A Day in the Life of a Medical Billing and Coding

Posted by CapMinds on February 19th, 2020

Capminds Medical coding starts with a patient meeting in a medical office, hospital or other care facility. When a patient arrives, the clinicians must detail the visit or service in the health record of the patient and clarify why certain facilities, products and procedures have been received.

Precise and detailed clinical reporting is important for medical billing and coding during a patient conference. "Do not mark or charge for it if not reported in the medical record," is the golden rule of health care billing and coding departments.

Clinical evidence is used by manufacturers to explain refunds to payers when a conflict occurs. If the providers or their staff do not adequately log a service in a medical record, it could face a complaint denial and perhaps write-off.

Furthermore, if providers attempt to bill payers and patients for services incorrectly documented in the medical record or not fully supplied with patient information, they might be subject to a healthcare fraud or liability investigation.

Once an operator discharges a patient from or leaves the hospital, a professional medical coder checks and analyzes clinical evidence in order to align facilities with diagnosis, procedure, charges and technical and/or facility code billing codes.

During this process, various types of code sets are used for various purposes:

* icd-10 diagnosis codes
* cpt and hcpcs procedure codes
* charge capture codes
* professional and facility codes

You can start today whether you prefer to set up your EMR system for your practice or want us to handle configuration and personalization.