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Your Career as a Medical
Coder
 Medical coding professionals provide a key
step in the medical billing process. Every
time a patient receives profession...
 Medical billing and coding is the
practice of helping physicians
and health care centers get
reimbursed for services giv...
 Provider
- To prepare a standardized “bill” for services
given to a patient.
 Payer
- To determine the amount to be pai...
 Insurance companies and
the government are
spending more time and
money researching for
ways to control claims’
fraud, a...
 Billing specialist
 Patient Account
Representative
 Electronic Claims Processor
 Billing Coordinator
 Coding Special...
 primarily responsible for abstracting and
assigning the appropriate coding on the claims.
 Coder checks a variety of so...
Medical coders use standardized codes to
accurately report medical services and facilitate
payment.
Diagnosis codes: Inter...
Coding steps:
1. Assess documentation for completeness and clarity.
2. Determine provider, patient type, place, and payer....
 Is documentation complete?
 Is documentation legible?
 Are diagnoses clearly stated with supporting detail?
2. Determi...
 Diagnoses and procedure codes should be linked to
demonstrate medical necessity.
 Codes must be based on documentation;...
Compliance = satisfying requirements, regulations, and
policies for correct coding and verification of codes.
 Issued by:...
Fraud & Abuse
 Fraud = intentional act to obtain an illegal or unauthorized benefit (e.g.,
billing for services that were...
Demand for medical coders has a very strong future.
Advancement:
o Professional certification
o Additional study
o Work ex...
Skills, Attributes, and Ethics: The Components of
Success
 Skills:
o coding skills
o communication skills
o computer skil...
 Formal education
 Job Experience
 Membership in Professional Organizations
 Certification as a Medical Coder
o Americ...
 Explains insurance benefits to patients and clients
 Accurately completes claimforms
 Handles day-to-day medical billi...
 ANATOMY & PHYSIOLOGY
 MEDICAL TERMINOLOGY
 CPT(Current Procedural Terminology)
 ICD (International Classification of
...
 ICD-9 is an international disease classification
system that groups related disease entities and
conditions for the purp...
 The Current Procedural Terminology coding system
describes medical and surgical procedures and
services performed by phy...
 If the CPT and HCPCS codes are not identical in
meaning or description (i.e., the CPT code is generic
and the HCPCS code...
 HCPCS
◦ Standardized coding system using alpha numeric
codes that are used primarily to identify products,
supplies, and...
27
Patient Encounter
Review of Medical Record
Assignment of Code Numbers
Sequencing of Codes
Selection of Diagnoses and
Proce...
 Correct code assignment is important and plays a significant role
in:
◦ Resource utilization
◦ Reimbursement
 Correct c...
 A Medical Coder earns an
average salary of Rs 186,485
per year. Experience strongly
influences income for this job.
 Pe...
Medical coders use standardized codes to
accurately report medical services and facilitate
payment.
Diagnosis codes: Inter...
 Medical coding is bridge between clinical data
and billing process that generates payments.
 Billing process = revenue ...
 Medical coding data easier to study and analyze than narrative
descriptions.
 Clinical data produced by coders may be u...
 Medical coding is bridge between clinical data and billing
process that generates payments.
 Billing process = revenue ...
 Providers include various types of licensed health care
professionals:
• physicians
• nurse-practitioners
• physician’s ...
 Medical insurance = written policy between individual (policyholder)
and health plan (payer).
 Major types of payers:
o...
 Emergency Medical Treatment and Active Labor Act (EMTALA) –
requires hospital emergency departments to provide care
rega...
Employment in medical coding expected to grow much faster than
average through 2014.
Medical coders work in both tradition...
 Durable medical equipment suppliers (DME) and ambulance service
providers
 Physician practices
 Ambulatory surgery cen...
 + experience  + skill  job
 National Salary Data (?)
 Rs 0Rs 150KRs 300KRs 450KSalary
 Rs 101,430 - Rs 411,737 
    ...
MEDICAL CODING FOR HEALTH PROFESSIONALS
MEDICAL CODING FOR HEALTH PROFESSIONALS
MEDICAL CODING FOR HEALTH PROFESSIONALS
MEDICAL CODING FOR HEALTH PROFESSIONALS
MEDICAL CODING FOR HEALTH PROFESSIONALS
MEDICAL CODING FOR HEALTH PROFESSIONALS
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MEDICAL CODING FOR HEALTH PROFESSIONALS

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Medical coding is the process of transforming transcribed data into set of numerical codes using a system of numbers to represent various medical problems, (diagnoses), and treatments (procedures

MEDICAL CODING FOR HEALTH PROFESSIONALS

  1. 1. Your Career as a Medical Coder
  2. 2.  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.
  3. 3.  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
  4. 4.  Provider - To prepare a standardized “bill” for services given to a patient.  Payer - To determine the amount to be paid to the provider.
  5. 5.  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.
  6. 6.  Billing specialist  Patient Account Representative  Electronic Claims Processor  Billing Coordinator  Coding Specialist  Claims Analyst  Reimbursement Specialist  Medical Collector  Claims Processor  Claims Reviewer  Private Consultant
  7. 7.  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.
  8. 8. 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 Procedures Supplies: Healthcare Common Procedures Coding System (HCPCS), Level II. 1-12
  9. 9. 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. 1-13
  10. 10.  Is documentation complete?  Is documentation legible?  Are diagnoses clearly stated with supporting detail? 2. Determine Provider, Patient Type, Place, and Payer 3. Abstract the Diagnoses and Procedures 1-14
  11. 11.  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 current o must be consistent with HIPAA code sets 1-15
  12. 12. 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 1-16
  13. 13. 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 1-17
  14. 14. Demand for medical coders has a very strong future. Advancement: o Professional certification o Additional study o Work experience o Specialty coding 1-18
  15. 15. Skills, Attributes, and Ethics: The Components of Success  Skills: o coding skills o communication skills o 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 1-19
  16. 16.  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 1-20
  17. 17.  Explains insurance benefits to patients and clients  Accurately completes claimforms  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
  18. 18.  ANATOMY & PHYSIOLOGY  MEDICAL TERMINOLOGY  CPT(Current Procedural Terminology)  ICD (International Classification of Disease)  HCPCS Level(The Healthcare Common Procedure Coding system)
  19. 19.  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 23
  20. 20.  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 24
  21. 21.  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 25
  22. 22.  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 26
  23. 23. 27
  24. 24. Patient Encounter Review of Medical Record Assignment of Code Numbers Sequencing of Codes Selection of Diagnoses and Procedure Codes 28
  25. 25.  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 29
  26. 26.  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
  27. 27. 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 Procedures Supplies: Healthcare Common Procedures Coding System (HCPCS), Level II.
  28. 28.  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.
  29. 29.  Medical coding data easier to study and analyze than narrative descriptions.  Clinical data produced by coders may be used for: o planning health care services o improving patient care o controlling costs o legal actions o research studies 1-33
  30. 30.  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. 1-34
  31. 31.  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) 1-35
  32. 32.  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 1-36
  33. 33.  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. 1-37
  34. 34. 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)
  35. 35.  Durable medical equipment suppliers (DME) and ambulance service providers  Physician practices  Ambulatory surgery centers (ASC)  Clinics 1-39
  36. 36.  + 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
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Medical coding is the process of transforming transcribed data into set of numerical codes using a system of numbers to represent various medical problems, (diagnoses), and treatments (procedures

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