Medical Coding

Medical Coding

Components of Physician Medical Billing

Patient Registration
When patients call to schedule an appointment with a healthcare practitioner, they are
essentially preregistering for their doctor's visit. If a patient has previously visited the
physician, their information is already on file, so they need to describe the purpose for their
appointment this time around (Kuhn et al., 2015). Patients new to the practice must supply
the provider with their personal and insurance information to confirm their eligibility for care.
Confirmation of Financial Responsibility
The term "financial responsibility" defines who is responsible for paying for which medical
expenses. After receiving all pertinent information from the patient, billers can determine
whether a patient's insurance plan covers services (Kuhn et al., 2015).
Check-in and check-out
You will need to complete some paperwork and/or verify your medical history when you
arrive for your appointment. The patient must produce a government-issued identity and a
valid insurance card (Kuhn et al., 2015).
Claims/Compliance Check-Out
The medical biller may use billing software or a paper claim form to enter information from
the medical coder's superbill. Billers will include the procedure's costs in the claim as well.
Instead, they will only transmit the amount they anticipate getting reimbursed based on their
arrangement with the patient and physician (Kuhn et al., 2015).
Transmit Claims

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The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires
that, except in certain instances, all health organizations covered by HIPAA file their claims
electronically. HIPAA covers the vast majority of service providers, clearinghouses, and
payers. Remember that under HIPAA, doctors are not required to conduct all of their business
online. Only those transactions that are required to be conducted electronically under HIPAA
must be done so (Stadler, 2021). Claims are a typical example of this kind of transaction.
Monitor Adjudication
As soon as a claim arrives at a payer, it is adjudicated. In adjudication, a payer examines a
medical claim and determines the amount the claim the payer will refund the provider based
on whether or not the claim is legitimate or compliant. Claim acceptance, denial, or rejection
occurs at this point (Kuhn et al., 2015).
Generate Statements
It is time for the biller to create the statement for the patient after the payer has provided them
with the necessary information. The patient's bill for the operation or procedures the
physician performed on him or her. As soon as the payer has promised to pay the provider a
part of the services on the claim, the entire balance is billed on the patient's bill (Kuhn et al.,
2015).
Payments Follow-Up
Ensuring the invoices are paid is the last step in the billing process. It is the responsibility of
billers to ensure that patients' medical invoices are sent out on time and are correct. Once a
bill has been paid, it is added to the patient's record (Kuhn et al., 2015).
Differences Between Inpatient and Outpatient Hospital Billing

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Patients who are treated in the ER but not hospitalized as outpatients are referred to as
inpatients. Within 24 hours, the patient is generally discharged from the hospital. You are an
inpatient if you have been admitted to an inpatient facility by your doctor, who will take care
of you for the duration of your hospitalization (Selden, 2020). Patients treated in an outpatient
setting are normally treated during a single visit, while those admitted to the hospital and
remain there for a long period will be coded according to the length of their stay.
The inpatient coding system primarily relies on issuing ICD-9/10-CM diagnostic and
procedure codes for billing and payment. Doctors and other healthcare practitioners use codes
to categorize and consistently code all diagnoses. Procedures are recorded using ICD-10-
PCS. Outpatient services are compensated based on Current Procedural Terminology and
Healthcare Common Procedure Coding System code assignments, whereas inpatient
treatments are reimbursed using ICD-9/10-CM diagnosis codes (Selden, 2020).
Documentation is critical regarding CPT and HCPCS codes used to describe healthcare
services.
The UB-04 Hospital Claim Form
As a standard claim form, the UB-04 medical claim form is used by any institutional
provider in billing inpatient or outpatient mental health and medi