So in this post, my goal will be to outline the differences between medical billing & medical coding and try to connect these 2 together, in the way they work.
Many of you may understand these basic concepts, in which case bare with me. For all the others, you definitely want to read this post ’till end.
Medical billing is really the reimbursement for all services provided to the patient. So medical billing covers the evaluation and treatment of a patient from a medical provider.
Medical coding has to do with the language via which the process works and the transaction is completed. So medical coding really consists of coding which basically puts all billing actions into its own “words.”
To use a regular daily example: In a regular patient visit, anything the medical doctor does to the patient (from evaluation to treatment and management), is written down in a CPT or ICD code. So whether the medical doctor examines its patients with a standard checkup procedure or specifically is evaluating the patient’s blood sugar, all of these actions are translated by the coding used. Anything the doctor does, gets a CPT code (during evaluation phase.) The diagnosis reached and anything related to that, is ICD code.
So after this point, the billing process moves on to the encounter and then on to the biller. During that process, all the information is filled into the HCFA 1500 claims form and sent to the insurance company. As we remember in an older post, many times the claim is denied by the payer (the insurer) because of wrong information or mistakes in the details. So in the case of a correctly sent claim form, then the insurance company would wire directly the entitled amount to the physician or center’s bank account. But when a claim is denied, then it’s sent back for correction.
Whether you are in the billing or coding “world” (or both) you will need to understand what Advanced Beneficiary Notice (ABN) is. ABN is used for Medicare patients and as the acronym suggests, it’s a notice that needs to be signed which allows Medicare to not pay for a service. Whenever you sign an ABN, it doesn’t mean that Medicare won’t reimburse you, but it means you acknowledge their right to not pay you. Medicare only pays for a certain number of times, and if for some reason they believe you shouldn’t be reimbursed, they maintain the right to deny you. An examples in which ABN may be signed is for laboratory tests. So Medicare isn’t reducing its coverage or being irresponsible. They just reimburse for a certain number of services provided (certain number of lab tests for example.)