Medical Billing and Coding New York

Standard Process of Medical Billing and Coding

1. Confirm the Validity of the Patient’s Insurance

• Verification. Before any medical service is provided, the patient’s insurance must be verified to confirm coverage. This involves contacting the insurance company or checking online portals to assess whether the policy is active, what portion of the treatment will be covered (co-pays, deductibles, co-insurance), and any pre-authorization requirements.
• Documentation. Record details of the insurance verification in the patient’s file to avoid future discrepancies.

2. Schedule an Appointment With the Provider

• Appointment Management. Using the practice management system (PMS), patients are scheduled based on the provider’s availability and the urgency of care. Any special instructions, like fasting before tests, should be communicated to the patient.
• Pre-Visit Instructions. Patients might be reminded about bringing identification, insurance cards, and previous medical records.

3. Delivery of Care (First Occurrence)

• Patient Consultation. During the visit, the healthcare provider examines the patient and delivers necessary treatments or orders diagnostic tests based on the patient’s needs.
• Documentation. The provider records all interactions, diagnoses, treatments, and prescribed medications in the Electronic Medical Record (EMR) system. Our coding professionals need critical data for accurate coding.

4. Details are Updated on the EMR

• EMR Update. Post-consultation, detailed notes are entered into the EMR. This includes patient history, physical examination findings, laboratory results, imaging, procedures performed, diagnoses, and the treatment plan.
• Accuracy Check. Ensure that all details are accurately documented, which forms the basis for healthcare coding.

5. Practice Support Identifies the Codes

• Code Assignment. Our certified medical coders review the EMR and assign standardized codes using ICD (International Classification of Diseases), CPT (Current Procedural Terminology), and HCPCS (Healthcare Common Procedure Coding System).
• Code Validation. Codes must be precise to facilitate correct billing and compliance with insurance requirements. Incorrect coding can lead to claim denials or delays.

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

• Subsequent Visits. If follow-up visits are required, the process for these visits mirrors the first occurrence. Each visit is documented, coded, and prepared for billing.
• Continual Documentation. Ensure continuity in documentation for any treatment provided during follow-up appointments.

7. Claim Submission

• Claim Generation. Using the PMS, claims are created based on the assigned codes and the documented care provided.
• Claim Review. Our billing specialists review the claims for accuracy and completeness before submission.
• Electronic Submission. Claims are typically submitted electronically to insurance companies through clearinghouses that facilitate the transmission and validation process.

8. Claim Processing

• Payer Review. Insurance companies review the submitted claims to verify coverage, medical necessity, and coding accuracy.
• Decision. The insurer processes the claim, which can result in approval, partial payment, denial, or request for additional information.

9. Payment Posting

• EOB/ERA. Insurance companies send Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) detailing the payment decisions, adjustments, and reasons for any claim denials or reductions.
• Posting Payments. Bookkeeping staff posts payments to the patient’s account and adjusts for any write-offs or patient responsibility.

10. Follow-Up

• Denial Management. Address denied claims by reviewing the reasons for denial, making necessary corrections, and resubmitting the claim.
• Patient Billing. Bills are sent to patients if there are balances due (co-pays, deductibles, or non-covered services). Payment options and plans can also be discussed to ensure patients manage their financial responsibility.

11. Reporting and Analysis

• Performance Reports. Generate reports on key metrics like claim submission rates, denial rates, and reimbursement times to assess the practice’s billing efficiency.
• Trend Analysis. Analyze trends in reasons for claim denials or delayed payments to identify and rectify systemic issues.
• Compliance Checks. Regular audits ensure practices comply with medical coding standards and billing regulations to avoid fines and legal issues.