Lesson 1 - Introduction to Medical Billing & Coding.

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Medical Billing and Coding:

Medical Billing & Coding is actually the financial field of the healthcare industry.
Medical billing and coding are two closely combined processes that form the backbone of the healthcare industry's financial system. They work together to ensure that healthcare providers are accurately and efficiently compensated for the services they render to patients. 

Medical Billing & Coding is divided into following main fields:

• Medical Billers
• Medical Coders 

What is Medical Coding or Coders?

Medical coding is the process of translating medical diagnoses, procedures, and other healthcare services into standardized codes using specialized coding systems like the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the Current Procedural Terminology (CPT) codes. Think of it as assigning a unique financial identifier to each medical event. Person who does medical coding is called medical coder.

Examples: (ICD-10 - Illness)

1. J20.9 - Acute bronchitis, unspecified
2. R51 - Headache
3. L50.0 - Allergic Urticaria
4. L40.9 - Psoriasis Unspecified
5. I10 – Hypertension

Examples: (CPT - Treatment)

1. 99203 – 30-44 min Office visit check-up.
2. 99391 – Preventive care for one year child.
3. 85018 - Hematology and Coagulation Procedures
4. 45378 - Colonoscopy
5. 11104 – Punch Biopsy with 11105 for each additional lesion

What is Medical Billing or Billers?

Medical billers take those coded diagnoses and procedures and converts them into claims that are submitted to insurance companies or patients for payment. This involves verifying patient insurance information, calculating charges based on codes and payer contracts, and managing the submission and follow-up of claims. It's like creating an invoice for the healthcare services provided. Person who does medical billing called medical biller.

Short Definition:

In short, medical billing and coding are the language of healthcare finance. They bridge the gap between clinical care and financial reimbursement, ensuring that the valuable services provided by healthcare professionals are recognized and compensated.

Key Players in US Healthcare

• Provider
  Providers are the individuals or organizations that deliver healthcare services, such as physicians, hospitals, nurses, therapists, and home health agencies.
• Payer
  These are the entities responsible for paying for healthcare services provided to patient. They can be public (Medicare, Medicaid) or private (insurance companies)
• Patient
  Patient is an individual who takes healthcare services/treatment. Patient is responsible for any remaining costs not covered by their insurance or a public program.

Departments in Medical Billing

• Front Office
  Responsible for scheduling patient appointments, verifying insurance, collecting patient documents and details, greeting patients, and managing check-ins/check-outs.
• Back Office
  They are responsible for overall billing process. Back Office is divided into 5 major parts:
  • Coding Team:
    Reviews medical documentation and assigns the appropriate CPT, ICD-10, and HCPCS codes to accurately reflect the services provided. Ensures coding accuracy and compliance with payer and regulatory guidelines. Works closely with providers and billing teams to prevent claim denials and support proper reimbursement.
  • AR (Account Receivable):
    Handles claim follow-ups, denial management, posting payments, and ensuring timely reimbursements from insurance companies. Also communicates with doctors and the front office to gather missing documentation and resolve billing issues and smoothing the practices.
  • Production Team:
    Responsible for charge entry, coding, claim submission, payment posting, statement verification, and assisting with any additional tasks assigned by the AR team.
  • Patient Service Team (PS)
    Assists patients with billing inquiries, explains charges and statements, helps with payment plans, and supports resolution of insurance or payment issues. Acts as the bridge between the billing office and patients.
  • Customer Service Team (CS)
    Handles communication with healthcare providers and business clients. Resolves service-related issues, provides updates on claims and account status, and ensures client satisfaction with billing services.
• Credentialing Team
  Manages provider enrollment with insurance companies, maintains up-to-date provider credentials, and ensures compliance with payer / insurance requirements.
• QA (Quality Assurance) Team
  Ensures accuracy and compliance in all billing and coding processes. Reviews claims, audits documentation, checks for coding errors, and ensures adherence to payer guidelines and regulatory standards, The QA team supports HIPAA compliance by identifying potential violations or risks and recommending corrective actions to HIPPA compliance Officers or senior management.
• Business Development Team
  Focuses on growing the organization by acquiring new clients, maintaining relationships with existing clients, identifying market opportunities, and promoting services. They also coordinate with internal teams to ensure smooth on boarding of new clients and support strategic planning for expansion.
• Team IT
  Supports all software, systems, and technical infrastructure used in medical billing. Responsible for system maintenance, data security, troubleshooting technical issues, ensuring system uptime, and assisting with system integrations and updates to support billing operations. 

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Did you know about the history of Medical Biling?

Medical billing has its earliest roots in the 18th century, when physicians in colonial America began recording the services they provided and charging patients directly. Billing was very basic—typically handwritten notes or ledgers—and patients paid out-of-pocket, often in cash or by bartering goods and services.

In the 19th and early 20th centuries, as hospitals became more organized and medical care more complex, billing systems began to formalize. Doctors and hospitals started keeping more detailed records of services, but payments were still mostly made directly by patients.

The shift toward modern medical billing began in the 1920s–1940s, with the rise of health insurance. This was especially true during and after World War II, when employer-sponsored insurance became common in the U.S. This created a need to bill insurance companies instead of just patients.

The real turning point came in 1965, when the U.S. government created Medicare and Medicaid. These programs required standardized methods of documenting and billing for medical services, which led to the development and use of medical codes such as ICD (diagnoses) and CPT (procedures).

By the 1980s and 1990s, with the rise of computers and electronic data systems, billing became digital, and regulations like HIPAA (1996) added new compliance standards. Today, medical billing is a highly regulated, technology-driven field essential to healthcare operations.