What is Medical Coding?
Medical coding is the process of translating signs, symptoms, diagnoses, and procedures documented by a healthcare provider in the patient’s record into alphanumeric codes in order to facilitate correct billing and classification.
Standard codes are used by healthcare organizations to refer to specific diseases and procedures. Diseases are coded using the International Classification of Diseases, 9th Edition (ICD-9) Clinical Modification (ICD-9-CM) which is maintained by the Centers for Medicare & Medicaid Services (CMS). ICD-9-CM is a adaptation of the full ICD-9 which is released annually by the World Health Organization.
Procedures are coded using Current Procedural Terminology version 4 (CPT-4) and the Healthcare Common Procedure Coding System (HCPCS) code sets. CPT-4 is maintained by the American Medical Association, while HCPCS is maintained by the CMS.
What is Medical Billing?
The billing process starts with an encounter between a patient and his healthcare provider. The provider documents this encounter in a medical record. Whatever happens during this encounter will be the basis for the services billed.
The patient’s record is processed by a medical coder. Diagnoses and procedures documented by the provider in the record will be translated into alphanumeric codes from ICD-9-CM, CPT-4, and HCPCS. On the other hand, the patient’s bill is processed by a medical biller. Codes are entered into the necessary forms for submission to the concerned agencies, such as private insurers, Medicare/Medicaid, or their authorized vendors.
Insurers process the physician office’s claim and assess whether the claims are valid or not. Valid claims are reimbursed according to how the physician’s office billed the services, which ultimately are the product of the coder’s work. Denied claims are not reimbursed, in which case the patient can file an appeal.
Why become a medical coder?
Medical coding is the process of translating patients’ diagnosis, procedures, and supplies information from the medical record into alphanumeric codes in order to facilitate and standardize the billing forms of doctors’ offices. The US government has mandated these standardized codes, and they have a deadline to comply by 2014 or else face huge fines. Because US health workers are expensive to retain for such non-clinical tasks, doctors’ offices and insurance companies have turned to outsourcing these tasks to India and the Philippines. It has been projected by the US Bureau of Labor Statistics that between 2008 and 2018, there will be a demand for 35,000+ workers to do medical coding and billing tasks.
Why get certified?
US healthcare outsourcing (BPO) companies are beginning to shift their operations to the Philippines from either their homebase in the States or their operations centers in India. Given their experience with call center projects, BPO companies have discovered the wealth of healthcare personnel in the Philippines as well as our close cultural affinity with the US. Healthcare delivery and education systems in the Philippines are patterned closely after the American models, which makes it ideal to use Filipino talent for these projects.
Coding companies generally require certified medical coders, especially for projects done outside the US. Some companies may hire non-certified coders, but they will eventually need to get certified. Also, on the average, certified medical coders earn 17% higher than non-certified ones.
In the same way that fresh graduates who started the call center industry in the early 2000s are now director- and VP-level executives in the Philippine call center industry, those who enter the medical coding industry as certified coders now are sure to be industry leaders within the next five years.
What do medical coders and billers do?
Medical coding and billing deal with medical information – data from medical records are gathered, analyzed translated into alphanumeric codes. These codes are organized and included in the claims form sent for reimbursement purposes.
Coders are tasked to ensure that the correct codes are assigned for the diagnoses and procedures found in a patient’s chart, so that healthcare providers to receive proper payment for the services they rendered to the patient. Coding errors may lead to either underpayment or nonpayment by the physician, or suspicion of fraud. Billers, on the other hand, prepare the paperwork that includes the codes and submit these to the proper agencies for reimbursement.
The tasks of the coder and biller may be performed by the same person or distributed to different members of a team. Coders may work either from home or within the office. Coders and billers are generally employed by coding/billing companies.
Who can apply as medical coder?
Anyone with knowledge of medical terminology, anatomy, and pathophysiology and able to learn the principles of coding and billing can apply for a billing/coding job. People with clinical experience have an advantage because they already have the knowledge of medical concepts and experience in handling patient records/charts. However, those who have no previous experience or knowledge can enroll in medical terminology, anatomy, and pathophysiology courses to enhance their knowledge.
What character or personality traits are important for coders to possess?
Coders must be able to:
• Work long hours in front of a computer, perusing electronic and/or handwritten medical records
• Work independently and yet have the social skills necessary to communicate with other coders/billers, physicians, facility personnel, insurance and Medicare staff
• Appreciate the finer details of a patient chart and yet be able to see the broad picture to definitively determine what codes to assign;
• Deal with huge amounts of data while maintaining strict confidentiality
• Work with honesty and integrity
What is the CPC® Certification?
This certification is conferred by the American Academy of Professional Coders (AAPC) and is the gold standard in coding for physician offices. CPC®s usually earn 20% higher than non-certified coders, and are more likely to be retained or promoted by healthcare employers.
What are CPC®s trained to do?
Have an advanced working knowledge of medical terminology, anatomy and physiology
Be experts in reviewing patient charts for diagnoses and procedures
Be proficient in coding charts from a wide range of specialties
Handle issues such as medical necessity, claims denials, bundling of services, among others
Integrate regular changes in reimbursement policies into the physician practice’s process>
How does one become a certified coder?
After undergoing training or even after some years of actual coding work, one can apply for certification from the AAPC. A certification exam will be given, composed of a 150-item multiple-choice part and a freestyle clinical part made up of 20 patient chart excerpts. Candidates have to pass both exams in order to obtain the CPC® certification.