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What is Medical Billing

What is Medical Billing?

Medical billing is a process whereby the medical billing specialist submit claims to health insurance companies to ensure payment for the services provided to a patient by a doctor or another health care provider. Medical billing specialists are also responsible for contacting insurance companies, Medicare and Medicaid to follow up on unpaid claims and to deal with problem claims. The process of medical billing is generally the same regardless of whether the insurance company is privately owned or is owned by the government.

The claim cycle...

Patient visits the doctor...

  • Physician treats the patient

·         Medical record is created (Physician dictates and Medical Transcriptionist transcribes the dictation)

·         Patient demographics and treatment is documented

·         Medical record contains chief complaint, history, examination, lab orders/tests, treatment plan and other pertinent information

·         Medical record is analyzed and appropriate codes assigned (Diagnosis/Procedures/Supplies)

·         The codes are entered into the claim form (CMS-1500) and submitted to the health insurance company

·         Insurance analyzes the codes and checks for medical necessity, charged amount, proper use of modifers, etc.

·         Patient eligibility, physician credentials, medical necessity (reason for visit) is established

·         Payment is given to the physician for the services provided to the patient.

 Medical billing specialists enter patient demographic details such as name, date of birth, address, insurance details, medical history, guarantor, codes and other details as provided by the patient and physician.

Medical Biller Responsibilities:

Registering of patient information.
Performing insurance verification, pre-authorization and referral tasks.
Preparing and posting transactions on day sheets, charge tickets and patient accounts.
Coding and billing insurance claims.
Collecting patient payments and performing collection activities.

Example: In the office, a patient was diagnosed as having right knee pain. The physician performed right knee X ray, 2 views.

1st Step: Code the Diagnosis: Knee pain. Locate the bolded main term Pain in the ICD-10-CM Alphabetic Index, then locate subterms 'joint', then 'knee'. In the Tabular List, locate M25.569  Pain in joint. The knee is part of the lower leg as defined at the beginning of the chapter.

2nd Step: Code the Procedure: Knee X ray. Locate the bolded main term Knee in the CPT Index, then locate subterm 'X-ray'. [CPT coding will be discussed in detail in further modules.] The code range given is 73560-73564. Indented entries for arthrography and bilateral do not apply in this case. Go to the Radiology Section, then locate 'Lower Extremities'. CPT code 73560 identifies Radiologic examination, knee; 1 or 2 views which describes the procedure performed.

[Remember: There is no need to remember the codes; always refer to the manuals. Real-world coding and national certification exams are 'open book'.]

3rd Step: Verify the patient name, age, DOB, address, insurance ID, etc.

4th Step: Enter all these details in the CMS 1500 Form. (This form will be discussed in detail in Module 23.)

5th Step: Submit the Claim to Insurance.

Insurance analyzes the codes. As 73560 is performed for code M25.569, insurance pays the physician.

In summary, the Medical Coder assigns the codes based on the documentation in the Medical Record. The Medical Biller enters the codes in the claim form, verifies the insurance, prepares the claim and submits to the appropriate insurance entity.

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