Medical Billing & Coding

Medical billing and coding are two key parts of the Community Health Center Revenue Cycle. Both elements are important factors in ensuring your Community Health Center gets paid for services rendered.

Revenue Cycle Management Chart

Medical Billing & Coding Basics

Once a patient has been seen by a provider at your Community Health Center, the provider notes all pertinent medical record documentation such as diagnosis, procedure, services, and equipment information in the EHR. Accuracy is important, and any mistakes made on the part of the medical coding process can cause issues down the road in the medical billing department.

There are many sets and subsets of medical billing code that a medical coding professional must be knowledgeable about including ICD codes, which are medical codes that correspond to the patient’s specific injury or illness. Current Procedure Terminology, or CPT codes, relate to the services performed on or for the patient. These medical billing codes serve as a universal language between your Community Health Center, hospitals, payers, claims clearinghouses, and government agencies.

How Does Coding Impact Medical Billing?

To ensure precision, once the provider reports are done, medical coding professionals then decide how to best ‘translate’ that information into universal alphanumeric medical codes in the designated form or medical billing and coding software. Online medical and billing software has made the process much easier than dealing with paper charts. It is vital that the medical coders ensure the procedure code correctly corresponds with the diagnosis code. If it does not match up a claim will be rejected down the road, which of course holds up payment.

Value-based care and quality payment models have made coding an integral part of the Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), and Quality Payment Program (QPP). While Community Health Centers are eligible but not obligated to report via QPP and penalties for 2018 data do not impact CHC PPS payments, Community Health Center exclusion won’t last forever. It is ever more important to understand how medical coding/billing patterns impact how your organization. For this reason, it is important that your medical coding staff keeps abreast of changing protocol and that providers are consistently educated.

Medical Billing and Claims Processing

Once the coding component is complete, your medical billing department or an outside medical billing company takes the medical codes from the EHR and creates a claim within the Practice Management System or your medical billing software. Medical Billers and medical billing companies alike must verify that every medical code is billable and create an accurate claim that complies with the submission guidelines of the payer in question. If a medical claim is sent out that does not comply with the payer’s rules the claim may be denied by the payer or clearinghouse and returned to the medical billing company or team for correction.

Once the medical claim has gone through the adjudication process, the medical billing staff or medical billing company are notified of the payer’s decision to pay all, a portion, or none of the bill. At this point, the medical billing staff or medical billing company can look to see if the patient is covered by more than one payer and attempt to send a claim to this secondary payer.

Medical Billing services also include payment posting, reconciling data from both paper EOB’s and ERAs ensuring that deposits match payment totals, this way medical billing staff can rework denials, resubmit claims as well as processing write-offs and deductions. Medical billing staff can also use this as a way to identify trends that are causing errors in the revenue cycle and correct these issues at the source. Another important component is moving balances to patient responsibility and the creation of patient medical bills.

Ensuring you have strong medical billing and coding processes ensures your Community Health Center is paid fairly for services rendered.

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