Medical Billing and Coding Services

For several decades medical billing was done almost entirely on paper. However with the advent of medical practice management software also known as health information systems it has become possible to efficiently manage large amounts of claims. Many companies have arisen to provide medical billing services to this particularly lucrative segment of the market. Several companies also offer full portal solutions through their own web-interfaces, which negates the cost of individually licensed software packages.

The medical billing process is an interaction between a healthcare provider and the insurance company (payer). The interaction begins with the office visit: A doctor or their staff will typically create or update the patient's medical record. This record contains a summary of treatment and demographic information related to the patient. The extent of the physical examination, the complexity of the medical decision making and the background information (history) obtained from the patient are evaluated to determine the correct level of service that will be used to bill the insurance. The level of service, once determined by qualified staff is translated into a five digit procedure code from the Current Procedural Terminology. The verbal diagnosis is translated into a numerical code as well, drawn from the ICD-9-CM. These two codes are CPT and ICD-9-coding is equally important for medical claims processing.

Medical classification or medical coding is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers. The diagnoses and procedures are usually taken from a variety of sources within the medical record, such as the transcription of the doctor's notes, laboratory results, radiological results, and other sources. Diagnosis codes are used to track diseases, whether they are everyday diseases such as diabetes mellitus and heart disease, to contagious diseases such as nor virus, the flu, and athlete's foot. These diagnosis and procedure codes are used by government health programs, private health insurance companies, workers' compensation carriers and others.

Medical transcription also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format. Medical transcription encompasses the MT, performing document typing and formatting functions according to an established criteria or format, transcribing the spoken word of the patient's care information into a written, easily readable form. MT requires correct spelling of all terms and words, (occasionally) correcting medical terminology or dictation errors. MT also edits the transcribed documents, print or returns the completed documents in a timely fashion. All transcription reports must comply with medico-legal concerns, policies and procedures, and laws under patient confidentiality.