A Bright Future for
By Christina Thielst, LFACHE
Medical Coding, Billing and Auditing
Healthcare administration job growth continues to rise as the population ages, and an increase in newly insured individuals creates more demand for health services. Also, the transition to the International Classification of Disease (ICD-10) coding system and a shift toward payment for value presents significant opportunities in the areas of medical coding, billing, and auditing. While each of these careers has a bright outlook, those with advanced education have a chance to develop a dual expertise that will contribute to the financial health of the medical practice, hospital or other provider organization.
Certified medical coders transfer patient diagnosis, services provided and equipment used into universal alphanumeric codes during a review of clinical documentation in the medical record. Coders have an important role in ensuring that the amount billed accurately reflects the level of care provided.
Since the 1970s, coders were using ICD-9, but the recent switch to ICD-10 has significantly expanded the number and specificity of codes to over 141,000. The benefits of the new codes include more accurately defined care for reimbursement purposes and refined data and information used for more effective decision makingThose with expertise in the ICD-10 coding system may be called upon to assist in the identification of trends and contribute to provider education and planning.
Once coders determine the appropriate ICD-10 code(s) for each patient encounter, this information is used by certified medical billers to submit claims and monitor their status to ensure reimbursement to the clinicians or the hospital/clinic for the services provided. The most valuable billers know what health plans want, ensure claim accuracy and assist with the collection of additional information from clinicians upon request from the insurance company, intermediaries, etc. Those who have developed particular expertise in the field of medical billing add value to the organization by minimizing denials, optimizing revenue and ensuring an adequate cash flow for the organization.
Medical Auditors and reviewers often have a background in either coding and billing or both. Primary duties are to assess claims for accuracy and the quality of documentation. Their primary role is to monitor compliance and support performance improvement.
Based on their findings from a review of medical records, these auditors or reviewers provide education and support to clinicians and report on the data collect so that use in quality improvement activities ultimately benefit patient outcomes. They can also request adjustments in claim payments to the healthcare provider. As a result, some healthcare providers proactively conduct internal audits improving practices/documentation and ensure they are in compliance or better prepared for external audits when they occur.
Four Key Trends
As patients assume responsibility for greater proportions of their healthcare costs, their expectations for value and convenience will increase. More patients are shopping for care and expect transparency and billing accuracy. Skilled medical billers will have an opportunity to contribute to pricing discussions with financial leadership and enhance service to patients.
Advanced analytics tools help in the analysis of large amounts of data and coders, billers, and reviewers who also have skills using these information systems can help identify missing documentation, errors, and misapplied funds to continue to improve documentation and billing accuracy.
There is growth in auditing, especially those designed to detect fraud and abuse of Medicare and Medicaid fund and of the new commercial health plans associated with Affordable Care Act’s health insurance exchanges.
As the expectation for value grows, more and more practices and other providers will see a significant increase in HEDIS and quality reviews from both government and private payers.
There are significant opportunities for certified coders and billers to contribute to the quality and cost of patient care in an important way. A career in either of these fields or as an auditor or reviewer will not only offer employment stability, but they can often be accomplished remotely or virtually - providing flexibility to those who desire alternative work schedules.
Columbia Southern University (CSU) is an online university based in Orange Beach, Ala., that strives to change and improve lives through higher education by enabling students to maximize their professional and personal potential. If you are interested in learning more about Health Care degree offerings, please visit http://www.columbiasouthern.edu/healthcare.
Christina Thielst has experienced the evolution of the healthcare system over the last 30 years as both a hospital administrator and consultant. She received a bachelor’s degree in social science/management from Louisiana State University and a Master’s of Health Administration from Tulane University, School of Public Health and Tropical Medicine and is a Fellow in the American College of Healthcare Executives.