Healthcare in the U.S. is hugely expensive, and for most people, insurance plans are a necessary evil. Medical providers work with a variety of insurance companies as well as government programs such as Medicaid and Medicare to ensure that they are paid for the services they provide. 

Every single part of a patient’s care – from diagnosis, testing, surgeries, medication, and everything associated with these services such as equipment used – and administrative tasks related to it are billed, with each one having its own unique code. In order for the facility to be reimbursed, the insurance company must be given the accurate information. This is done by way of medical coding and billing. 

What is Medical Coding and Billing? 

Medical coding is the process of taking a patient’s information and translating it into universal codes used by medical providers and insurance companies throughout the U.S. and across the world. Most countries use the International Classification of Diseases (ICD) codes. CPT (Current Procedural Terminology) codes are also used and these help with the streamlining of reporting, which improves accuracy and efficiency. 

Once the coding has been done the next process is medical billing, which is where coded information related to a patient’s care will be used to generate an invoice to be sent to the relevant body for payment. 

The Importance of Accuracy

When coding and billing is completed accurately, the insurance company or government body can quickly process the invoice and make the necessary payment. This then helps the medical provider to ensure they can pay staff and treat patients effectively. The experts on chiropractic diagnostic coding at Findacode.com explain that coders can quickly find the information they require by searching in an online database. These databases, contain the hundreds of thousands of codes used in the industry, with easy-to-use functions such as NPI lookup. It makes it easier to find the right ICD 11 diagnosis codes as well as any other codes that might be required. 

Nevertheless, there is more to just picking the right code. Coders must ensure that they are following the specific rules and regulations, complying with the Health Insurance Portability and Accountability Act (HIPAA). 

As you can see, accuracy is particularly important in this role. There are many profound consequences associated with inaccurate coding and non-HIPAA compliance. Using incorrect codes when making a claim could at the very least lead to a rejection of a claim, meaning it must be reassessed and recoded for payment. At worst, it could lead to accusations of medical fraud, resulting in fines or worse, or a federal penalty such as imprisonment.  

Whether deliberate or unintentional, coding and billing mistakes that result in monetary gain for a medical facility are considered medical abuse or fraud. If this abuse occurs over a prolonged period, or if it happens across a wide range of patients, it will most probably be seen as fraud. What’s more, submitting inaccurate claims to government agencies such as Medicaid or Medicare is a violation of the Federal Civil False Claims Act (FCA), and because there is no requirement for intent, the penalties can be quite damaging. 

If a medical facility is found guilty of violating the FCA, it could result in a fine of up to three times the cost to the government plus additional penalties running into the tens of thousands. It could also result in a prison sentence. 

Those in charge of medical facilities must make sure that their coders are following all the relevant guidelines and that they are working accurately. Because of the possible penalties associated with incorrect coding, many institutes opt to outsource this work to a reputable agency.