In the 21^st century, paying for visits to healthcare providers is a simple process for patients. They simply present their insurance cards, make a copay and go on their way.

The system can be a nightmare for medical insurance billers (MIBs), who complete hundreds of reimbursement claims each week covering a wide spectrum of treatment. In the following article, Nitin Chhoda examines what MIBs need to know about healthcare coding basics.

MIBs will encounter a multitude of technical terms in healthcare coding that will affect the codes used when preparing a claim for reimbursement.

Billers will need to be fluent in medical terminology and healthcare coding procedures to accurately code claims.

The knowledge enables them to submit claims that are reimbursed quickly, meet the demanding standards required by insurance carriers, and maintain compliance with federal and state standards.

Documentation

Billers will be working with multiple and disparate healthcare coding documentation that provides substantiation to payers that the services, procedures and treatments provided were needful and appropriate to the practitioner’s diagnosis.

Each piece of documentation is the evidence that carriers will utilize for reimbursements and a single omission will result in a denial.

CPT Codes

The acronym CPT stands for current procedural terminology. CPT codes will be used on claims to describe the medical services and procedures provided by the practitioner.

CPT codes must match the services they represent to avoid denials and payment interruptions. This is very important.

ICD-9 Codes

The International Classification of Diseases (ICD) codes will soon be updated to CPT-10 to encompass new diseases and technology.  The alpha-numeric healthcare coding is the primary diagnostic tool used to document and explain the signs, symptoms, illnesses and diseases clinicians will encounter.

The codes provide insurance companies with essential information about a patient’s condition and resulting treatment.

Some billers will encounter alpha-numeric C codes and V codes:

• C codes are used to identify the external causes of poisonings and injuries.
• V codes are utilized to categorize factors that have a direct influence on a patient’s health status, along with encounters that aren’t due to an illness or injury.

Modifiers

There are times when a procedure is altered from its original description. Healthcare coding modifiers are used when a procedure requires additional time and expertise, or has extenuating circumstances.

Billers will use the two-digit modifiers in the CPT healthcare coding to report such occurrences. They provide MIBs with the means to bill very specifically and obtain additional revenues to compensate practitioners.

Modifiers are also appropriate when a technical component (TC) is involved.

Sometimes a clinician will need the use of equipment, labor and/or supplies to perform a procedure that is maintained by another specialist or medical facility.

Modifiers in healthcare coding are used to explain that those items are billable by entities other than the practitioner.

MIBs will encounter a host of different codes and medical terminology that must be entered on claims accurately to facilitate quick reimbursements and avoid costly denials and delays.

Medical billing staff who are familiar with the healthcare coding basics are well on their way to becoming masters in their profession.