All Products

Exploring Medical Coding and Billing: 5 Ways to Get Paid Correctly

January 24, 2021

Medical coding and billing are two different processes. Both are essential for healthcare providers to obtain reimbursement. 

Medical coding involves the retrieval of billable details from clinical documentation and medical records. Medical billing, on the other hand, uses specific codes to establish healthcare payments and bills. Generating claims is where medical billing and coding converge. In this way, they form the core of the healthcare revenue cycle. 

The medical billing and coding phase may take between a few days to several months, depending on the complexity of services provided. The procedure begins with patient identification and ends once the insurance provider pays off all the services in full.  

Three categories of medical coding 

Medical coding consists of three basic categories meant to clarify both the concern and why it occurred. 

The codes themselves, if used correctly, replace the need for the patient’s narrative. 

 Suppose a patient has been assessed or a provider has performed an examination or other treatment. In that case, a medical coder must then allocate a particular code to any of these acts. 

Most of these codes fall within the following categories: 

  1. International Classification of Disease Codes (ICD) 

 The codes in the ICD have been in existence since 1893. However, they are revised annually to incorporate developments over time in health and medical research. The categories reflect reviews and feedback from doctors and insurance organizations.  

 In particular, the 43rd World Health Assembly approved the ICD-10 in May 1990. ICD-10 is used in the U.S. and 100 countries worldwide. It is the international standard for illnesses and health conditions to be described and reported. Transcending languages, the ICD-10 helps healthcare practitioners the world over to compare and exchange health knowledge. 

 2. Current Procedure Terminology (CPT) 

 Since their introduction in 1966, CPT codes have experienced several changes to conform to the ever-changing medical climate. These codes are collected for each patient and then forwarded for payment to an insurer or other payor. 

 CPT codes identify evaluations, examinations, surgeries, and any other surgical treatment conducted on a patient by a healthcare provider. This particular collection is extensive and contains the codes for thousands of medical procedures. 

 3. Modifiers 

A reporting healthcare provider uses modifier codes to indicate that a patient’s treatment has been changed due to specific circumstances. Despite this, there are no changes made in the code modification. The careful application of modifiers removes the need for different lists of procedures that may define the modifying circumstances. 

 Modifiers are a vital aspect of coding. Misuse can result in unrecorded sales and potential audits.  

 Five best practices for medical billing 

 A healthy revenue cycle is vital to maintain the costly job of delivering treatment. However, it is not easy to guarantee that a dental practice is getting paid for the services it has provided. It can be difficult because insurers frequently reimburse healthcare professionals once the patient has already come and gone. Thus, there is a gap in rendering treatment and obtaining reimbursement. 

 For different reasons, insurance applications may be refused or declined. Human error plays a significant role in many of these rejections. Up to 42 percent of statements are incorrectly coded, and 19 percent lack suitable documentation. 

What are the best ways to reduce risks in your practice and secure prompt and full reimbursement for the work already done? 

  1. Understand the billing process 

Guarantee the timely filing of claims and deter fraudulent practices by taking ownership of this aspect of the business. Here’s the step-by-step guide to fully understand the billing process: 

 Step 1: The billing method begins by checking for the eligibility of benefits. The process also includes receiving the patient’s half (such as copayments, coinsurance, and deductibles) at the time of treatment.  

 Step 2: For each appointment, doctors provide treatment and diagnosis codes. 

 Step 3: Coders validate the correct choice of code and apply the necessary modifiers to better define the treatment. 

 Step 4:  Coded claims are submitted to a practice management software such as Genesis or Nextech. After this, they are posted to a clearinghouse and sent to individual insurance companies. Insurers will decide to accept or deny the demand for payment. 

 Step 5:  Carriers collect the reimbursement, and any surplus is transferred either to the patient or a secondary insurer. All denied, unpaid, or partly compensated cases should be dealt with immediately. 


2. Pay attention to details when filing claims. 

There will be no reimbursement on cases that are not appropriately submitted, so take the time to ensure all codes are accurate and all criteria fulfilled. 

In this way, better claims can be created. A significant drop in denials and enhanced payor contact emerge as a result. Making several edits to the claims before submitting to providers can make healthcare services more reliable and efficient. 

 3. Involve the patient in the process. 

Providing the highest possible patient experience will be beneficial to the billing and collection process. Healthcare practices that build strong relationships and develop open communication with patients are more likely to gather accurate insurer information. This way, healthcare professionals will recognize the financial obligations of insurance organizations to their patients. 

 When dealing with insurance company rejections and following up on denials, it is often necessary to have a positive relationship with patients. 

 4. Maximize technology to the fullest. 

In optimizing the billing process, technology is integral. Technology can offer patients several ways to pay through streamlined digital transactions. New technologies, such as advanced medical software, can connect different divisions of medical practice. It can also create a more continuous flow of knowledge between physicians, workers, and administrators. 

5. Know carriers well and contracts even better. 

Ensuring clear and open communication lines with insurance carriers creates a path to resolve issues when they emerge. This prepares a dentist to advocate for the practice and patients when faced with rejection, by keeping track of new healthcare reforms, federal and state laws, and insurance policies. 


Practice the right way 

Healthcare providers who are encountering problems with collecting dues or insurance claims must start assessing their business process. Understanding the different methods that can help billing and coding functions is the first step. 

Healthcare providers must think through their processes thoroughly to ensure that they are paid accordingly. 






3 Facts You Might Not Know About Your Dental Insurance
Insurance & Billing

As dental professionals, to be in-network is not about benefiting from dental insurance alone. It is crucial to know its types and, most importantly, to review [...]

Dental insurance and PPO plans: Should you hold ’em or fold ’em?
Insurance & Billing

Insurance companies seem to hold all the cards with dental practitioners. Due to the ever-changing stance at practices, the stakes have never been higher.[...]

Building Your Future in Dentistry: Beyond PPOs
Insurance & Billing

For many young dentists, being a part of a Preferred Provider Organization, or PPO, may seem like the best option to broaden possibilities when cultivating a de[...]

Five steps to help establish an in-office Private Dental Plan (PDP)
Insurance & Billing

Tired of tussles with insurance companies and the aggrieved patients they often produce? Consider a self-administered in-office plan instead. Have you ever c[...]