Coding is necessary so that medical providers (hospitals, therapists, physicians) can communicate with the insurance and government payers.
ICD-9 ( and soon to be ICD-10) means International Statistical Classification of Diseases and Related Health Problems 9th edition. An update is in progress. This system codifies medical conditions so that the payers can understand what is being treated.
CPT mean Current Procedure Terminology. These codes represent specific treatments, procedures or diagnostic evaluation. This is how the providers communicate what procedure or evaluation was performed for a specific medical condition.
Most payers will match the CPT codes with the ICD codes to make sure the appropriate treatments have been performed for the problem. If the coding does not match up, the reimbursement for the procedure or evaluation may be delayed or denied.
As there are many medical conditions and treatment options, you can imagine the logistics in matching the right conditions with the right authorized treatments. Because the need for these treatments need to meet the criterion of Medical Necessity, careful documentation of the condition, and prior treatments are necessary to achieve proper authorization to perform a procedure or diagnostic study.
As a patient, you may think that this should not be your concern. However, if your physician and his(her) office staff cannot obtain the necessary coding to obtain the authorization, you may have a delay in your treatments, or, you may be billed for the treatments. In that scenario, you “Good Doctor”, who now cannot get your care authorized, and may need to bill you, becomes “that incompetent, uncaring, greedy Doctor”.
That is part of the problem facing delivery of healthcare today. Most physicians go through medical school not knowing about this facet of medical practice. But now, to be a “good Doctor”, s(he) needs to be a good administrator, organizing a staff that can take care of you as a patient, while also hiring staff to process the ever increasing insurance bureaucracy. Life was much simpler in the days before insurance, and thus medical coding.
Back in the “good ole days”, a physician was in solo practice with a receptionist who makes appointments and greets the patients, a nurse who helped delivery and documentation of the medical care, and an office book keeper who collected the cash payments and paid the expenses.
Now, a physician needs a receptionist, a nurse, a billing and coding specialist, an authorization clerk, and an office manager who manages the process. In this simple example, you can see how just in terms of billings and coding, you will most likely need two more people. Those costs do not include additional office space, phone lines, computers, and training of these additional staff members.
As medicine became more sophisticated, the “good and caring” Physician, who delivered the most timely care to his patients, became the one who also possessed the “business savvy” to put a good medical as well as clerical team together.
Last modified: October 22, 2019