Medical Billing vs. Medical Coding

Alicia: Q: Billing versus Coding. “What’s
the difference between Billing versus Coding?” A: Well, if I can answer that question. Let’s
see here. OK there we go. Do you like that little graphic I found of the gears of the
brain? Isn’t that great? Medical Billing is really all about reimbursement,
first of all. Think of the Billing as reimbursement. It’s much more than that but when you think
of billing, that’s the first thing that’s probably going to come to your mind.
It’s about obtaining the reimbursement for the work that was done to the patient by the
provider and that usually is the E/M — the Evaluation and the Management of the patient.
Whether they did any procedures on the patient or not, he is evaluating and he is managing
the care of the patient, maybe it’s the disease process of the patient.
Now, Medical Coding is really just the language in which the transaction is carried out. Coding
is literally a code that the actions are translated into. Let’s explain that a little bit differently.
Your physician sees a patient. Let’s say our patient’s name is Judy. So, Judy comes
in and the doctor does an Evaluation and Management of Judy. By what he does to her with the Evaluation
and Management, CPT codes and ICD codes are assigned by the coder.
Let’s say that he did a yearly physical for her and checked her diabetes, and noticed
that it appears that she has hypertension. In all that stuff that he did, every procedure
that he did gets a CPT Code and the Evaluation and Management is all CPT. Then, the diagnoses
that he gives her, which will say that he diagnosed her with diabetes and hypertension,
those are ICD codes, diagnosis codes. So, the coder assigns the codes to the encounter
and then passes those to the biller. So, the biller then takes those codes, which would
be a CPT Code for the Evaluation and Management and the two diagnoses codes which would be
250.00 and 401.9 puts those on the CMS-1500 form, and fills out all the patient’s pertinent
information, the insurance’s information, and demographic information and stuff. Then,
that is sent to the payer for reimbursement. So, the transaction is easier when it gets
to the payer, which is the insurance company. It runs through their system and it’s either
accepted or rejected. If it’s accepted, then they more or less
cut a check, but it’s not really cutting a check, it’s electronically reimbursed
into the bank of the provider, which is the physician. If it’s rejected, it might be
rejected because the biller did not put the social security number, if they fat-fingered
part of the social security number so it didn’t match the name of the patient or for whatever
reason. So, it’s rejected, so it’s sent back to the physician and the physician then
in turn gives it back to the biller, and then it has a code on it saying, “This is a problem.
The social security number didn’t match the patient.” Then, she verifies it and
corrects and then it’s resubmitted back to the payer and then it’s accepted and
then the transaction goes through and the money is submitted in.
Or, let’s say the wrong code was given, then the biller looks at it, sees what the
problem is, takes it to the coder, the coder corrects it and then the biller resubmits
it, and this all has to be done within a certain amount of days to be reimbursed. But that’s
how a biller and a coder work together. They work as a team.
In some cases, you might have a coder and a biller be the same person. It depends what
size of a facility that you’re working with, but both the medical coder and the medical
biller work hand-in-hand and what they’re doing is they’re translating the information
that the physician is providing for the patient into a code that the people that are going
to pay or reimburse understand so that everything can be done in a timely manner and it can
be done electronically, but people also forget that it’s done for statistical purposes.
So, not so much the biller but the coder was initially coding was initially done for statistical
data, and so the information the coder provides is again given to the biller, the biller sends
it off for reimbursement, but it’s also stored for statistical data. In that way,
Health and Human Services can tell how many patients had breast cancer in Dallas, Texas
in 1999 and how many of them had a mastectomy and how many of them had a lumpectomy and
how many of them subsequently had cancer in the other breast within five years, things
like that. That all boils down to statistics, and even what medications were given and things
like that. The biller and the coder performed two different
services, their jobs overlap and you could have one person performing both jobs if it’s
a small, maybe a one physician or probably not a small facility but a small practice,
even maybe two doctors or maybe a specialty, maybe a podiatrist or something that is a
small… maybe more than one doctor, but it’s repetitious. It’s very important, and you
have to know coding with both of them, and really, you have to be aware of billing with
both of them, because both cross your path.

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