Your Career as a Medical Coder

Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS.

Medical billing and coding is the practice of helping physicians and health care centers get

reimbursed for services given to their patients.

Medical coding: Translation of medical terms for diagnoses and procedures into code numbers from standardized code sets

Provider - To prepare a standardized “bill” for

services given to a patient. Payer - To determine the amount to be paid to

the provider.

Insurance companies and the government are spending more time and money researching for ways to control claims’ fraud, abuse and “medical necessity” issues.

This need has increased the demand for expert billers and coders.

Billing specialist Patient Account

Representative Electronic Claims

Processor Billing Coordinator Coding Specialist Claims Analyst Reimbursement

Specialist Medical Collector Claims Processor Claims Reviewer Private Consultant

primarily responsible for abstracting and assigning the appropriate coding on the claims.

Coder checks a variety of sources within the patient’s medical record, (i.e. the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources) to verify the work that was done.

Assign CPT codes, ICD-9 codes and HCPCS codes to both report the procedures that were performed

To provide the medical biller with the information necessary to process a claim for reimbursement by the appropriate insurance agency.

Medical coders use standardized codes to accurately report medical services and

facilitate payment.

Diagnosis codes: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM),

Volumes 1 and 2.

Procedure codes: Current Procedural Terminology (CPT), Level I.

ICD-9-CM Volume 3 Facility ProceduresSupplies: Healthcare Common Procedures Coding System

(HCPCS), Level II.

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Coding steps:1. Assess documentation for completeness and clarity.2. Determine provider, patient type, place, and payer.

3. Abstract the diagnoses and procedures.4. Assign accurate, complete codes.

5. Verify codes are compliant.6. Release codes for billing.

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Is documentation complete? Is documentation legible? Are diagnoses clearly stated with supporting detail?

2. Determine Provider, Patient Type, Place,

and Payer3. Abstract the Diagnoses and

Procedures

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Diagnoses and procedure codes should be linked to demonstrate medical necessity.

Codes must be based on documentation; not on what coder assumes took place.

Codes must be accurate under HIPAA:o must be currento must be consistent with HIPAA code sets

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Compliance = satisfying requirements, regulations, and policies for correct coding and verification of

codes. Issued by:• Federal government• State governments• The Joint Commission• Agency for Healthcare Research and Quality (AHRQ)• URAC• Payers

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Fraud & Abuse Fraud = intentional act to obtain an illegal or unauthorized

benefit (e.g., billing for services that weren’t performed) Abuse = intentional or unintentional act that misuses

government money (e.g., billing for services not medically necessary)

Primary enforcement by HHS Office of the Inspector General (OIG)

Compliance Plans: written documentation of policies & procedures to identify, correct, and prevent fraud and abuse; includes physician and staff training

6. Release Codes for Billing

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Demand for medical coders has a very strong future.

Advancement:o Professional certification

o Additional studyo Work experienceo Specialty coding

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Skills, Attributes, and Ethics: The Components of Success

Skills:o coding skillso communication skillso computer skills

basic Windows and document management; Internet practice management programs (PMP) used for billing charge description master (CDM) programs electronic medical record (EMR) programs encoder products or computer-aided or computer-assisted

coding (CAC) products grouper programs

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Formal education Job Experience Membership in Professional Organizations Certification as a Medical Coder

o American Health Information Management Association (AHIMA) Certified Coding Associate (CCA) Certified Coding Specialist (CCS) Certified Coding Specialist-Physician-based (CCS-P)

o American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC) Certified Professional Coder-Hospital (CPC-H) Certified Professional Coder-Payer (CPC-P) Certified Professional Coder-Associate (CPC-A) Various specialty coding certifications

Health Information Management (HIM) Education & Certification

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Explains insurance benefits to patients and clients Accurately completes claim forms Handles day-to-day medical billing procedures Adheres to each insurance carrier’s policies and

procedures Prompts billing to insurance companies Documents all activities using correct medical terminology

ANATOMY & PHYSIOLOGY MEDICAL TERMINOLOGY CPT(Current Procedural Terminology) ICD (International Classification of

Disease) HCPCS Level(The Healthcare Common

Procedure Coding system)

ICD-9 is an international disease classification system that groups related disease entities and conditions for the purpose of reporting statistical information◦ Volume 1 tabular list of diagnosis codes◦ Volume 2 alphabetical index◦ Volume 3 contains procedure codes, which are

used for billing inpatient hospital stays

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The Current Procedural Terminology coding system describes medical and surgical procedures and services performed by physicians and other health providers◦ Essential to billing for patient care services ◦ System used to develop the Resource Based

Relative Value System (RBRVS) to assist in determining the amounts paid to doctors and other medical providers for services

◦ Uniform codes that translate the same for doctors, hospitals, patients, insurance companies, and other parties

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If the CPT and HCPCS codes are not identical in meaning or description (i.e., the CPT code is generic and the HCPCS code is more specific), the Level II code should be used

Coders should ensure they check for HCPCS codes when a CPT code description contains instructions to include additional information such as:◦ Specific medication ◦ Supplies and materials

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HCPCS◦ Standardized coding system using alpha

numeric codes that are used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office

Leveling: Often the same procedure will be coded at two or three levels. The following guideline applies:◦ When both a CPT and HCPCS Level II code have

virtually the same meaning or service, use the CPT code

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Patient Encounter

Review of Medical Record

Assignment of Code Numbers

Sequencing of Codes

Selection of Diagnoses and Procedure Codes

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Correct code assignment is important and plays a significant role in:

◦ Resource utilization◦ Reimbursement

Correct code assignment permits access to medical records by diagnoses and procedures for use in:◦ Clinical care◦ Research◦ Education

Correct code assignment is beneficial to health policy development and planning

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A Medical Coder earns an average salary of Rs 186,485 per year. Experience strongly influences income for this job.

People in this job generally don't have more than 10 years' experience. The skills that increase pay for this job the most are Medicine / Surgery and Emergency Room (ER).

• Rs 100K• Rs 130K• Rs 190K• Rs 290K• Rs 410K• MEDIAN: Rs

186,485

Medical coders use standardized codes to accurately report medical services and

facilitate payment.

Diagnosis codes: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM),

Volumes 1 and 2.

Procedure codes: Current Procedural Terminology (CPT), Level I.

ICD-9-CM Volume 3 Facility ProceduresSupplies: Healthcare Common Procedures Coding System

(HCPCS), Level II.

Medical coding is bridge between clinical data and billing process that generates payments.

Billing process = revenue cycle = continual process of providing clinical services, billing, collecting payments, and using funds for operations.

To be paid by insurance companies (payers), treatments and procedures must be medically necessary.

Medical coding data easier to study and analyze than narrative descriptions.

Clinical data produced by coders may be used for:o planning health care serviceso improving patient careo controlling costso legal actionso research studies

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Medical coding is bridge between clinical data and billing process that generates payments.

Billing process = revenue cycle = continual process of providing clinical services, billing, collecting payments, and using funds for operations.

To be paid by insurance companies (payers), treatments and procedures must be medically necessary.

o Medical necessity = services are reasonable and required for diagnosis or treatment of condition, illness, or

injury.Services may not be elective, experimental, or

performed for convenience of patient.

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Providers include various types of licensed health care professionals:• physicians• nurse-practitioners• physician’s assistants• therapists• facilities (e.g., hospitals & departments such as

radiology)• suppliers (e.g., pharmacies)

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Medical insurance = written policy between individual (policyholder) and health plan (payer).

Major types of payers:o Private payers o Self-funded plans o Government-sponsored programs

Medicare Medicaid TRICARE CHAMPVA

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Emergency Medical Treatment and Active Labor Act (EMTALA) – requires hospital emergency departments to provide care regardless of patient’s ability to pay.

Providers send health care claims in electronic or hard copy format to payers on behalf of patients.

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Employment in medical coding expected to grow much faster than average through 2014.

Medical coders work in both traditional health care environments and nontraditional jobs.

Environments include: Acute care hospitals Hospital departments (e.g., radiology) Skilled nursing facilities (SNF) Long-term acute care facilities (LTAC) Rehabilitation facilities Home health agencies (HHA) Hospices Military treatment facilities Special care facilities (e.g., cancer facilities)

Durable medical equipment suppliers (DME) and ambulance service providers

Physician practices Ambulatory surgery centers (ASC) Clinics

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+ experience  + skill  job National Salary Data (?) Rs 0Rs 150KRs 300KRs 450KSalary Rs 101,430 - Rs 411,737     Bonus Rs 0.00 - Rs 49,938  Total Pay (?) Rs 102,016 - Rs 423,097  Country: India | Currency: INR |

Updated: 18 Jul 2015 | Individuals Reporting: 640