Staking Your Claim

Posted on 27 Jun, 2018 |comments_icon 0|By Elizabeth

Coding is integral to claim submission.

To prepare and submit a claim for reimbursement, you need documentation of all services and procedures performed and the reason, providing a diagnosis for each to demonstrate medical necessity. Medical practices use a superbill, also called an encounter form, which is a preprinted charge slip listing codes that represent the practice’s most common services, procedures, and diagnoses. At the time of the patient encounter, the provider simply circles or checks items on the superbill. The superbill also provides space for the provider to write in any items that are not preprinted.

The superbill, along with the documentation written by the clinician(s) in the patient’s healthcare record, is what will be used by the coder to determine the appropriate codes to submit for reimbursement.

Here’s how coding happens: The coder reads the medical documentation in the patient’s record and finds the services/procedures that the patient received. The coder also finds the patient’s diagnosis(es) documented in the chart. The coder then searches for the services/procedures in a procedure coding manual to find the corresponding codes to bill the insurance that represent the services/procedures. The coder also searches for the diagnosis(es) in a diagnosis coding manual to find the corresponding codes to bill the insurance that represent the services/procedures. Both the procedure and diagnosis codes must be listed on the claim form, or bill, that the provider sends to the insurance, or the insurance won’t pay for the patient’s services/procedures.

Documentation in the patient’s medical record can be contained in an electronic medical record (EMR), an electronic health record (EHR), or in the form of a paper chart with documentation handwritten or transcribed. Documentation is typically a record, or step-by-step account, of everything that happened during the patient’s visit, or encounter, which can include an office visit, surgical procedure, test, or other services. The coder must read and interpret all of the documentation in the record to determine the appropriate diagnoses and procedures to code. Documentation includes information the patient provides at the first service (patient registration forms) and a record of the visit that the clinicians (physician, physician assistant, registered nurse, medical assistant) document about the visit. Each service must be documented by the clinician who performs it.

Diagnosis codes come from the International Classification of Diseases (ICD) and procedure codes come from Current Procedural Terminology (CPT®) and the Healthcare Common Procedure Coding System (HCPCS).

Although coding is one step within the revenue cycle, you can clearly see how it intersects with each component of the patient encounter, like the gears that turn a motor. Having all the moving parts of a practice in top shape, meaning the coding is accurate and timely, will keep the coding process flowing and the revenue cycle moving in the proper direction so that the provider can collect revenue efficiently and have enough money to continue to survive.

Get to know Coding Principles

Medical Coding Demystified: Coding 101 for Non-coders 2018 is an indispensable resource to learn medical coding.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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