provide while also ensuring accuracy and compliance with coding and billing regulations.