Medical coding
Medical coding focuses on translating documented diagnoses, services, procedures and certain supplies into standardized codes used in healthcare transactions. Code selection must be supported by the clinical documentation and current coding guidance.
Medical billing
Medical billing focuses on turning the documented and coded encounter into a claim, transmitting that claim, monitoring payer responses, posting payments and following unresolved balances.
| Medical Coding | Medical Billing |
|---|---|
| Reviews clinical documentation | Reviews information needed to prepare and follow claims |
| Assigns diagnosis and procedure/service codes | Creates and submits claims |
| Reviews coding rules and modifiers when applicable | Tracks claim status and payer responses |
| Focuses on documentation-supported code selection | Works rejections, denials and unpaid balances |
| Supports coding accuracy and compliance | Supports reimbursement workflow and account resolution |
Why they depend on each other
A technically complete claim can still fail when the coding is unsupported or incorrect. Likewise, accurate coding can still be attached to a claim containing incorrect subscriber, provider or insurance information. Strong billing workflows require both sides to communicate.
Examples of problems
- Incorrect diagnosis information may create a claim issue.
- A missing or inappropriate modifier may affect processing.
- An invalid insurance member ID may cause rejection.
- Incorrect provider information may delay or prevent processing.
Practice: who primarily handles it?
Assigning an ICD-10-CM diagnosis code
Medical coding.
Checking whether an insurance claim has been paid
Medical billing.
Reviewing documentation for code selection
Medical coding.
Following up with a payer about an unpaid claim
Medical billing.
Submitting a corrected claim when the correction involves coding
Usually billing workflow with coding input when the code itself must be reviewed or changed.
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