Important Features of Medical Billing and Coding Cycle

Important Features of Medical Billing and Coding Cycle




Medical billing and coding is the time of action of computer aided centralization of a coding system, accurate electronic recording and data entry processing of a patient’s symptoms, diagnosis and treatment records, insurance processing, invoicing, transmittance of billings, tracking and receipt of payments and account receivable management.

For the past several years, medical billing has been employing the paper-based technology. However, because of the entry of the computer technology and the internet, paper processing of medical billing has evolved and transformed into electronic billing and coding. Medical software companies have developed and upgraded their medical billing software to come up, promote and market their own effective health information systems to all players involved in the medical industry.

As a patient, your billing cycle course of action starts with the recording of the summarized details of your personal profile. Documentation of medical history record, tests done, symptoms observation and diagnostic physical examination procedures, hypothesizedv treatments, number of appointments and visits, your current health position and all other accurate and applicable data about you are entered into the patient’s profile record.

Regarding how much the health provider will bill the insurance company; here is how they do it. A specialized medical staff or medical coder translates into a number coding your diagnosis record based on the CPT and ICD-9-CM. By October of 2013, these formats will be phased out by ICD-10-CM. A five digit procedural code is stated to your level of service info from the terminology database. These codes are their basis for insurance claims processing.

As soon as procedural and diagnostic codes are finalized, the medical biller will electronically format the insurance claim to an ANSI 837 file before sending to the insurance company or a clearing house. The claim gets processed by committees depending on the amount of claim involved. To verify info about eligibility of patient and the profile of the health provider, insurance companies use the rubrics procedure. Approved claims comprise an agreed percentage of the total submitted claim. Rejected claims are transmitted electronically by a remittance advice.

If your billing is rejected, your service provider will verify, make modifications and transmits back the claim again and the time of action goes on in accordance with the procedures on claim processing. Statistics show that there are a high percentage of rejected claims by insurance companies for multiple reasons. Some of them are due to patient’s without of eligibility and errors in the diagnostic and procedural codes used. There is a final legal cure to contest a rejected claim which is the filing of an allurement before the appropriate authorities who have jurisdiction when a case is elevated to them for review of the decision.

When it comes to electronic eligibility and assistance of patient inquiry, the health care service provider performs this procedure by its medical billing software. The format used is termed as X12-270 Health Care Eligibility and assistance Inquiry. Response to the inquiry is also done electronically with the format of the X12-271 Response. As soon as you as patient are confirmed to be eligible, the healthcare sets are provided. When the time for medical billing comes, the transmission is done by an X12-837 format to be responded by an X12-997. For the final adjudication of claim, the insurance company uses the response format of an X12-835.

The medical billing and coding department should be well oriented in all aspects of electronic billing and coding, all types of plans being serviced by insurance companies, and needs to be aware of the applicable laws, rules and regulatory requirements. With respect to you as a patient, it is advisable to know by heart the billing and coding course of action so that you can interact with the biller and payer, get involved and make a stand if it affects your rights.




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