Medical Billing and Coding Kansas

The Standard Medical Billing and Coding Process

1. Confirm the Validity of the Patient’s Insurance

Before providing any medical services, the patient’s insurance coverage must be verified. This involves contacting the insurance company to confirm that the policy is active, the patient is covered, and the specific services are eligible for reimbursement. Accurate insurance verification helps prevent claim denials and ensures that the provider and the patient are aware of any out-of-pocket costs.

2. Schedule an Appointment With the Provider

Once insurance coverage is verified, the patient will schedule an appointment with the healthcare provider. This involves coordinating with the patient’s availability and the provider’s schedule. During this process, administrative staff collect information like the reason for the visit, which helps in pre-authorization. Proper scheduling helps manage patient flow and ensure timely delivery of care.

3. Delivery of Care (First Occurrence)

During the first visit, the healthcare provider delivers the needed care to the patient. This includes various activities, including the initial consultation, examination, and any immediate diagnostic tests or treatments. Accurate and thorough documentation of this encounter is vital as it forms the basis for our team’s medical coding and subsequent billing.

4. Details Are Updated on the EMR

After the patient’s visit, all details of the care delivered are documented in the Electronic Medical Record (EMR). This includes patient history, health complaints, diagnoses, procedures performed, and written prescriptions. Accurate data entry into the EMR is essential as it records critical health information and supports continuity of care. Our coding and billing team will use this data later.

5. Practice Support Identifies the Codes

During this phase, medical coders review the EMR documentation and assign appropriate medical codes for diagnoses, procedures, and other services provided. Codes, such as ICD (International Classification of Diseases), CPT (Current Procedural Terminology), and HCPCS (Healthcare Common Procedure Coding System), standardize the description of medical, surgical, and diagnostic services.

6. Delivery of Care (Second Occurrence, if Needed)

Additional appointments are scheduled if the patient needs further treatment or follow-up care. This second occurrence of care involves similar steps, including documentation of all services provided during the follow-up visits. Each visit must be coded accurately to reflect the ongoing treatment and any patient care plan adjustments.

7. Claim Submission

After coding, the next step is preparing and submitting the claim to the insurance company for reimbursement. This involves compiling all necessary information, including patient details, insurance information, and coded medical services. The claim submission can be done electronically via billing software or manually through paper claims.

8. Claim Processing

Once the insurance company receives the claim, it undergoes processing. This process includes reviewing the claim for accuracy, verifying the patient’s coverage, and cross-referencing the services provided with the patient’s insurance plan. The insurer evaluates the claim to determine the portion of costs it will cover and what will be billed to the patient. Based on this evaluation, claims may be accepted, denied, or partially reimbursed.

9. Payment Posting

After the insurance company processes the claim, payment is issued to the healthcare provider. Payment posting involves entering the reimbursed amount into the provider’s billing system and updating the patient’s account balance. This step helps maintain accurate financial records and bills any remaining balance, such as patient responsibility.

10. Follow-Up

This involves contacting the insurance company to resolve claim issues, re-submitting corrected claims, and coordinating with patients for any owed balances. Proper follow-up is essential to ensure the healthcare organization receives all due payments.

11. Reporting and Analysis

Lastly, reporting and analysis involve generating detailed reports on the billing and coding process. This can include metrics like claim acceptance rates, denial reasons, reimbursement timelines, and overall financial performance. Healthcare providers can analyze these reports to identify areas for improvement, enhance revenue cycle management, and ensure compliance with coding and billing regulations.