Maximizing Reimbursement through Coding

For healthcare providers, records are not only a way to stay up to date with their patients’ progress, but a tool to get paid. The diagnoses and procedures on the records are assigned certain codes which transform into bills for the services rendered. Sounds simple enough, but coding is a specialty in its own right, as there are more than 10,000 codes in use. So much so, that every year, doctors lose millions of dollars in revenue due to coding mistakes and unhealthy billing practices. When it comes to maximizing reimbursement, is it key to partner up with an expert medical coder. However, you must know the basics of coding so as to be able to oversee that everything is copacetic. This article will help you do just that.

Coding 101

Diagnoses, procedures, and equipment are all part of the services that a healthcare provider offers. As such, when billing patients and payers, they translate into alphanumeric codes to streamline the payment process (among other things). There are different types of codes, as described below:

  • CPT (Current Procedural Terminology). For procedures and services performed.
  • ICD-10 (International Classification of Diseases, 10th Revision). These represent a patient’s diagnosis and reason for the visit.
  • HCPCS (Healthcare Common Procedure Coding System). Used mainly for billing Medicare and Medicaid.
  • Modifiers. These are additional codes appended to CPT codes to provide more information about the service, such as whether it was a bilateral procedure or if more than one procedure was performed during the same session.

There are professionals who perform the task of translating services into codes, called medical coders. They analyze the patient information and usually work closely with the billing team to ensure everything is perfect at the time of issuing bills. Maximizing reimbursement is about being diligent and creating healthy habits within your practice.

Let’s Look at an Example

A patient visits their doctor because they have been experiencing nausea. Therefore, the physician examines the patient and orders a blood and urine test. In this scenario, coding and billing would look something like this:

Diagnosis: The ICD code for “nausea NOS and nausea without vomiting” is R11.0.

Examination: The time that the doctor spent evaluating the patient could be coded as 99213, “Established patient office or other outpatient visit, 20-29 minutes.” 

Lab tests: Likewise, the bill will include  blood and urine tests as codes CPT 85027 (blood count, complete (CBC), automated) and CPT 81001 (urinalysis, complete with microscopic examination with reflex to urine culture, comprehensive).

Therefore, the bill in turn will reflect these services through these codes and each code is reimbursed accordingly. In very simplistic terms, this is an example of how coding works. Please note that the purpose of the example is to illustrate and that real-life coding can be much more complex. For instance, the patient’s medical history, pre-existing conditions or other details come into play as well.

Proper Coding for Maximizing Reimbursement

Implementing best practices when coding can greatly affect reimbursement and, consequently, revenue cycle management. Proper coding ensures that doctors communicate clearly to their payers about the services they provide. In turn, it is, as we have mentioned, the way to obtain the right reimbursement for said services. Also, when coded correctly, the payment process is optimized.

Read more: Is Revenue Cycle Management Important in Healthcare?

Regulation Changes and Maximizing Reimbursement

The coding standards are being constantly updated to stay up to date with the ever-evolving healthcare landscape. This makes it so that experts need to be continuously on top of the modifications implemented in order to help professionals maximize their reimbursement. For example, in 2015, the ICD code launched its 10th revision, ICD 10. This revision brought a myriad of changes which meant that experts had to familiarize themselves with a whole new array of codes. Also, there are digital systems that translate codes from one revision to the other, but they cannot be trusted to do that without human revision. In addition, as with everything, coders need to learn how to operate the system correctly to avoid billing errors.

Read more: Can Automated Procedures Help Maximize Reimbursement?

What an Expert Medical Coder Can Do for You

Learning to code for the services rendered takes up a significant proportion of the time that a provider could dedicate to treating patients (and being reimbursed for it). Not only is it time-consuming, but also physicians are more prone to getting coding wrong and risk being underpaid or, worse, accused of fraud.  

Consulting experts like Peregrine Healthcare are the perfect partner for practices and providers. Our in-depth knowledge of coding and billing makes it so that they can focus on their patients with the peace of mind that we are working continuously with the aim of maximizing reimbursement for them. 

Learn more about our coding and billing solutions here.

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