Walking in the Steps of a Medical Biller or Coder

By Karen Smiley

The job of a medical biller or coder is to transform a patient visit into revenue. In order for this to happen smoothly, you must follow several steps.

Step 1: Establish patient demographics

Everything starts with patient demographics, including correct payer identification. Before a patient walks in the door, you must know who is paying for the encounter. (Obviously, this doesn’t apply to the emergency room doctor — he must see whomever comes through the door.)

Verify that the patient is correctly identified, which is usually achieved with a government-issued photo ID. You also must verify active coverage on the service date and through whom. Is the patient the insured or is she a dependent? If the patient is a dependent, you need information regarding the insured, including date of birth.

You also need to find out what type of coverage the patient has. Then you need to answer the following questions: Is there a copay? Or is the plan a value-based plan, which will assign full allowed charges to the patient’s deductible? Has the deductible been met? Is there a co-insurance responsibility? Your office should always collect copays should up front, and, if possible, any known deductibles and co-insurance amounts. This strategy keeps overhead costs down and ensures prompt payment.

Step 2: Check documentation

After the patient has been treated, you need the clinician’s documentation before you can assign any codes. Many physicians will indicate the E&M (evaluation and management) level for an office visit, but you should still check the documentation to ensure that it meets the requirements. You should attach any appropriate modifiers, and diagnosis codes should be as specific as the documentation allows.

The clinician must state or write why the patient is being treated. He may not just circle a code on a charge slip. Coders don’t translate test results, arrows, and so on; indicating a diagnosis is up to the clinician. If he doesn’t do it, you need to initiate a physician query and ask the doctor to state why the patient was treated.

Step 3: Start the billing process

When you’ve deemed the documentation acceptable, the claim is entered into the billing software and uploaded to the clearinghouse. The clearinghouse sends the claim to the payer and, viola! Payment should be received in a timely manner.

In a perfect world, the claim is sent without error and paid according to contract and patient benefits. In the real world, you may need to follow up on unpaid claims, underpaid claims, rejected claims, missing claims — you name it.

If a claim isn’t paid correctly, you may need to send an appeal and state why you feel the payer has erroneously processed the claim. This appeal should be based on facts, not emotion. The medical billing and coding world has no room for subjectivity. Appeals must be supported by billing guidelines, contracts, policies, and other objective documentation.

If you’re certain that a claim isn’t processing correctly and your appeal hasn’t helped turn things around, you can send a second-level appeal and request the name and credentials of the individual who has made the determination.

Step 4: Keep up with ICD-10

The other stakeholder in medical claims is the World Health Organization (WHO). This organization’s goal is to identify methods that provide better health to people worldwide. How does WHO relate to you?

It’s the driving force behind the implementation of ICD-10. The United States is the only industrialized nation that doesn’t use ICD-10 for reporting injury and diseases, primarily because the United States also doesn’t have a socialized medical structure that underwrites the cost of implementation. ICD-10 offers a higher level of specificity than ICD-9 that’s considered an asset to WHO’s mission. After October 1, 2015, part of a coder’s daily regimen is to know the ins and outs of ICD-10.

The movement to ICD-10 has also required clinicians to provide more detail in their documentation. Reviewing current documentation and seeing how it maps or translates to ICD-10will likely fall to the coder. In other words, the coder will be responsible for determining whether the current record contains enough detail to accurately report in ICD-10. Many payers likely won’t allow payment for unspecified codes after the new system is in place.

What payers will do is issue a list of payable codes. ICD-10 contains more than 70,000 codes, and the burden of identifying which codes are missing from the current documentation will fall to the provider. That will be your job. Make sure that your codes are payable because they will be the codes that the clinician documents going forward.

Bottom line: You will need to make sure that the clinicians have the necessary information to know what they need to say so that you can get them paid.