Coding Does Make a Difference

Coding Does Make a Difference

By Bonnie Bigler

According to Deborah Grider, a senior manager at Blue & Co., “Physicians tend to think that payment is derived only by the procedure code. That’s not necessarily true. It’s driven primarily by the medical necessity which is the diagnoses that they report on their claim.” Collecting and reporting aggregate information through codes allows the medical community a way to provide information quickly and easily. Medical codes are translated into reimbursement amounts on bills, which are submitted to insurance payers for reimbursement. Incorrect code assignment results in denied payments to providers. Basically, if it’s not documented and coded, it didn’t happen and you won’t get paid.

Typically, medical billing and coding go hand‐in‐hand and those who do the billing are also responsible for ensuring that the coding is correct and accurate. Medical coding is a detail‐oriented position that makes sure the ICD codes and CPT codes are correct prior to submission to the insurance companies for reimbursement. ICD codes are codes that physicians use in order to render a diagnosis of a patient and CPT codes are codes for the treatments and services that are given to the patient upon receiving a diagnosis. For example, if a patient visit (called an “encounter” by coding professionals) results in a diagnosis of a laceration requiring stitches, there will be a number of codes associated with the entire visit. Those codes will need to be checked and submitted to the patient’s insurance company for reimbursement. Reimbursements and payments are only released if the insurance company approves the coding and documents submitted. Thus, medical coding plays a very important role not only to physicians and hospitals but to insurance companies as well.

Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS. If you document and code the visit correctly, you have a better chance of being paid.