How Medical Reception and Coding Affect Medical Billing

by  Find-A-Code™
Jan 11th, 2024

Medical billing represents the final step of submitting medical claims to payers. A medical biller takes all the data generated from a single medical encounter and translates it into a claim that is then sent off to a private insurance company, Medicare or Medicaid, or a self-paying patient.

As you might expect, a variety of different things take place before a medical biller gets to their part of the equation. This suggests that other people involved in the process directly affect what the medical biller does. Two people in particular have a big impact: the medical receptionist and medical coder.

The Medical Receptionist

The medical receptionist is the person who sits behind the desk at the check-in desk. They sign patients in. A major part of the check-in process is gathering and verifying information. The medical receptionist is expected to:

• confirm the patient's name, address, and contact information
• verify the patient’s insurance information (if applicable)
• verify the reason for the visit
• collect any copays or other fees associated with the visit

It goes without saying that important information is exchanged during check-in. All that information is entered into the patient's record, a record that will be accessed by clinicians, medical coders, and billers. Inaccurate information will affect everyone else down the line. So it is important that medical receptionists maintain accuracy when collecting and verifying information.

The Medical Coder

A medical coder's main responsibility is to translate the data generated by doctors and nurses into a series of codes that will ultimately become the foundation of a submitted claim. Medical coders are not worried so much about personal information like name and address. Their main focus is on services, procedures, diagnoses, etc.

Medical coders utilize a variety of code sets to do what they do. The American Medical Association's Common Procedural Terminology (CPT) codes are among the most commonly utilized. They describe medical services and procedures. Likewise, ICD-10-CM codes are the most common diagnostic codes. Between these two code sets, most things on a typical medical bill will be covered.

The big thing for medical coders is volume. There are literally tens of thousands of codes along with a variety of modifiers. Coders are not expected to memorize them all. However, they do have to possess a working knowledge of each code set they utilize. They also need to know how to quickly look up codes they are unfamiliar with.

Data Accuracy Matters

Just as the information collected by a medical receptionist needs to be accurate, medical coders are expected to be accurate with the codes they generate. This is often easier said than done. Not only do medical coders have to deal with applying modifiers, but they also need to wrestle with the fact that a lot of the codes they work with overlap.

You can have a single diagnosis or procedure expressed by four or five different codes. A coder needs to try to understand a clinician's notes to decide which of the codes is most appropriate. It is not an exact science by any stretch.

When all is said and done, the medical biller is responsible for taking the data generated by reception and coding and creating an accurate bill. That bill is submitted to the payer as a claim. Provided everything is accurate and in order, the claim is paid and that is the end of it. But if any of the information is incorrect, the claim could be denied. Billers don't want that. They depend on medical receptionists and coders to provide accurate data that leads to accurate claims.