Detailed Report: Medical Billing and Coding Processes and Practices

This report delves into the multifaceted world of medical billing and coding, offering a comprehensive overview of the profession. It begins by defining medical coding and billing, highlighting their distinct roles while emphasizing their interconnectedness within the healthcare system. The report explores the importance of compliance with regulations such as HIPAA and the role of medical terminology in accurate billing. It discusses internal and payer audits, detailing the importance of accurate coding. The report then outlines the practical steps involved in the billing process, from patient demographic verification to code input using CPT and ICD-9 codes. It also addresses the significance of modifiers, rejection management, and payer contracts. The report concludes with suggestions for avoiding common mistakes and upholding professional standards, emphasizing the critical role of medical billers and coders in ensuring the financial health of healthcare providers and the fair treatment of patients. This report provides valuable insights into the complexities of medical billing and coding within the healthcare industry.

Running head: MEDICAL BILLING AND CODING
MEDICAL BILLING AND CODING
Name of the Student
Name of the University
Author Note

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Introduction -The book (Drdmedsearch.com, 2019), is an author’s reflection where he
gives his readers an insight of medical billing and coding. These terms are useful in the
healthcare profession and all the physicians, clinicians and other health care providers. It
provides the readers about the definition of the terms “medical coding” and “medical billing”.
It also provides them with the differentiation between the two which is helpful in
understanding the terms better.in addition to this it displays about the important titbits which
the readers must know in order to succeed in their medical billing and coding profession, thus
helping them to become a professional in this job. Lastly, this book concludes by the author’s
suggestions to the professionals.
Discussion -According to the author, the profession of medical billing and coding
affects most lives because in this profession, all the healthcare providers like physicians,
nurses, office staff as well as healthcare gainers like patients and bill payers are involved. All
of them relies on them in any health related queries and bill payment methods. Due to
handling of such a big responsibility, they also have great power which must be treated with
respect and integrity. These powers should not be misused. Medical coder and billing are two
individual professions which must be handled carefully. A medical coder interprets the
documentation of the patient about his interaction with his assigned doctor. They then
determine the best suited procedure as well a diagnosis code in order to reflect the services
which were provided to the patient. On the other hand, a medical biller takes those diagnosis
codes and enters them in the billing software. The author opined that they also enter required
insurance information in the software and they hand over the whole bill to the payer or the
insurance company in order to claim the desired amount. Both the medical coder and the
biller are in constant interaction with the stakeholders in order to gain the amount claimed
properly. Billers are also responsible in providing the correct billing format to the insurance
company prior submission of the actual bill to them. Like many countries, United States also

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have certain rules and regulations in their healthcare system in order to prevent fraud cases by
the healthcare providers. They must be familiar with the basics of compliance, which states
that an individual who has introduced a program to run practice under the set of regulations
which are introduced by the United States Office of Inspector General. Another Act named
HIPAA or Health Insurance Portability and Accountability guarantees some rights to
individuals with respect to the healthcare treatment provided to the individual. Medical coder
should also be accustomed with the doctor’s language and know all the prefixes and suffixes
they are using in the codes which might help them later. This book also focusses on the
common prefix and suffix used in the codes which are necessary for the coders to memorize.
The second part of the book focuses on the requirements which the billers and the
coders need to know in their profession in order to reduce mistakes. This part describes the
rules and regulation in a detailed manner. Health Insurance Portability and Accountability
should be followed seriously. Violating it will result to non-compliance which is not
acceptable in this profession and hence is punishable. However, coding books are available in
the market which contains symbols that serve as the reminder with respect to the codes. Such
books also have symbols which helps the coders in analysing their code for being unilateral.
They also indicate whether the codes follow all the regulations or not. This book contains
symbols for males, females and other various specifications. Therefore, it can be concluded
that such books comprising with Medicare and payer website guides the professional coders
about the information irrespective with the patients when they wants to collect them from
their medical records. The author also describes about the difference between the internal and
the payer audits. Every huge organisation has an internal auditing department in which the
auditors are selected in a randomised order and they select their charts to evaluate. Such
orders mostly evaluate the under-coding, over-coding and incorrect coding and if any error is
detected they are submitted in order to claim. Another audit which is present in such

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organisation is payer audit. Most of them are under contracts and hence are not permanent.
Their job is mainly to maintain medical records, invoices and other related documentation in
order there are any claim from the patient party. Medicare is one such payer which shows up
and requests to instill such records on site. They are actually payed in order to clarify the
claims made and whether such claims are submitted to reimbursement along with proper
documentation or not. According to the author, in the profession, medical biller and coder
also need to acquire some medical terminology which helps them in making the bills properly
without any mistake. This part also focusses on the teaching of the coder profession.
According to the author, the first teaching class in coding is about the human anatomy.
In the third part, the author mainly focusses on the learning practice of the coding as
well as billing profession. It gives the readers the detailed scenario of suffix and prefixes that
was introduced in the first part. The third part is correlated with the second one but is just a
more detailed version of it. The fourth part mainly summarises the on job details and how
it should be dealt. The author opined that all billing scenarios are not same. They vary from
one another. However, they do follow a general process. Firstly, they need to complete the
initial framework. The biller and coder must check the patients’ demographic form; verify
their identity and also whether they need preauthorization or not. They are also responsible in
collecting any co-payments, deductibles as well the co-insurance obligations. After they
collected all the required details, they have to condense the codes based on the physician’s
documentation. These informations must be inputted into CPT (procedure) as well as ICD-9
(diagnosis) codes by the coders and then passed on to the biller in order to update it in the
biller software. In case of contracts, the payers look into the matter and are in charge of the
case. They provide the desired coverage to their patients. The medical billers and coders
should also have the knowledge which codes should be used where. Codes cannot be fused
with other codes and codes can be billed only for a single time for a particular patient.

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According to theory, the author also opined that the codes are not compatible with other
codes hence cannot be combined. The author also described the importance of modifiers and
how it should be used significantly. The coders and the billers are also trained on how to
overcome rejection and should not encourage malpractice by any other healthcare
professional. Each patent should be familiar with the benefits and this explanation of benefits
(EOB) should be provided by the coders to the patients. This part lastly deals with the
difference between the contracted and non-contracted payers and the way they are related in
the healthcare industry.
Part five mainly focusses on the experiences of the medical coders and billers on
working with the stakeholders. It further discuses on the advantages of having a contract. The
providers know the application of strong relationship with the commercial insurance payers.
Being a contracted payer they also have huge benefits regarding management of an insurance
company. The author further describes how the patients’ benefits can be verified in case they
are seen in out-of-network. The professionals are advised to first verify whether the
individual have out-of-network coverage or not. They are also advised to verify the methods
that should be used to price the claims regarding the out-of-network patients. According to
the author, a third party administrator is administered in all huge organisations in order to
handle the execution of another company’s insurance plan. The organisations who appoint
the third party administrator should previously notify about the panned participants in writing
the responsibilities should be carried out by such administrator. This part also provides a
detailed view of the Medicare plan. The coders and billers are also trained regarding the way
they should handle the patients as well as payers. Lastly, in part six, the author provides some
suggestions related to the frequent mistake made by the medical coders and billers which will
help them to overcome such mistakes and do their duty professionally and accurately. Many
billers are dishonest and is capable of shift their blame on others. Another common mistake

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made by them is some thinks that billing is more important than documentation. The author
suggested that the coders and billers must maintain proper documentation and verify all the
patient’s benefits and should be honest in their views and should treat all patients equally
keeping in mind all the procedures for proper coding and billing.
Conclusion -This book thus portrays the role of medical coders and billers and the
importance of billing and coding in the healthcare industry. It further portrays the role of two
different audits and the role of payer audits in general. The author strictly displays that the
medical coder and biller should maintain all the rules and regulations introduced by United
States Office of Inspector General. Lastly, he concludes his book by providing some useful
suggestions to his readers in order to improve the service of medical coder and biller.

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References
Drdmedsearch.com. (2019). Retrieved 31 July 2019, from https://drdmedsearch.com/wp-
content/uploads/2017/11/339-pgs_MEDICAL-BILLING-CODING-FOR-
DUMMIES.pdf