Essentials for Success in Medical Billing (USA)

Essentials for Success in Medical Billing (USA)

The key component for maximum reimbursements  is to provide proper and updated CPT codes, following ICD guidelines,  for any medical consults, Imaging needs, surgical or treatment procedures performed, consults, treatments, physicals, etc., with the responsibility of every clinic, surgical center, treatment center, and Hospital to have ICD/CPT experts who can competently process account receivable claims before submissions to the insurance providers to enable a timely reimbursement rate of return of service and to provide no delay in necessary medical treatment.

What are the Key Components?

Correct, complete , proper and expedient coding is the difference in an organization while processing and submitting medical insurance claims.Updated CPT and procedural codes are tantamount to success.

Who are the Responsible Parties Involved?

Success hinges on the need of claims to be coded and billed correctly on the front end. This in turn will lead to higher reimbursement. The goal is a maximization of effort for the claims acceptance, while keeping claim denials to less than three percent.

Firstly, the process begins with medical personnel, primarily beginning with the physician (or provider.)  and  the need for cohesion through education in the chain of success, which (again) begins with the proper physician  order translation and pre-certification of specific orders (many including chemotherapies, surgeries, Imaging, etc.) which may be high dollar studies or procedures, all of which rely upon physician familiarity with the proper coding or even proper wording of the diagnosis or request for treatment order for service.

These procedure or service CPT codes are direct descendants of ICD codes, or how medical procedures need to be followed by ICD guidelines. Thus, having the codes reviewed by experts, ie; physicians, providers, clerks, techs, so as  to be transferred to the billing staff for the review of charges and the correctness of the requested insurance submission is another key to success. . Education along this chain (should)  will result in claims being submitted in a timely matter which will result in no delays for patient care and ensure proper reimbursement.

What does this mean to the Organization Performing Procedures?

Error proofing and the correct coding, whether it’s a $25.00 laboratory test or a $15,000 chemotherapy regimen is necessary in keeping the inflow of revenue to the organization and reduce the number of accounts receivable that are un-reconciled.

For instance, if a lab technician has to wait to process a lab or send out a lab due to the simple fact/error  that a  diagnosis has not been provided  to them by the provider, a breakdown in the chain has occurred. Once this occurs, the necessary steps that are needed to be made to provide a necessary solution will trigger a trickle down effect, not only in service and treatment to the patient, but essentially a delay in the billing process, ultimately affecting the health of the organization..

This scenario may be played out for any service the provider wants to be performed, from not only  lab testing, but also those involving Imaging (CT, MRI, PET/CT, etc.) or more life threatening cases, for example,  those for heart catheterizations, stenting, TAVR and Watchmen procedures,as well as those  to either continue or begin patient chemotherapy treatments.

The need for medical personnel to remain updated and on top of CPT code and  changes in medical procedural coding,  translates directly to success for the patient, provider, and the overall  health and reputation of the institution.

My extensive experience as a  medical billing and coding specialist has seen many changes in the medical field regarding  procedures and in addition has brought stricter guidelines in order for institutions to succeed. To be successful, education, knowledge of procedures, and attention to detail are the keys.

Incorrect coding causes a reaction of delays and the rejection of claims, while creating  more work in the proper re submission of these rejected claims,

If a drug or test of some sort is coded incorrectly, it will get denied by insurance.  In some instances a charge can be re-filed with the correct diagnosis and may get processed and reimbursed, depending upon the insurance company. Other insurances will require that the billing department file an appeal, which again, involves more delay of service and reimbursement payment.  If after the first appeal the denied claim gets processed as valid, but oftentimes, the appeal must be submitted to another level of appeal, which again may delay patient care and reimbursement payment as insurance companies offer different criteria for claims appeals.

So, in conclusion:  Know your ICD and CPT procedure codes! Be informed of changes and additions. Study the ICD  code book and the additions at the end of each calendar year so you can be informed!

Remember, clean claims equals few or no denials, which equals expedient reimbursements!

Related articles:
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  2. Perspective Analysis of ICD Codes and the Relationship to Procedural Coding in the USA