Coding and Claims Processing
Securing appropriate payment for healthcare services or medications is dependent upon healthcare providers and their staffs submitting claims that accurately assign codes to describe patient diagnoses, therapies, and procedures rendered by the provider. Providers are responsible for selecting appropriate codes to report all patient interactions. In order to secure appropriate payment, it is critical to understand the medical coding and billing guidelines of the third party payer.
Inaccurate or incomplete claims submissions often result in delayed processing or denials.
Medical billing is the process of submitting and following up on claims to third-party payers in order to receive appropriate payment.
Medical coding is a means of assigning a numeric or alphanumeric designation to a diagnosis, procedure, or therapy. Properly coding claim forms will help facilitate timely claims processing and reduce the risk of denied claims. Coding requirements may vary by payer. Providers need to be familiar with the coding systems in the table below.
Claims processing is the method by which payers review and process claims for payment. Payers can respond in one of three ways: paying the claim, denying the claim, or pending the claim while additional documentation is requested.
| Coding System | Explanation | |
| Patient diagnosis | ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification | Providers use ICD-9-CM diagnosis codes to report diseases and conditions. ICD-9-CM diagnosis codes identify why a patient needs treatment by documenting the medical necessity for prescribing specified medication. |
| Drugs & biologicals | HCPCS Healthcare Common Procedure Coding System | Most payers recognize the Healthcare Common Procedure Coding System (HCPCS) for reporting specific services, drugs, biologics, supplies, and medical equipment. |
| Drugs & biologicals | NDC National Drug Code | All FDA-approved drugs are assigned an NDC. |
| Service or procedure | ICD-9-CM | Providers use ICD-9-CM procedure codes to report procedures performed in the hospital inpatient setting. |
| CPT® Current Procedural Terminology* | CPT codes are published by the American Medical Association, and used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other healthcare providers. | |
| Facility cost centers | Revenue Codes | Revenue codes are used to identify specific accommodations, ancillary services and billing calculations as determined by the National Uniform Billing Committee. |
*Current Procedural Terminology (CPT), Professional Edition, 2011. American Medical Association, 2010. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no responsibility for the data contained herein. CPT is a registered trademark of the American Medical Association.
