Healthcare providers specialize in the area of medicine that interests them most. The same is true of the back office staff who code medical records and assemble healthcare claims. They are just as dedicated to their specialty as the providers they work with.
The healthcare process does not end when the patient walks out the door of the treatment room. A physician, PA or Nurse Practitioner makes entries into the EHR and that information is translated into industry-standard medical code that is submitted to commercial insurers and government healthcare programs. The business side of medicine depends on professional medical billers who can examine a patient record and ensure that the provider is paid the maximum legal rate of reimbursement.
Medical billing specialists deal with the government-mandated language of standardized medical codes. These include procedure codes, quality measurement codes, durable medical equipment codes, drug codes, and diagnosis codes. The same standards apply to every medical specialty, but every specialty utilizes different code sets on a regular basis.
A clean healthcare claim that is submitted electronically can be reasonably expected to be paid within fourteen days. Prior to the Health Care Portability and Patient Protection Act of 1996 (HIPPA) and the Patient Protection and Affordable Care Act of 2010 (PPACA), healthcare claims were submitted to payers via regular mail and were paid after 45 days adjudication. Professional, experienced medical billers remember the slow, old days and they know that submitting clean claims electronically improves a private medical practice’s cash flow and bottom line.
Medical codes, unlike the strings of Latin and Greek root words found in physician notes, are only composed of a few numbers, and sometimes, a letter. Every digit makes a difference and there is little margin for error when reporting medical services for accurate reimbursement.
Any licensed physician can provide a variety of services outside his or her specialty. A medical billing specialist will recognize these services and code and bill them accordingly, capturing deserved, but maybe unexpected, potential revenue. Many medical specialty practices bill for services that are included in a global surgical package. Many medical specialty practices bill the same codes over and over, getting into a rut, just as physicians check the same boxes on a superbill out of habit. Accurate procedure and diagnosis coding demands a fluency of all the codes available to describe delivered healthcare services to receive reimbursement as contracted from third-party payers.
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Some physician procedure codes are billed with the technical and professional components of separate services. Some services only consist of a technical component, such as laboratory tests and some radiology procedures. Other services consist of only a professional component, such as a medically distinct evaluation and management of a patient’s presenting complaint. Medical billing specialists know how to apply modifiers to procedure codes to ensure they are reported accurately to payers. Accurate coding and billing reduces the number of denied claims, and it also reduces the need for costly and time-consuming appeals to receive proper payment for services.
No primary care provider would refer a suspected sarcoid lung patient to an endocrinologist. No endocrinologist would refer his or her hypothyroid patient to an audiologist. No audiologist would refer a patient with gross hearing loss to a dietitian, and no dietitian would refer a patient suffering from vitamin deficiency to a dermatologist. All of these specialized healthcare providers deliver their services within their realm of expertise. They do not refer their patients to other providers who are unlikely to do the most good.
The business of medicine is the same. Specialized providers rely on specialized coders and billers in their field to submit clean healthcare claims for timely reimbursement. Private outpatient medical practices improve the health and quality of life of the patients they serve. They should receive timely payment for services rendered as submitted by medical billing specialists based on the contents of the documented medical record.