In the healthcare profession, doctors and nurses get the brunt of the glory. While we are indebted to these caregivers, they are not the only personnel who make the system work. Behind the scenes, medical coders and billers help to streamline the financial side of healthcare. Medical coding and billing are essential facets of our healthcare system.
The origins of medical coding trace back to England in the 17th century. At that time, data about disease and mortality were collected into the London Bills of Mortality and assigned numerical codes. The intent was to determine the most common causes of death. This rudimentary system was a vital stepping stone toward improving healthcare, but its inconsistencies in terminology left much to be desired.
In the 1830s, British epidemiologist Dr. William Farr proposed a more uniform classification system before the International Statistical Congress. Over the next one hundred years, the International List of Causes of Death evolved. It was incorporated into the World Health Organization’s research on international disease epidemics and health trends, losing its long-held focus on only cases resulting in mortality.
This broadened scope led to more comprehensive data and another name change. The International Classification of Diseases continues to grow, allowing medical providers to give more beneficial care to their patients. As of January this year, the ICD is in its eleventh revision, and the system is referred to as ICD-11. Currently, there are over 140,000 ICD-11 codes to facilitate the accurate diagnosis of conditions and diseases.
ICD-11 is not the only format for medical codes. The Current Procedural Terminology codes are also essential in the medical coding process. They are developed by the American Medical Association, while ICD-11 codes are developed by the World Health Organization. The primary difference between the two is their scope. ICD-11 codes refer to conditions and diseases being treated, while CPT codes define the clinical procedures undertaken to treat them.
While ICD-11 codes are consistent across the world, the CPT system is utilized only in the United States by programs like Medicaid and Medicare, the federal government, and insurance companies. All of these codes are listed online, though DSM-5 codes (used in the diagnosis of mental health disorders) which are sometimes used to determine ICD-11 codes do not always line up with the latter perfectly.
The purpose of medical codes is to ensure uniformity in care as well as during the billing process. Medical coders serve as translators so the billing process does not get bogged down by medical terminology. This improves the efficiency of the healthcare system overall and allows medical professionals to concentrate on treating patients.
Once a medical coder has assigned the proper ICD-11 codes to a medical visit, they send the codes to the correct billing facility. It is then the responsibility of a medical biller to use the codes provided to create an appropriate medical bill. The claim is sent to the patient’s insurance company for evaluation. When the insurance company approves it, the bill is returned to the medical biller to determine how much the patient owes out of pocket.
As technology advances, the medical coding and billing processes become increasingly streamlined while adapting to new challenges. The explosive dissemination of the modern computer has improved the efficiency of medical records and coding databases astronomically, making conditions and their corresponding codes readily available at a stroke of the keyboard. This saves medical coders and other professionals vast amounts of time, and because ICD records can be updated immediately, it makes their work more accurate and precise.
Even before the outbreak of COVID-19, the medical community has seen an influx in the utilization of telehealth services to facilitate diagnosis at a distance. With the introduction of telephone triage and other telehealth services, the need for stringent protocols for who can manage medical coding of a call or remote visit has increased. The number of businesses offering remote professional medical coding and billing services has increased dramatically. These entities can offer their services at a fraction of the cost of an in-house coder or biller.
While the layman does not need to understand the minutiae of medical coding and billing, an increased appreciation for the complexity of the process helps to improve appreciation for all members of the medical community. Attending to people’s medical care is a group effort, and every member matters.