medical insurance billing and codingMedical billing is one of the services that keeps the healthcare industry moving smoothly. There is no doubt that without this system of accurate coding of all medical services and pharmacology as well as the professional billing completed by billing specialists, this entire behemoth of healthcare would quickly come to a grinding halt.

The system that we employ today actually has its origins around 1966 when the AMA began to standardize a system called CPT codes. What must be understood is the fact that everything, and I do mean everything, revolves around money.

Don’t get me wrong, I don’t mean that unadulterated greed is what drives this machine, but without some type of profit or funding, there would be no incentive to perform the services that keep people alive. Why should a doctor take on thousands of dollars in academic debt unless there was a promise of future wealth awaiting? Why would diagnostic labs analyze samples without expectation of suitable payment for their services?

As I said, money and income sources is, of paramount importance, and anything that slows the flow of funding is bad, but anything that efficiently speeds or improves the flow of money is great.

Medical Billing And Coding Origins

The expanded need for medical billing professionals can probably be traced to the Social Security Act which became law in 1965. It was at this time that both Medicare and Medicaid came into existence. The HCFA or health care financing administration was established in 1977 and later became the Centers for Medicare & Medicaid Services or CMS.

Medical insurance billing and coding came about as a means to help standardize terminology among medical physicians as well as to serve as a kind of shorthand that would simplify patient medical records for doctors and record clerks, It was never intended as a system to aid reimbursement.

The American Medical Association (AMA) developed the CPT or Current Procedural Terminology through the CPT Editorial Panel around 1966. The original CPT code set identified surgical, diagnostic and medical services and was intended to communicate uniform information about medical services and procedures among physicians, payers, patients, coders, and accreditation organizations, for analytical, administrative, and financial, purposes.

There began a shift with the second edition release in 1970. Additionally, the original four digit codes increased to five digits, and laboratory procedures were added into the system. But it wasn’t until 1983 when the HCFA officially mandated the use of CPT for Medicare billing that a new occupation for medical billing and coding jobs really began to take off.

Medical Insurance Billing And Coding Benefits

Although CPT is considered a primary coding system, there are in fact others that are also commonly used, such as the (ICD) International Classification of Diseases, (SNOMED) Systematized Nomenclature of Medicine, which is managed by the College of American Pathologists, and (LOINC) Logical Observation Identifiers Names and Codes.

The advent of these coding systems helped to develop more consistency among medical service providers, as well as improve the speed of reimbursement. By adhering to compliance, errors and liability could also be reduced and, an important by-product of relevant statistical data could also be mined.

By coding such things as, anesthesia, radiology, surgery, medicine, and pathology these CPT core services could be managed easily throughout the healthcare system by a variety of medical professions.

The medical billing and coding salary that was paid in the mid 1960’s for this new profession gained serious momentum in the 1990’s, because of the continual complexity of the medical coding development.

New evaluation and management coding guidelines were established in 1995 and again in 1997 but were not approved by the AMA until 1997. The evaluation and management codes were then added to the existing five core or category I codes sections. Category II codes are for performance measurement and category III are for new or emerging technologies.

Medical Insurance Billing And Coding Content Management

The process to maintain the effectiveness and accuracy of the coding system is ongoing and the primary voice involved is the AMA. Since they are the owners of the CPT system, they are tasked with the responsibility to ensure the accuracy and relevancy of this vital healthcare system. A symbiosis between service providers and medical insurance billing and coding professionals makes this process viable.

A common complaint is the fact that, only slightly more than half of doctors may agree on the same CPT code for a given visit, and only approximately 60% of professional coders may agree on the same code for a particular visit. In addition, the criteria used to assign a code are often related to the amount of written documentation that has been recorded. This common situation often leads to undercoding by the medical insurance billing and coding specialist.

In order to improve these circumstances the CPT editorial panel, a group of sixteen physicians is supported at the AMA by an administrative staff of over ten, and by approximately 75 CPT advisors who represent nearly all of the medical specialty societies seated in the AMA House of Delegates.

The panel contains representatives not only from some of the larger medical specialties, but also commercial representatives from the Blue Cross/Blue Shield Association, HCFA, the private insurance industry, and the American Hospital Association. This panel meets at least four times a year to consider code alterations and other CPT business.

While certainly not perfect, the medical insurance billing and coding system used in America, is the envy of the modern medical world and it’s continual improvement should spur greater efficiencies in the future.

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