In any medical practice or clinic, the objective is to provide the best care possible and be reimbursed at the highest possible rate.  The former is in the hands of the provider—usually the clinic or practice owner—who has a vested interest in making sure that “best care possible” proposition is carried out.  He has direct control and authority over the level of care patients receive, and can easily make adjustments when circumstances warrant.  He is comfortable with his level of knowledge and education, knows his limitations, and brings in consultants when necessary to compensate for any lapse in quality he may feel would detract from the care scenario his patients receive.  We all know this is a full time job—and then some.  So what about the latter—being reimbursed at the highest possible rate?  Usually the physician has some knowledge of coding requirements that comes through osmosis from filling out encounter slips for the patients he sees, but there is hardly enough time in the day for a physician to double check every code on every chart processed by his billers and coders.  He is justified in expecting that the biller or coder will exhibit the highest commitment to excellence in knowledge, professional standards, compliance and ethics, even though the biller or coder does not have the ownership interest in the practice that the provider has. 

But how can he be sure the biller or coder does not view their role as “just a job?”  Investment.  When a biller or coder has made the investment of time and money to become a certified professional coder, it gives some assurance that he or she is committed to performing their function correctly and with a high level of integrity. The medical billing and coding professions have designated certifications for the very reasons that other professions have them:  to ensure the holder of the certification possesses the knowledge and standards that are essential to excellent performance within the specified industry.  Professional associations provide opportunities to raise the standards of medical coding through training, education, and testing.  Attainment of the designation of Certified Professional Coder ensures a coder has a solid understanding of anatomy, physiology, medical terminology, and can serve as notice to any employer that these individuals can perform coding with proficiency.  These certifications allow coders to stand out among their peers and validate their expertise.

But how to ensure the biller or coder has that vested interest in getting you reimbursed at the highest rate possible?  There is no way to certify work ethic.  Unless the coder is paid on a commission basis, it is easy to see how he or she could lapse into a daily grind malaise and let attention to detail and follow up of denials go underperformed.  By the same token, the unsupervised coder paid on commission could try to bend the rules to get you reimbursement to which you are not entitled.  For these reasons, we recommend outsourcing your practice’s billing function.  In the same way that the physician has control and authority over level of care performed, supervisors and managers at a billing company monitor accounts and see that receivables and collections stay within specific parameters and ensure that regulatory compliance is observed.  When the billing and coding are performed by a certified professional coder at an outsourced billing company, the company has the vested interest in ensuring you receive the highest possible reimbursements because they are usually paid on a percentage basis, and they have a vested interest in observing compliance because the educated biller or coder knows that he or she can be held personally responsible for fraudulent billing practices.

So what’s the best way to go?  An in house biller or an outsourced billing company?  The answer is the outsourced billing company.  Why?  Because there is safety in numbers.  The average one or two provider practice may have a budget for one individual to perform the billing and the coding functions.  Although medical billing and coding are often used synonymously, they are actually different functions that share a cause and effect relationship.  The two are better understood when addressed separately.  Medical Coders are specialists who interpret medical reports written by providers, and translate them into simple medical and descriptive terms for billing purposes.  Once the record is fully coded, the process moves from the medical coder to the medical biller.  The Medical Biller’s main responsibility is making sure the providers get paid for their services.  They prepare and submit claims, appeal any denials, and collect all payments made by both patients and payers.

The quandary for the practice principal or manager comes in when there is no room to bring in “consultants” or for the coder to discuss appropriate coding with colleagues much the way a physician can do when he or she refers a patient to a specialist or brings in another provider to review a chart and review of symptoms.  At an outsourced billing company, the principals and their agents have the common background of being certified in the field that is their primary profession.  They can confer with each other to reach the best decision about what code to use in an uncertain situation, and they generally have the professional networking in place to allow them to “refer” certain cases to “specialists:”  other recognized authorities in the industry.

The transition to ICD-10 will occur in October of 2013, and with it we are poised to witness perhaps the most massive change in coding in 30 years.  The sheer change in the volume of codes will be daunting.  Currently ICD-9 has 13,000 diagnosis codes and 4,000 procedure codes totaling 17,000 codes, while ICD -10 has 68,105 diagnosis codes and 72,589 procedure codes totaling 140,694 codes.  For this reason alone, the CPC will become vital to any healthcare organization.

Even more valuable to any practice is the coder with specialty certifications.  Coders can specialize in cardiology, dermatology, surgery or a variety of other specialties.  The more knowledgeable a coder is, the more accurate the billing becomes, which usually results in larger reimbursements, especially for specialty coding.  A cardiologist should require a Certified Cardiology Coder (CCC) to code their claims; a surgeon should require a Certified General Surgery Coder (CGSC) to process their claims; and a dermatologist should require a Certified Professional Coder in Dermatology (CPCD) and so on. 

Here at Medical Billing Resources many of our employees are Certified Professional Coders as well as certified specialty coders.  This is ultimately about reimbursements and the best way we know to ensure you’re collecting all allowable monies is the use of Certified Professional Coders.