What every patient needs to know about medical coding & billing

Nicole Broadhurst |

This post was written for Thatch by Nicole Broadhurst. Nicole is a patient advocate at Tennessee Health Advocates; she's been in the healthcare field for more than 20 years.

Have you ever wondered what doctors and nurses are reading and writing during your appointment? Generally, they’re entering information into your medical record that will then be “coded” to submit a claim to your insurance company for payment. We often hear that we need to be watching for “coding errors” in our bills. In this article, we’ll explain what that means, and give you enough basic knowledge to catch and correct errors in your medical bills.

What is Medical Coding?

Medical coding is the process of translating the medical services you receive into codes which will be included on your medical bill and insurance claim. Coding takes place early in the medical billing process to determine how much you’ll be charged for your services. Make sure you ask for a copy of your superbill, which contains the coded services you received, along with your clinical visit notes after a medical visit. These documents contain the information that was recorded during your visit, which can help you catch medical billing discrepancies due to coding errors.

What is Medical Billing?

While medical billing and medical coding are two separate and distinct processes, they are both required components for providers of medical services to get paid for their services. Medical billing is the process of creating a medical claim. A medical claim is a universal form that is submitted to an insurance carrier requesting payment. A medical claim is different from a medical bill, which is the request for payment from a patient for the balance of what is owed to the provider after the insurance company pays their piece. The process of creating a medical claim includes medical coding.

Medical Billing Process

Let’s break down the medical billing process, and where medical coding fits in.

1. Medical services are provided and documented

The medical billing process begins when a patient receives medical services from a provider, including things like a doctor’s appointment, an X-ray, getting blood drawn at the lab, even picking up medications at the pharmacy. During or immediately following the services, the provider (doctor, hospital, lab, or pharmacy) enters notes into the patient’s medical record. Typically, the electronic medical record automatically adds the corresponding procedure codes for the services provided.

2. Superbill is created

Upon completion of the visit, the information entered into the electronic medical record is used to create a superbill. The superbill contains both the description of services provided along with the corresponding procedure codes. This is the information used to create the medical claim in the next step of the process.

Superbill mockup

3. Medical claim is created

A medical claim is now created using the information from the superbill along with the diagnostic codes entered by the doctor during or immediately following the service or visit. There are two standard medical claim forms; the CMS 1500 which is the form used to bill for office visits and services that are typically covered by Medicare part B and the UB-04 which is the form used to bill for facility services such as hospitals and inpatient services.

Superbill mockup showing 2 superbills

4. Medical claim is filed with the insurance company

Once the claim form has been completed, the provider submits it to the insurance company for review and payment.

5. Insurance company processes the claim

Upon receipt, the insurance company reviews the claim against the benefits of the policy to determine if the claim will be paid. If the claim appears to be payable, it will then be reviewed against the specific benefits of your insurance policy and then paid as determined by those benefits. This process is referred to as claims adjudication. If the claim is approved, payment is then made to the submitting provider as determined by the policy benefits.

6. Insurance company issues an explanation of benefits (EOB)

After reviewing and determining if the claim is allowable and payable, the insurance company will then issue an explanation of benefits (EOB) to both the submitting provider and the plan member (patient). Generally, patients receive their EOBs in the mail by default. Many times they are also available in the member portal. The document explains if and why the claim was approved or denied and at what benefit the claim was paid. If the claim was approved and paid, the provider will also receive the explanation of benefits when they receive payment.

7. Medical provider issues a bill to the patient

Once the insurance company has reviewed the claim and paid their portion of responsibility to the provider, the medical provider will issue a bill to the patient for any remaining balance. This is the bill you’ll ultimately receive in the mail or online.

What to do if you think there’s an error in the coding of your medical bill

If the service description on the superbill does not match the services you received, there may be a coding error on your bill. If this happens, here are some simple suggestions to get it clarified and resolved.

1. Ask for the insurance claim form and request a coding audit

Call your provider’s billing department and tell them you're concerned there might be a coding error. Inform them the information on the superbill doesn’t match the service you received and you’d like them to review the medical coding to ensure accuracy before making payment. This is also a good time to request additional time to pay the bill if that would be helpful to you.

2. Ask the provider for your medical records

In addition to having your provider's billing department conduct a coding audit, you might consider having your own patient advocate complete an “independent medical coding audit.” You'll need to share your medical records and the claim form submitted to the insurance company with your patient advocate, so make sure to request them from your provider.

3. Get an independent coding audit

Getting an independent coding audit is not as difficult as it might sound. However, the coding requirements are quite complex and we recommend finding a patient advocate who is experienced in this area. There are many independent patient advocates who specialize in medical billing and coding, and you can find some tips for finding the right advocate to help you here.

Be your own advocate by understanding the billing and coding process

Understanding the medical billing and coding process will help you know where to look to identify errors in your medical bills. If your employer offers Thatch as a benefit, you have access to medical coding experts who can help you with coding errors in your medical bills. If your employer uses Thatch and you need help with a bill, reach out any time!

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