Karen Smiley

Cheat Sheet / Updated 11-13-2024

Working as a medical biller and coder is a challenging and rewarding job that takes you right into the heart of the medical industry. You are the touchpoint for everyone involved in the healthcare experience, from the patient and front office staff to providers and payers. To succeed, you'll need to know how to file an error-free claim, important acronyms, and what to look for in a payer contract.

Article / Updated 01-23-2020

Before you start job-hunting as a medical billing and coding specialist, give some thought to what sort of environment you want to work in. The possibilities are almost endless, and if you think about your preferences before you search for a job, you can narrow down your list of possible employers, saving yourself a boatload of time. Are you, for example, interested in the fast-paced, volume-heavy work that you’d likely find in a hospital? Or does the controlled chaos of a smaller physician’s office seem more up your alley? The good news is that all medical facilities and offices need some sort of billing and coding staff who can either work in the office or work remotely. Medical billers and coders are essential to the efficient processing of data, compliance with government regulations, and protection of patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Currently, medical billing and coding jobs comprise one-fifth of the healthcare workforce, a number that is expected to grow. The transition to ICD-10, the updated version of the International Classification of Diseases that replaced ICD-9, increased the demand for medical coders because it made the coding and billing process more complicated (due to the increased specificity of the classifications) and more time-consuming. On the heels of ICD-10 is ICD-11, which is tentatively scheduled to become effective after January 1, 2022; ICD-11 will unlikely create concerns that were part of the ICD-10 delay. As you consider where you want to ply your trade, keep in mind that the environment you choose can impact how broad or narrow your exposure to the coding and billing profession is. For example, if you work for a general surgeon (an optimal — and most sought after — position for a coder), you get experience in most areas of coding. The surgeon may use evaluation and management codes in addition to procedural codes from every section of the coding book. In contrast, a position in a pathology laboratory may limit your experience to that area of practice. A coder with experience in all areas becomes more valuable as an employee to the bigger employers. The doctor is in: Working in a physician’s office If you’ve seen someone buried under stacks of medical files as you take care of your copay in the doctor’s office, chances are you’re looking at a medical biller or coder. Just think — that could be you! Several different kinds of physician offices employ their own coders and billers. Here are just a few possibilities: Working in an office in which a group of physicians share a practice: In a multi-physician office, the pace is usually a little faster, and more demands are placed on the administrative staff. Usually, a larger practice has an office manager in addition to the clerical staff. Working in an office that has just one or two docs: In this situation, the coder may function as the receptionist and biller as well. These offices can be great places to work. Due to size, you may find less office politics, and life usually tends to move at a slower pace when you’re dealing with just one doc. The downside is that getting time off can be difficult, and your days off generally correspond to the physician’s days off, so you have less flexibility with regard to personal time. Working in an office in which the physicians do their own coding: In this case, the physicians may use only the services of a biller. A certified coder is optimal to fill this type of position because, when the physician is out of her comfort zone from a coding perspective, a certified coder can assist with assigning the correct codes, as well as keeping abreast of code changes and other requirements. The downside to working in this environment is that your coding may not be as accurate as it should be (you may work with a physician who likes to “do it his way”), and moving to another job will be more difficult. Keeping providers like these on the right track is often a difficult and delicate position to put yourself in. Hooking up with a hospital Get all the images of Grey’s Anatomy out of your head right now. Working in a hospital may be busy and exciting, but it’s not always that dramatic, especially in the “back of house,” where billers and coders do their stuff. That said, working in a hospital environment has a lot to keep you hopping. Working in a hospital can be a rewarding experience for the coder. Hospitals are very departmentalized, with each department having its own coders. In most circumstances, the coding in a particular department is specific to a certain specialty or set of specialties, just as it would be if you were working in a physician’s office. The difference is that the coding is for the facility, so expenses that are incurred by the facility — including drugs and implantable items such as stents or shunts, for example — are reimbursed through the hospital coding. In addition, most hospitals have a centralized billing department (or they may send the billing out to a billing company; see the next section). Medicare and some state Medicaid plans reimburse hospitals based on diagnosis-related groups (for example, MS-DRGs or APR-DRGs) for inpatient claims. This means that the admitting diagnosis is linked to the severity of the patient’s illness. The level of risk associated with the treatment can affect the level of reimbursement received from Medicare and other payers. In other words, the sicker the patient, the greater the risk, and the higher the level of reimbursement. Coding that drives diagnosis related groups (DRGs) is more complex than non-DRG claims. There are specific rules that govern sequencing diagnosis codes and also the documentation that is required to support using those codes. Don’t think that you can’t create a niche for yourself in a larger hospital setting. You can, thanks to all the smaller sub-clinics and offices under the hospital umbrella that service the entire facility. For example, many surgeries can’t be performed without anesthesia (well, they could, but it wouldn’t be a popular choice!). So hospitals use anesthesiologists, who have to bill patients just like any other function of the hospital. Focusing on a billing or practice management company Other options for employment as a biller or coder usually involve working for a practice management or billing company. These companies provide various levels of administrative support, with some handling all of a provider’s practice administrative duties (even though having someone on site who understands insurance is still important for every provider office). Billing and practice management companies come in all sizes and specialties. The larger companies handle numerous clients and usually have a team of people working on one or two of the accounts. In addition, if the company provides practice management — including coding and billing for a physician or group — the work is the same as if the provider were handling this aspect of the practice in-house. Work at a billing or practice management company may be a good bet for the novice coder or biller because it’s a great way to learn the ropes under the tutelage of a more seasoned professional. It also provides an outlet for giving and receiving feedback and working through some of the stickier details with a coworker. In this work environment, you wouldn’t be flying solo! As a general rule, bigger companies usually have more structure with regard to how they do things, and they provide the best on-the-job training. That being said, be mindful of companies that have internal training programs run by people who have only worked at that one company! Just as with hospitals, you can find your own niche in practice management companies, too. Some practice management companies within larger organizations, for example, specialize in certain areas, such as anesthesia or radiological practices. Working for one of these companies enables you to focus on and gain expertise in those specialties. With anesthesia, for example, you would need to know all surgical and procedural codes, and radiology overlaps with cardiology because of the noninvasive cardiac procedures that are now common. Many billing companies are contractually obligated to their clients to employ only certified medical coders to perform the coding. Although the AAPC (American Academy of Professional Coders) now offers a Certified Professional Biller certification, billers may often be trained on the job, but having knowledge prior to employment gives you an advantage as a job seeker. Processing claims for an insurance company You may decide that you want to work in claims. Working in a claims job is one way to stretch the limits of your billing and coding knowledge. Major insurance payers use automated claims processing. The claims are received electronically and do not require a human touch unless there are problems. Smaller payers may either receive the information electronically or scan it into their processing software, where it is processed, ideally correctly. To ensure more efficient, yet timely claim processing, many of these companies also use a claims processor. To be successful as a claims processor, you need to know medical claim coding, billing procedures, and insurance obligations. These processors carefully examine each claim to determine its validity and accuracy. The processor then refers to the patient’s insurance policy benefit or plan to determine the correct level of payment for the claim. The processor also has software that contains the contracts that are linked to individual medical providers by their tax identification number or National Provider Identifier (NPI). They apply the plan provisions and payer contract to the claim to determine payment. After doing all this, the payment is issued accordingly. If the claim needs additional clarification or information, the claims processor sends a notice to the appropriate office to request the missing details. In addition to payer-processing positions, insurance companies also need people to handle incorrectly processed claims when the providers appeal them. Again, solid knowledge of medical terminology, diagnosis, and procedural codes are valuable tools for these employees. The best of the rest The possibilities are nearly endless in the billing and coding field. Even though you’re most likely to find employment in a physician’s office or in a larger facility like a hospital or clinic, here are a few other options you may find enticing: Nursing homes Outpatient facilities Home healthcare services Durable medical equipment providers Federal government agencies such as the Department of Health & Human Services, Social Security, Medicare, Tricare, or the Department of Labor In short, billing and coding is important to any business that provides healthcare. Getting your foot in the door Whether you find work in a doctor’s office, at the local hospital, at a practice management company, or for an insurance company, you have several options for jobs within those offices. Think of the world of billing and coding as a buffet, and you have a plate just waiting to be filled with a big, tasty job. The good news is that you get to pick based on your level of skill and your interests. Still, finding employment as a novice can be a challenge. Many offices are fully staffed and may hesitate to hire a newly trained coder without any medical office experience. An excellent way to get your foot in the door is to accept a position that involves verifying each patient’s benefits.

Article / Updated 01-02-2020

Compliance — it’s such a serious word, and for good reason. When people in the healthcare industry speak about compliance by healthcare providers, they mean that an office or individual has set up a program to run the practice according to the laws established by federal or state governments and regulations established by the Department of Health & Human Services (HHS) or other designated agencies. The regulations are designed to prevent fraud and abuse by healthcare providers, and as a medical biller or coder, you must familiarize yourself with the basics of compliance. The rule-making game has several players, and most of them are somehow related to good ol’ Uncle Sam. The Department of Health & Human Services (HHS) is the primary U.S. government agency responsible for regulating the American healthcare industry. Medicare and Medicaid, part of the Centers for Medicare & Medicaid Services (CMS), are two of this agency’s programs, and together they provide healthcare insurance for millions of Americans. This department’s programs serve the United States’ most vulnerable citizens. The OIG protects the operations of the HHS. This oversight also extends to programs under other HHS institutions, including the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the Food and Drug Administration (FDA). The American Medical Association (AMA), which develops, maintains, and owns the copyright to the Current Procedural Terminology (CPT) codes, determines what the codes represent. CMS works with the AMA to determine code changes (“edits”) and which codes are incidental to others. As a biller and coder, you need to be familiar with these organizations. The following sections outline the key organizations that you’ll work with as a medical biller and coder. The Centers for Medicare & Medicaid Services (CMS) As mentioned previously, the Centers for Medicare & Medicaid Services (CMS) is the home of two government healthcare programs: Medicare and Medicaid. Originally, Medicare was intended to provide healthcare to the elderly at the age of 65. In the years that followed, the need for access to healthcare for others, including children, the disabled, and those with certain chronic illnesses, became apparent. Today, Medicare also includes those with physical or mental disabilities and those awaiting organ transplants, as well as prescription drug coverage. Because these programs serve so many Americans and use taxpayer dollars to do so, the government has established rules governing what services are covered, the acceptable level of compensation for the service providers, and how claims should be processed. Medicare policies regarding medical necessity, frequency of procedures, and other payment rules are often used as guidelines for commercial payers as well. For complete information about the policies for Medicare claims processing, check out the Internet-only manuals on the CMS website. Medicare policy rules change pretty frequently, and they affect payment for certain procedures. Take a procedure as simple as a lesion excision (removing a cyst or skin growth), for example. Medicare pays for this procedure only under a specific set of rules (the diagnosis must support medical necessity). If the rules regarding this procedure change, and if these changes affect your employer, it may be your job as a coder to keep the physician or staff informed. The Office of Inspector General (OIG) The Office of Inspector General (OIG) was established in 1976 to oversee programs administered through HHS. Much of the OIG’s efforts focus on identifying waste, fraud, and abuse in Medicare, Medicaid, and other federal programs like Indian Health Services. The OIG conducts audits and tracks how government funds are spent. The findings of these investigations are often the foundation for Medicare or Medicaid policy changes and procedural code changes initiated by CMS or the AMA. The OIG publishes the results of its investigation on its website. If action is necessary to enforce compliance with laws and regulations, the Department of Justice or the FBI are called upon to execute. Even though most of these government organizations are sole entities, they typically rely on each other in one way or another. For example, because developments in medical technology and treatment options are usually far ahead of legislation, Medicare often discovers through an OIG investigation that taxpayer funds are not being used efficiently. The individual payer (insurance company) When you hear the term individual payers, you may assume it refers to individuals, but it doesn’t. Individual payers are actually the insurance companies that provide group and individual coverage plans to patients. Each payer has its own policies and procedures, which are published and available for both patients and providers to review. The payer may be a plan administrator that is part of a pricing network or may serve as administrator for sponsored plans. More often than not, CMS sets the bar when it comes to payer rules. As I mention earlier, Medicare follows a strict set of claims-processing policies that include correct coding edits, mutually exclusive procedures edits, modifier requirements, unit requirements, and numerous other specifications. In addition, Medicare requires that claims be submitted within 12 months of the date the services took place. Individual payers may follow the Medicare rules for payment, but they don’t have to follow them. In fact, many often have their own policies. Individual payers employ their own processing policies, including which edits they follow, which modifiers they recognize, and other payer-specific rules. As the coder and biller, you must be knowledgeable about each payer’s policies when you prepare a claim for submission. If you don’t follow the payer’s policies, the claim may pay incorrectly or not at all. In addition, most commercial payers have much shorter timely filing requirements than Medicare’s 1-year limit, usually 90 days — which isn’t a long time when crucial documentation is missing! Also, you need to be mindful as to the type of private insurance the patient carries. Is it a fully insured plan? An ASO (administrative services only)? A Medicare replacement plan? Or maybe a Medicaid plan? Payment rules and policies vary within payers depending upon which type of coverage the patient carries.

Article / Updated 01-02-2020

At the top of the government heap is the biggest government payer of them all: good old Medicare. Medicare is funded by payroll taxes deducted from every employed American. (You’ve probably seen the acronym FICA, which stands for Federal Insurance Contributions Act, on your pay stub. This FICA deduction is what helps fund Medicare.) Everyone who gets a paycheck gets FICA withheld, but you don’t see the dividends of that investment until you actually qualify for Medicare. Here’s how you can tell whether you (or any patients in your office) fall into that category. Generally, those eligible for Medicare are Legal U.S. residents who are 65 or older who paid FICA for at least ten years Individuals who are suffering end-stage renal disease who are receiving dialysis treatments or are on a kidney transplant list Individuals who are eligible for Social Security Disability Insurance and are suffering from a permanent disability Medicare has different levels of coverage, referred to as Parts. The coverage a patient gets is determined by how that patient paid (or continues to pay) into the plan. Here’s a brief overview: Part A has already been paid for through the patient’s payroll taxes. Part B is paid for through deductions, usually from the patient’s Social Security dividends. Part C, added to the program in 1997, allows individuals who are eligible for Medicare to enroll in Medicare replacement plans offered by private health insurance plans. Part D, adopted in 2006, is the drug plan. Part D covers prescription drug coverage. Working with Medicare Claims Think of Medicare like a nice, distant relative who sends you a check for $7 each year for your birthday. It’s not flashy, but it’s reliable. In other words, Medicare should be your most predictable payer. How so? Well, the fine folks at Medicare provide you with as much information as possible so that you can do your job effectively (and they can do theirs). Medicare policies and procedures are available on both the Centers for Medicare & Medicaid Services (CMS) website, as well as on all the local contractor websites. Medicare also reliably follows the National Correct Coding Initiative (NCCI) edits, and it recognizes modifiers and the payments that link to them. Medicare, for the most part, lets providers know upfront what to expect. Here’s how your provider gets paid with Medicare: Medicare Parts A and B (what’s considered “original” Medicare) is administered through regional contractors that accept and process Medicare claims in accordance with Medicare policy. Professional providers, including most physician practices, are paid under Part B per fee schedules, which are available on your local contractor’s website. Fee allowances are based on relative value unit (RVU) equations. Getting Medicare-approved Before a provider can receive payment for treating a Medicare patient, the provider must apply for Medicare’s approval. The registration process to become a Medicare provider takes several weeks to complete. The enrollment forms are available on the CMS website, and you can complete most of the enrollment online. To enroll with Medicare, providers must be licensed professionals and have both a National Provider Identifier (NPI) number and a tax identification number (TIN). After completing registration, Medicare assigns a Provider Transaction Access Number (PTAN), which allows providers to submit claims and have access to check the status of claims that are in process. Providers who are not registered with Medicare cannot submit claims to Medicare, period. Large organizations often have employees that specialize in payer enrollment, but if you work for a small physician practice, you may be responsible for leading the effort to fill out all the necessary paperwork to get your provider Medicare-ready. Registering with Medicare does not automatically mean that a provider is a participating provider. A provider can be registered with Medicare and be what the pros call non-par (non-participating). If a patient visits a non-par registered provider, the provider is not obligated to accept fee schedule allowance as payment in full. Instead the provider can charge up to a higher level called a limiting charge, and the provider would then need to bill and collect payment from the patient. Medicare reimburses the patient for 80 percent of the fee schedule allowance, but the patient must pay the remaining 20 percent out of his own pocket. Sometimes collecting from patients is difficult, to say the least, so a provider must decide whether to participate with Medicare and receive a lower fee directly from the carrier or risk collecting his fee from the patient at a slightly higher rate. Processing Medicare claims After your provider is good to go as a Medicare provider, you can start processing claims. You submit all claims to the local Medicare contractor, which processes them according to Medicare processing guidelines and policies. When no national policy applies to a particular service, the decision whether to cover the service may fall to the local Medicare contractor or something called a fiscal intermediary, a private insurance company that serves as an agent for the federal government in the administration of Medicare. The lack of a national policy sometimes happens when a modification has been made with regard to a procedure. Procedural modifications are often the result of advancements in medicine. The development of new tools or equipment that may be used by physicians can result in new procedural codes, for example. Initially, these items are represented by unspecified codes, which are not reimbursable by Medicare. Subsequently, new codes are added to represent these services or items. Similarly, when a claim is processed incorrectly, the initial appeal process goes through the local contractor, although the process is uniform for all regions. Working with Medicare Contractors When you think of Medicare, you probably (or will soon) immediately think of the umbrella organization, the Centers for Medicare & Medicaid Services (CMS). Who you should be thinking about are the local Medicare contractors or fiscal intermediaries, because these are the people providers deal directly with. Submitting your claims You submit your claims to the local carrier, who processes them. Each carrier is required to follow Medicare processing guidelines, which help contractors provide the same Medicare level of service to all providers. Each Medicare contractor must do the following: Accept electronic claim submissions Maintain an interactive voice response (IVR) provider phone line Follow the same timely filing requirements set by Medicare Make payment according to Medicare fee schedules and timely payment rules Operate the same way when it comes to the Health Insurance Portability and Accountability Act (HIPAA) communications and observe all HIPAA regulations Regardless of which contractor you call, you can always expect the process to follow these steps: At the contract’s request, you supply the provider’s PTAN (Provider Transaction Access Number), the provider’s NPI (National Provider Identifier), and the last five digits of the TIN (tax identification number). You will be asked for the patient’s Medicare number, name, and date of birth before any privileged information will be shared. You may then make claim or member-specific inquiries. By following the same protocols for every single phone call, the contractors allow Medicare to operate with more expedience and efficiency for the large number of claims that are submitted daily. Regardless of which government program you’re dealing with, you work with a regional, or possibly a local, company. Each of these administrators has its own contact information (phone number, electronic payer identification number, and physical address). Getting along with your Medicare rep Each Medicare contractor has provider representatives available for assistance when you’re not sure what is wrong with a submitted claim, but these representatives can’t advise you how to code or how to bill. They can only direct you to the correct resources that will assist in getting your claim paid. When calling Medicare, make sure you have the following info handy: The PTAN, the number assigned by Medicare to the individual provider The provider’s NPI, the 10-digit provider number issued by CMS The last five digits of the provider’s TIN, which is similar to an individual’s Social Security number The patient’s Medicare number The patient’s name and date of birth The date of service and billed amount of the claim in question

Article / Updated 01-02-2020

So, what does a medical biller and coder do? To secure timely payment for the provider (that is, your employer or client), you’ll find yourself working and communicating with many different people. As a representative of the office, being friendly and approachable to patients and payers alike is fine. After all, the professional demeanor you exhibit toward patients, fellow office staff, your superiors, and the payers with whom you work goes a long way in helping you establish your role as advocate-in-chief. But you must respect professional boundaries and behave in a professional way at all times. Whether you are discussing missing patient intake information with the front office staff or making your case to a payer representative after being on hold for an hour, you must temper your frustrations with some level of kindness and understanding. Claims processing is business, and you’ve got to view it and communicate about it objectively, especially when you’re doing the detective work of following up on unpaid claims. No matter who you’re dealing with — your friends in the front office or your new best buddy George from the Medicare help line — stay focused on the facts. Leave your emotions at the door and stick to what’s on the paper or computer screen. In the following sections, I tell you how to keep your employer/client at the top of your priority list as you interact with patients, payers, and others. Medical biller and coders deal with patients Although you’ll spend the lion’s share of your time cozied up to your coding books and software, you occasionally need to interface with patients. In these interactions, your diplomacy chops come in handy. Navigating the sometimes choppy waters of patient relations isn’t always easy, especially when the patient with whom you’re working may be visibly emotional. In this kind of situation — or in any situation involving a patient — your best bet is to be courteous, maintain your professional demeanor, and focus on the facts. In the following sections, I explain how to handle some of the more challenging interactions you may have with patients. Patients are the physician’s clients (not yours), so always treat them with respect and empathy. Without patients, healthcare providers would have no revenue, and if they don’t get paid, you don’t get paid. When the patient can’t pay the bill In a way, patients are payers of sorts because, in many cases, they’re responsible for at least some portion of the bill you code. For example, a patient may be responsible for a 20 percent coinsurance, meaning she has to pay 20 percent of what you code and bill. (Chapter 6 goes into more detail on insurance plans and the kinds of patient contributions that are commonly expected.) In a small office setting, you may be the same person who receives a call from the patient who can’t pay her bill, and these issues can be very difficult to address. In this situation, remain professional but be sympathetic to the patient’s dilemma. Here are some suggestions: Follow your employer’s rules about contacting patients. Providers let you know when contacting a patient is okay and what method they prefer for this communication. Identify yourself upfront. When you call patients, always let them know that you are with Dr. Smith’s billing office or the billing office at Smith’s Clinic. Be a listener, not a talker. You don’t need to impart too much information about the inner workings of your client or employer’s office to a patient, if any at all. For example, providers don’t necessarily want their patients to know when the billing company or representative (you) is off-site. Explain any available payment plan options. If your office accepts credit cards, installment payments, or financing options, explain those to the patient. When the patient doesn’t understand how his insurance works Patients with whom you interact may not fully understand how insurance works, so you may be called upon to explain some insurance basics. This situation often arises when the insurance company sends a payment to the patient instead of the provider by mistake, when a patient receives an explanation of benefits (EOB) statement he doesn’t understand, or when the patient receives a bill from the provider that he wasn’t expecting. Many such situations arise when patients are out-of-network and, as a result, are often responsible for a large portion of the bill themselves. In these situations, the following suggestions can help you resolve the issue: Before making any calls, make sure you know what the provider’s policy is regarding out-of-network patients. If the provider is knowingly treating patients outside of the network, a policy should be in place to address how these claims will be handled. If the patient receives a check from the insurance company by mistake, it may be your responsibility to call the patient and explain that they need to surrender the check to the provider. An alternative is to inform the patient of the situation and then bill them for the full charges, explaining that they can use the insurance check to pay the bill. Unfortunately, some patients refuse to surrender the check. In that case, collection agencies get involved or lawsuits are filed. Inform patients of payment plan options. When additional payment is expected of the patient, explain any payment plans that are available, including credit cards or financing options accepted by the provider. Always be cordial, even when patients may get angry and direct their anger toward you. Don’t allow yourself to be drawn into an argument. Try to remember that the patient’s frustration isn’t personal. Keep your comments friendly and professional, and you’ll do right by your employer or client. Medical biller and coders work with payers Your primary goal when interacting with payers is simple: Make sure payers show your client the money! Ideally, your billing software and clearinghouse will keep you apprised of the status of claims (where they are and when they were received) through reports they can generate. The clearinghouse (the agency that relays the claim from the provider to the payer) also generates a batch report that identifies the claims transmitted in each batch. As a result, you should know where every claim is in the process. Occasionally, however, a claim doesn’t process. In that case, you need to talk to a real, live human being to find out why. When calling a payer to follow up on a claim, you are the voice of the healthcare provider, so always act in a professional manner. Remember, being nice gets you better service. Make note of the representative’s first name (and the first initial of her last name) when you call to follow up on a claim, and then use her first name as you talk. People like to hear their own names, so repeat the representative’s name back to her. After the rep says, “My name is Sue,” you can introduce yourself with, “Hi, Sue. This is John from Provider Smith’s office. How are you doing today?” Keep the tone friendly rather than confrontational (at least in the beginning). It doesn’t hurt to note the phone number and time of your call either. That way, during subsequent calls, you can use this information to prove that you spoke to someone in the payer’s office; this information comes in especially handy if the payer’s system doesn’t have a record of your call. Remaining patient Normally, the payer representative is required to get three pieces of identification for both the provider and the patient. In most cases, the representative asks you for the provider’s name and specific information such as tax identification number (TIN) or National Provider Identifier (NPI) number. You also need to provide the patient name, member identification number, and date of birth. Only after providing this information can the provider representative discuss the specific claim information with you. Asking for this information isn’t a stall tactic on the part of the payer representative. It’s required by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA guarantees that a patient’s privacy is protected, and only those with a need to know are privy to this protected information. Getting the resolution you want Only after getting through the initial step (proving you have a need to know the patient’s confidential information) are you able to inquire about the specific claim in question. Here are some pointers: If the person with whom you are speaking is unable to assist with your inquiry, ask to be transferred. When you are transferred to a supervisor, don’t cast blame. Simply describe the issue and the reason you feel that the other person was not providing the resolution you need. Let the supervisor know that you have every confidence that he or she can resolve the issue. If you are still unable to resolve the issue, submit a written request and identify the issue in addition to your expectations. Make sure you also define the contractual obligation that supports your position. After you submit this written request, follow up with a call to make sure that the request was received and forwarded to the correct department for appropriate action. Don’t threaten or accuse. Instead, stand behind the claim in question and your expectations as defined by any contract or state laws with regard to claim processing and payment. You don’t gain anything by accusing the provider relations representative of failing to process a claim. Instead, ask the representative to help you identify the reason(s) the claim processed incorrectly or was rejected. Make that person your ally, not your adversary. Any information the representative gives you on the call is not a guarantee of payment (in fact, early in your conversation, the representative should tell you that directly). As always, payment depends on the benefits outlined in the patient’s individual plan. Medical biller and coders provide positive feedback to colleagues Part of being a professional is being able to provide positive feedback to coworkers. Let’s face it: Office politics are often (okay, always) at play, so getting along with your coworkers is important. From the receptionist at the front desk to the intake nurse, you have multiple opportunities to keep things positive around the office (even if someone’s driving you nuts). The success of your job as a biller/coder depends largely on the accuracy of the information gleaned when each patient checks in. Here are some tips on how to get (or continue to get) the info you need from the front desk: Make sure that the people at the front desk who are facilitating this process understand its importance, and let them know how much you appreciate the effort they put into getting cooperation from the patients. If necessary information is often missing or incorrect, examine the form and see whether you can identify a particular area that makes gathering the necessary information difficult. Discuss the issue with the office manager and diplomatically remind the staff that mistakes on the front end of the claim delay payment. If the office uses electronic medical records that employ electronic patient registration, make sure that the necessary information is programmed to the required field. Most offices that use electronic medical records are contracted with or have their own software support (the Information Technology department). Work with the IT department to make sure that the necessary information is entered. When discussing deficiencies in an office process or a coworker’s performance, try to use constructive suggestions. The following examples illustrate how to phrase feedback in a positive way. Notice how each identifies the issue and opens the door to a possible solution without accusation or blame: “Do you think that we need to revise the demographic form since we’re not always capturing the necessary information up front?” “Do we have a contact at XYZ insurance that we (or I) can reach out to for assistance with this issue?” “I’ve identified a pattern that shows we’re not differentiating between the AEIOU insurance plans when we enter them into the billing software. Please make sure to check the address on the each patient’s insurance card when entering demographic and billing information.” “Dr. Smith usually does not dictate until being reminded. Can we set up a remote dictation system to make it easier for him?” “It would make claim submission faster if we had the necessary invoices without requesting them. Can we set up a process to have the invoices copied to the billing office upon receipt?” “We can’t submit claims that are waiting for pathology reports. Is there a way for us to access these reports directly through the lab?” “If Joe needs help with payer matching, I’d be happy to do it with him.” (as opposed to telling Joe you will do it yourself). “Thanks!” The most important sentence of all.

Article / Updated 01-02-2020

The majority of medical billing and coding training programs begin with basic human anatomy and physiology, more commonly referred to as body systems. You need to understand how each organ within a particular body system works, how disease or illness affects the system, and why the treatment was necessary. Most textbooks contain diagrams specific to each body system. These diagrams show the organs within each system and describe the function of each organ as it relates to the individual system. In addition, you’ll see illustrations showing cells, tissues, and several different types of disease processes. As you read the text, closely study the illustrations. Doing so not only clarifies the general concepts, but it also reinforces the information. The human body has ten systems, each of which is made up of specialized organs that must work together for the human body to function properly and efficiently. When one system is affected by illness, all the other systems are affected in some way. A solid foundation in human anatomy and physiology is a huge asset when taking the certification examination. In fact, it’s a prerequisite for most American Health Information Management Association (AHIMA)–accredited programs and is suggested (but not required) for AAPC (American Academy of Professional Coders) programs. But knowing human anatomy and physiology is important for more than just passing the test. Without a thorough understanding in anatomy, you’ll have a difficult time locating the correct procedural codes. After all, you need to know which part of the body is being treated so you can apply the proper codes. The circulatory system The circulatory system transports nutrients and gasses to all cells of the body. There are two parts of this system: The cardiovascular system is composed of the heart, blood vessels, and blood. The lymphatic system is made up of the lymph nodes, lymphatic vessels (which carry the lymph fluid), the thymus (the gland that helps produce T-cells, which are a type of white blood cell), and the spleen, as well as other parts. The digestive system The digestive system, shown in the following figure, converts food into nutrients that the body can use (or metabolize). The primary organs of this system are the mouth, stomach, intestines (small and large), and the rectum. The system’s accessory organs (organs that assist the system in performing its function) are the teeth, tongue, liver, and pancreas. The endocrine system The endocrine system maintains growth and homeostasis (a fancy way of saying the body’s “status quo”). It is made up of the pituitary gland, pineal gland (the gland that secretes melatonin, the hormone that regulates the sleep-wake cycle), thyroid gland, hypothalamus, adrenal glands, and ovaries in the female and testes in the male, as well as some other parts. The following figure shows the endocrine system. The integumentary system The integumentary system protects the internal organs from damage, protects the body from dehydration, and stores fat. It is made of skin, hair, nails, and sweat glands. The musculoskeletal system The musculoskeletal system is made up of two systems: the skeletal system and the muscular system. The skeletal system protects the body and gives it its shape and form. It’s made up of bones, joints, ligaments (fibers that connect bones to other bones), tendons (fibers that connect muscles to bones), and cartilage. The muscular system is made up of — you guessed it — muscles, tendons, ligaments, and cartilage. It enables the body to move. The muscular system has three kinds of muscles: Cardiac muscle: This is the heart muscle. Smooth, or involuntary, muscles: These muscles make up several internal organs. They’re called involuntary muscles because we don’t control their movements (the movement of the intestinal walls, for example). Skeletal, or voluntary, muscles: These muscles allow us to move. They’re called voluntary muscles because we control them. The nervous system The nervous system monitors the internal (body temperature, pulse rate, and so on) and external (sights, sounds, and smells) environment and sends messages to the individual organs or systems to respond accordingly. It is made up of the brain, spinal cord, and nerves. Messages travel from the brain down the spinal cord to nerve receptors throughout the body. The reproductive system The reproductive system enables the production of offspring. The male reproductive system is made up of the testes, scrotum, penis, vas deferens (the passage way for sperm), and prostate. The female reproductive system is made up of the ovaries, fallopian tubes, uterus, and vagina. The mammary glands are considered accessory organs. The respiratory system The respiratory system provides oxygen to all cells of the body by performing gas exchanges between air and blood gases. It is made up of the nose, trachea, lungs, and bronchi (the main passages of the trachea that leads to the lungs), as well as other parts. The urinary/excretory system The urinary/excretory system, shown in Figure 9-6, removes wastes and maintains water balance in the body. It is made up of the kidneys, urinary bladder, urethra (the passage from the bladder that transports urine outside of the body), and ureters (the passages from the kidneys to the bladder).

Article / Updated 03-26-2016

The world of medical billing and coding is like one big bowl of alphabet soup. Just about any term that comes up in your daily dealings has a corresponding acronym. Every office becomes familiar with the abbreviations specific to that particular practice, but some acronyms are known industry-wide and are familiar to everyone who works in the healthcare business. ACA: Patient Affordable Care Act The Affordable Care Act refers to the federal statute signed into law by President Barack Obama on March 23, 2010 (for this reason, the slang term is Obamacare). This statute represents one of the most significant revisions of the U.S. healthcare system since the passage of the Social Security Amendments in 1965, which resulted in Medicare and Medicaid. The ACA is intended to provide access to healthcare coverage for all, with a goal of ­lowering the number of uninsured citizens and thus reducing overall healthcare costs. This law also requires insurance companies to cover all applicants within mandated standards regardless of preexisting conditions. The policies are marketed through the government website. OON: Out‐of‐network Out‐of‐network (OON) refers to insurance plan benefits. An out‐of‐network provider is one who does not have a contract with the patient’s insurance company and, therefore, is not obligated to accept whatever discounted reimbursement the insurance company was able to negotiate with its in‐­network providers. Every commercial insurance plan outlines the benefit level for members. Usually when a non‐contracted provider treats the patient, the benefits are lower. Your patient may have a fairly inexpensive copay for an in‐­network provider and a much larger copay for an out‐of‐network provider. Some carriers may not cover out‐of‐network providers at all! INN: In‐network An in‐network (INN) provider is one who has a contract with either the insurance company or the network with whom the payer participates. Patients who go to in‐network providers usually have to pay less in co‐insurance and deductibles. In addition, INN office visits may require that the patient make a copayment at the time of the visit. CDI: Clinical documentation improvement CDI is a program dedicated to facilitate the accuracy of a patient’s clinical status when it’s translated into coded data. This data is then used to track physician performance, reimbursements, public health, disease tracking, and so on. As a coder, accurate and thorough documentation are essential to maintain correct coding. ICD‐10 implementation has been a driving force for improvement of clinical documentation due to the specificity of individual­codes. CMS: Centers for Medicare & Medicaid Services The Centers for Medicare & Medicaid Services (CMS) is a division of the United States Department of Health & Human Services. CMS administers Medicare, Medicaid, and the Children’s Health Insurance Program — ­programs that serve the most vulnerable segments of the population. In addition to serving these populations, CMS also sets the standard for healthcare, and many commercial payers follow CMS payment guidelines. ACO: Accountable Care Organization An Accountable Care Organization (ACO) is intended to tie provider reimbursements to quality metrics that are tracked for patients. In other words, providers coordinate care of patients by using a strong base of primary care services complimented by specialists and hospitals who work together. Part of the ACA includes a provision that allows ACOs to be rewarded for demonstrating savings when caring for Medicare populations. Some commercial payers are also supporting this concept by offering similar incentives or by purchasing providers in an attempt to improve patient care and control cost. NCCI: National Correct Coding Initiative NCCI is the CMS development intended to promote national correct coding methodologies and discourage improper medical coding that may lead to incorrect payment for Medicare Part B claims. It involves two categories of edits: Physician Edits, which apply to physician and non‐physician providers in addition to ambulatory surgery centers; and Hospital Outpatient Prospective Payment System Edits (Outpatient Edits), which apply to other providers such as hospitals. Both sets of edits are maintained to identify codes that bundle together and indicate when unbundling may be permissible with the proper use of a particular modifier. They also indicate when unbundling is never appropriate. NCCI edits are maintained and revised if necessary on a quarterly basis. EOB: explanation of benefits An explanation of benefits (EOB) is the document that the insurance company issues in response to a claim submission. The EOB reflects how the claim was processed and shows the billed charges, any reductions applied (either by contract, fee schedule, negotiation, or arbitrarily assigned), the allowed amount, and, finally, any remaining patient liability. Patients are billed as indicated by the EOB, meaning that providers can’t bill them any additional amount to make up for any discounts applied to the claim. HIPAA: Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) was approved by Congress to protect the privacy of patients and insure that patients have access to their medical files. All patients must sign a notice stating that the provider made them aware of their rights, and all employees must sign a confidentiality agreement that states they understand the need to protect patient confidentiality and the penalties involved if they violate HIPAA. In addition, HIPAA requires patients to identify others (such as a spouse or parent) who can have access to their healthcare information. Under HIPAA, any conversation between a physician and patient is confidential, and information regarding that interaction cannot be left in a voice mail or on an answering machine unless specifically instructed to do so by the patient in writing. EHR: Electronic Health Record The EHR is a digital record that may be shared by providers from more than one practice or entity such as a hospital. It is a key provision of the American Recovery and Reinvestment Act of 2009, which went into effect January 1, 2014, and required all public and private healthcare providers to adopt the use of electronic health records in order to avoid penalties that affect reimbursement. Financial incentives were also created for healthcare providers who demonstrate proof of “meaningful use,” which is industry‐speak for improving patient care. EHR implementation is the foundation of meaningful use; without EHR adoption, it is not possible to progress through the stages of meaningful use. The EHR differs from the EMR (electronic medical record), which is simply a digital version of a paper chart and is not shared outside the practice.