How Do Billing Codes Affect Reimbursements And Auditing

January 25th, 2023 - Find-A-Code
Categories:   Coding  

Your job as a medical biller or coder has a direct impact on the jobs other people do. Your work impacts medical reimbursements, auditing, and even research. That's why it's so important that coders and billers get it right. A lot rides on the information behind medical billing codes.

This post will focus mainly on how coding affects reimbursements and auditing. The reimbursement portion you may already be familiar with to some degree. Auditing may be another matter. Unless you have reason to know about medical auditing, you may not think of it in terms of your daily routine.

Billing Codes and Reimbursements

As you know, the primary purpose for developing medical billing codes was to streamline the reimbursement process. Between private insurance carriers and Medicare/Medicaid, there are a tremendous number of players in the payment pipeline. Do not forget those patients who pay with cash, either.

Reimbursements are essentially payments to healthcare providers. One reimbursement may be a payment to your GP to cover your last physical. Another might be a payment to a hospital to cover your emergency room visit.

Insurance companies and federal agencies rely on medical billing codes and other data to determine how much to pay. Private insurance companies must meet standards set by the U.S. Department of Health and Human Services (HHS). However, most of the rules they have to follow are implemented at the state level.

As for Medicare and Medicaid, they are controlled by HHS. It is not unusual for the two programs to establish some sort of policy only to have private insurance companies follow their lead.

Medical Billing Codes and Audits

In a general sense, the point of any audit is to track quality, performance, accuracy, or some other metric. Some audits track multiple metrics. In terms of healthcare auditing, it can be utilized for any number of purposes. It is most often utilized to track coding and billing performance.

An audit reveals the accuracy of the coding and billing procedures. It measures the performance of the coding staff. An audit is designed to reveal both strong and weak points, particularly so that weak points can be addressed. In addition, an audit might also be used to:

●    track quality of care
●    measure adherence to organizational policies
●    educate individual providers on those policies
●    defend against malpractice claims or federal audits
●    maximize revenue-generating capabilities.

As a medical coder, you may be subject to annual performance reviews based on audit data. That really depends on the policies of your employer. But rest assured that you and your coworkers are being audited from time to time. It is part of being a medical coder.

The Best of the Best

Given how interrelated medical billing codes are with both reimbursements and audits, it stands to reason that healthcare providers and third-party coding and billing providers stress accuracy. Efficiency is a pretty big factor, too. When they hire coders and billers, they want the best of the best.

So what makes for a good medical coder? First and foremost is an attention to detail. There is a lot to learn about medical billing codes even before an individual can start working. A good coder must be able to figure out exactly what services or procedures were rendered and enter the appropriate information into the appropriate fields in the relevant database.

Coders are not expected to memorize thousands of medical billing codes. Instead, they utilize websites like ours to call up codes as needed. So to be successful, a coder must also be proficient in computer use. Otherwise, reimbursements and audits can run off the rails.


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