Claims for medical service are based on the documentation in the medical record. The oldest adage in coding is “If it wasn’t documented, it wasn’t done.” Coding for the services provided is the second step after the documentation is done.
Selection of Diagnosis Codes
Coding is done using several systems. Diagnosis codes are selected fro the ICD-10 coding system ever since October of 2015. These short strings of numbers and letters identify why the patient was being seen and/or treated. More than one code usually assigned.
Procedures, Office & Hospital Visits
Procedures, office and hospital visits done by your physician are coded using the the Common Procedural Terminology codes, formulated and kept by the AMA. These short strings of numbers and letters can convey a lot of information about what was done to the patient.
Billed by the Hospital Using ICD-10
Procedures that are done in the hospital are billed by the hospital using the ICD-10 procedure codes. These are different from the CPT codes and are used for hospital services. Hospital claims are then assigned to payment groups. This is also true of claims filed for ambulatory surgery centers.
After the coding has been done, demographic information on the patient, including insurance information is used to complete a claim, usually electronic. Additional information about the place of service, the identity of the physician or other supplier and the address the payment is to go to along with any special notes is also added to the claim.
Claim Submitted through Clearinghouse
The claim is submitted through a claims clearinghouse that acts as an intermediary between the provider and the many thousands of insurance companies out there. The clearinghouse usually has some level of editing to turn back claims to the provider when they know the claim won’t be or can’t be accepted by the insurance company on the claim. The practice or facility will have to change those before re-submitting the claim.
It is a complex process. In end the providers usually get paid. For medical claims processing and clean submission, please Contact Us