Article

Medical coding and claims

The entire medical claims process presents ongoing challenges in medical practice management. The accurate medical coding of claims — absolutely essential for swift and accurate payment — has always been difficult, and will become significantly tougher during the transition to the ICD-10 code set, when the number of codes will increase almost fivefold.

One of the difficulties inherent in submitting medical claims efficiently and accurately is the number and complexity of steps in the process, and the frequency with which rules are added and changed. Below are suggested steps to take over the course of the medical claims revenue cycle1,2.

  • Pre-Registration – Enter patient insurance information and demographics into a practice database fully and accurately; have it double-checked to avoid problems later.
  • Benefit Verification – Confirm patient benefits, deductibles and co-pays with payer, and make sure patient understands them; confirm that the physician delivering care is on the patient’s insurance contract.
  • Check-In – Copy the patient’s insurance card and make sure there are no changes in coverage; give the patient a copy of practice payment policies.
  • Documentation of Services – Document patient history, symptoms, diagnosis and treatment plan in the medical record.
  • Assignment of Codes – Assure accurate medical coding by recording the proper codes in the medical record and physician super bill; consider purchasing a CPT (Current Procedural Terminology) code set spreadsheet for each insurer to see which codes receive higher reimbursement.
  • Check-Out – Collect patient co-pay, deductible and co-insurance (money collected in person is immediate revenue).
  • Verify Coding – Have a professional coder verify medical coding based on clinical record, ensuring codes will be paid by insurer.
  • Pre-Authorization – If the patient is to have a procedure, get an authorization number from the insurer in a timely manner.
  • Claim Generation – Enter codes and fees, and generate claim form. Generally done by medical billing staff.
  • Claim Review – Carefully review every claim for errors that might lead to a denial.
  • Claim Processing, Adjudication and Payment – Payer responds to claim submission with payment or rejection; accurate medical coding will limit the latter.
  • Claim Follow-Up – Track all claims to ensure timely processing, adjudication and payment.
  • Claim Appeal – If the amount paid by insurer is not adequate, file an appeal immediately to avoid additional payment delay.
  • Payment Posting – Post insurance payments to the medical practice account.

This can be an arduous procedure — and the list above is not exhaustive. In addition, two sets of data must be collected, analyzed and reported to the practice: the amount of time between submission and payment, and the difference between claim amounts and payment amounts. When this information is accurately tracked and shared, a practice can best understand its success at medical coding as well as the viability of its relationships with various payers, and see that adjustments are made where necessary.

1 “Prepare that Claim,” American Medical Association, http://www.slideshare.net/RajinikanthDhakshana/ama-prepare-that-claim-taking-an-active-approch-to-the-claims-management-revenue-cycle

2 “The Lifecycle of a Medical Claim: Identifying Practice Problems,” P. J. Cloud-Moulds, Physicians Practice, December 3, 2011, http://www.physicianspractice.com/blog/lifecycle-medical-claim-identifying-practice-problems.

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