Medical Record and Coding, Assessment Example

Chapter 2 Medical Record and Coding

When looking at my own medical bills I have often wondered how the amounts were decided and what the diagnosis codes mean.  Was there a universal secret medical language that used?  Are the costs at random?  These are some of the questions that I personally had and I am sure many others who are not in the healthcare industry have as well.

In reading chapter 2 I was interested to learn the reasons for all the information that is collected when arriving at the doctor’s office.  Anytime I have had an appointment the medical assistant at the desk usually asks for some key information; identification, medical card, date of birth, and address verification.  This information that is collected is typically all used for billing purposes, either to the patient or to the medical insurance carrier for the patient.

Once services are provided for a patient diagnosis and procedure codes are entered by the physician or practioner into the patients’ medical record.  These codes are generate a cost, usually a standard cost that is determined by the charge master; a price list of predetermined cost for specific services.  The information from the patients’ medical record and the charge master are what are used to generate the claim.

There are basic categories for the claim; a Uniform Bill 2004 (UB-04) and Centers for Medicare & Medicaid Services (CMS) 1500. The UB claim is usually used by hospitals and the CMS claims are usually used by physicians and independent professional offices.  Once generated these claims are typically sent to the patients’ medical insurance carrier for payment.  If a patient does not have medical coverage financial arrangements can often be made in house for the patient.

Once claims are submitted to a patient’s medical insurance carrier the insurance company makes a determination of how much they are going to pay for each service, typically there is a Usual Customary Rate (UCR) that is used to determine what amount are paid versus the actual billed amount. Typically the patient’s responsibility is the remaining balance after the UCR is paid.  In some cases once the insurance payment is received by the billing physician claims are aligned to the UCR and the patient balance is removed.

After reading this chapter I have a much better understanding of how the medical record and coding process works. I can now understand the methods used to determine patient balances and standard charges for a doctor’s visit and the process in which the medical office is paid.