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

3. Your Career as a Medical
Coder

5.  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.

6.  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

7.  Provider
- To prepare a standardized “bill” for services
given to a patient.
 Payer
- To determine the amount to be paid to the
provider.

8.  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.

9.  Billing specialist
 Patient Account
Representative
 Electronic Claims Processor
 Billing Coordinator
 Coding Specialist
 Claims Analyst
 Reimbursement Specialist
 Medical Collector
 Claims Processor
 Claims Reviewer
 Private Consultant

11.  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.

12. 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

13. 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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14.  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
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15.  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

16. 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

17. 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

18. Demand for medical coders has a very strong future.
Advancement:
o Professional certification
o Additional study
o Work experience
o Specialty coding
1-18

19. 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

20.  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

21.  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

22.  ANATOMY & PHYSIOLOGY
 MEDICAL TERMINOLOGY
 CPT(Current Procedural Terminology)
 ICD (International Classification of
Disease)
 HCPCS Level(The Healthcare Common
Procedure Coding system)

23.  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

24.  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

25.  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

26.  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

27. 27

28. Patient Encounter
Review of Medical Record
Assignment of Code Numbers
Sequencing of Codes
Selection of Diagnoses and
Procedure Codes
28

29.  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

30.  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

31. 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.

32.  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.

33.  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

34.  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

35.  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

36.  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

37.  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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38. 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)

39.  Durable medical equipment suppliers (DME) and ambulance service
providers
 Physician practices
 Ambulatory surgery centers (ASC)
 Clinics
1-39

40.  + 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