Medical Coding: Why Is An 'Easier' System So Complicated?

January 16th, 2023 - Find-A-Code
Categories:   Billing   Coding   Electronic Medical Records (EMR/EHR)  

Believe it or not, there was a time in this country when paying for medical care was fairly simple. Your doctor rendered services for which you paid at the time of the visit. Medical insurance only offered catastrophic coverage for major medical events. Those were simpler days.

These days, medical payments are so much more complicated. Yet it is not supposed to be that way. Medical coding and billing standards were originally introduced to make payments and reimbursements easier. It didn't work out that way. What was supposed to be an easier system is much more complicated than it ever was before the system was developed.

Tens of Thousands of Codes

As any medical coding specialist knows, looking up and assigning codes is a gargantuan task. There are literally tens of thousands of codes a specialist might deal with in a given year. Granted, some of the codes are used more frequently than others.

The most frequently used are easily memorized by coding specialists. But nothing in healthcare is routine. Even what appears to be a simple record of services performed can be turned upside down by one arcane code a specialist isn't familiar with.

Assuming you are a medical coding specialist, you know what you're up against. You need to be familiar with:

●    ICD-10 and ICD-11 codes
●    Common Procedural Terminology (CPT) codes
●    National Provider Identifier (NPI) numbers
●    HIPAA Compliance

These four things barely scratch the surface. There are other code sets and identification numbers to be familiar with. It's a good thing that medical coders can trust sites like ours to look up codes online. Having to thumb through printed manuals in the modern era would be a nightmare.

No Easier for Some Patients

Our overly complex coding and billing system is tough enough on healthcare providers and their coding and billing specialists. It is tough on payers, too. But the one forgotten group in this whole mess are the patients. Things are no easier for them.

Imagine a patient looking over a group of medical bills trying to understand what he is being billed for. He doesn't understand the codes. And even if he can find a website that allows him to look up diagnostic codes for free, he is not likely to understand the medical terminology associated with those codes. How is the patient to know if he is being billed correctly?

Another example is found with transgender patients who have trouble getting reimbursed from their insurance companies for covered procedures. Regardless of how any of us feels about transgenderism, an insurance company that promises to cover medical procedures should do so. Patients should not have to jump through hoops to get reimbursed.

On this particular issue, some say that a big problem lies with ICD-10 codes. First introduced in 2015, the codes are inadequate for defining some of the treatments transgender patients receive. Coders do not know how to code services, ultimately leading to disputes between billers and payers. Transgender advocates say that the U.S. system should be switched over to ICD-11. Making the switch would alleviate some of the difficulty.

Too Many Hands in the Pie

Stepping back and looking at it from a neutral perspective reveals that there are too many hands in the pie. There are too many organizations and entities involved in establishing medical coding standards. As such, the standards we do have are not really standards at all.

Establishing medical codes was supposed to make medical billing easier. Instead, it has made things much more difficult than they ever were. Adding new codes to old doesn't make the system any better.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.
Accurately Reporting Signs and Symptoms with ICD-10-CM Codes
October 5th, 2023 - Aimee Wilcox
Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.
The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance
September 19th, 2023 - Aimee Wilcox
Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.
Documenting and Reporting Postoperative Visits
September 12th, 2023 - Aimee Wilcox
Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? 
Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding
August 22nd, 2023 - Aimee Wilcox
Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association