Billing vs. Coding

What is medical coding and billing?

Coding is a term that is used to describe the process of selecting the appropriate code that accurately describes the patient’s condition and the type of care that was provided. Correct coding generates from the provider’s documentation of the encounter which is later translated into codes. Medical providers are responsible for assigning the correct ICD-10, CPT and HCPCS codes, although they may use the assistance of a procedural coder to help.

Care must be taken to ensure that the right codes have been selected. Each code should be a perfect fit; this means it should not only perfectly describe the service or supply that was provided but the patient’s condition as well. If not a perfect fit, a miscellaneous code should be used with a special report attached that provides a more accurate and detailed description of the encounter.

Improper coding, whether it’s accidental, intentional or due to lack of experience, could result in the doctor being “suspected" of fraud by the carrier. A provider could be subject to a fraud investigation beginning with an audit of his practice. If evidence of improper coding is found, the provider could face possible criminal and financial penalties and sanctions.

Billing is the process of taking those codes that were assigned by the provider, along with any particulars of the visit, including the patient and plan information and date of service to complete a CMS 1500 claim form and bill the carrier for payment. 

Medical Billers do not normally assign the codes that are billed. The pre-coded “trip slip” provides most of the codes needed to bill the claim correctly.

Care must be taken to ensure that a claim is billed correctly. Undocumented or unperformed services, exaggerating the complexity of the visit, changing dates to reflect eligible periods or changing the diagnosis to take advantage of plan benefits are all examples of fraud. Committing fraud sets the provider's practice, as well as the Medical Biller, up for potentially serious legal problems

Although billers do not assign codes, they do have the responsibility of making sure that the claims that they bill all match up. This means that a biller should not ignore any claim that appears suspect. The codes should match the treatment and diagnosis, the dates and place of service must be accurate and the patient information should be correct.    

A medical biller is expected to bill the claim based on the information that was provided on the coded trip slip but they also have the responsibility of making sure that the claim has everything it needs to meet the clean claim standard. The claim may require additional data or additional codes may be needed to ensure correct payment. A modifier, for example, may not be listed on the trip slip but it may be critical to ensuring correct reimbursement and is usually medical biller assigned.

Simply put, the medical billing process is all about taking great care to make sure that the claims that you bill are always of the highest quality and integrity, always accurate and always correct.


Back to Chapter Four

Next to CPT-4 Codes