Are you interested in becoming a medical assistant and wonder what are the guidelines for medical billing and coding? Medical billing and coding is a complex discipline with high standards. Properly coded and billed services are vital for doctor accountability, patient safety, the efficiency of the healthcare system, and obtaining reimbursement.

Working as a medical assistant is personally and professionally rewarding because you help ensure the continued function of the healthcare system. Career success requires a broad skill set, perseverance, and an eagerness to face new challenges. Medical assistants must learn a wide array of guidelines and policies. The fundamentals of billing guide each task medical assistant must complete as part of their duties.

The U.S. federal government enacted legislation to formalize and unify coding principles so that healthcare providers and insurers can easily communicate with each other. The uniform standards and practices make it easier for providers to secure reimbursement, hold facilities accountable to combat waste and fraud, and ensure effective continuity of care because records are consistent nationwide.

As a medical assistant, your entire job will interact with these medical billing and coding guidelines. Medical assistants must also understand the core guidelines of the industry and respond to ongoing revisions to existing policies. The best way to attain fundamental knowledge is by completing a comprehensive training program through a vocational school.

Medical Billing and Coding Guidelines

These guidelines influence almost every duty performed by a medical assistant. The specificity and detail needed to perform the role of a medical assistant necessitate expansive guidelines and rules. While medical assistants must retain a lot of information, there are many resources they can leverage to navigate unique and challenging cases. The following guidelines impact day-to-day tasks.

ICD-10-CM

The primary language used by medical assistants is the International Statistical Classification of Diseases Clinical Modification (ICD-10). This system is an alphanumeric language used to identify the illness, injuries, and conditions impacting patients. The World Health Organization oversaw the creation and implementation of the system. ICD-10 codes are so specific that they reflect the nature of an injury, the affected body part, and the severity of the condition.

Medical assistants must create medical records and ensure the codes selected are consistent with the examination performed by the healthcare provider. The ICD-10 codes are essential for establishing medical necessity for rendered treatments and feed into which procedure and treatment codes are chosen.

Skilled medical assistants learn through training how to quickly and efficiently navigate reference materials to help them select correct and accurate codes. Thriving in the profession requires you to become comfortable and conversant in the ICD-10 system. You will use the codes when speaking with doctors to obtain clarification on cases and to assistant medical billing and coding specialist when following up on outstanding or denied claims.

Medical assistants must also follow industrywide updates. As new diseases emerge or scientific advancement leads to the reclassification of existing conditions, the ICD system evolves to reflect the changing realities of patient care.

Researching Eligibility and Applicability

Medical assistants must account for the specific rules that dictate the area where the service was performed. As a medical assistant, you may need to read Local Coverage Determinations (LCDs) to determine if a particular service or item of durable medical equipment (DME) is allowable.

The LCDs explain the coverages using ICD-10, CPT, and HCPCS codes. Medical assistants must be able to interpret the documentation and ensure the service adheres to the standards of care. Before the medical assistant moves forward, they will need to consult the LCD to ensure they provide the necessary supplemental documentation to the patient’s electronic health records.

LCDs are often lengthy documents you can confidently read with proper training and experience. Your knowledge will build as you leverage separate facets of your role to complete tasks.

CPT and HCPCS Procedure Codes

Medical assistants must select the correct Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for medical billers to generate valid invoices. These codes are tied to reimbursement and identify the service or procedure rendered by the provider.

Even the most skilled medical assistant could not memorize the entire coding list. Many electronic and hardcopy aids are available for investigating the necessary and appropriate codes. Medical assistants are ethically obligated to select codes that accurately reflect the services rendered while at the same time maximizing reimbursement for their provider.

This responsibility requires reading and interpreting medical records that use specific anatomy and physiology terminology. Medical assistants must exercise extreme attention to detail when selecting CPT or HCPCS codes because they are specific and detailed. Errors can lead to claim denial and the need for revisions.

CPT and HCPCS Modifier Codes

Beyond the codes used to describe procedures and services, medical assistants must understand and use hundreds of modifier codes. Based on the type of cases being coded and the scope of the healthcare provider or facility, medical assistants may need to amend CPT or HCPCS codes with modifiers to specify everything from how many wounds were treated to which finger was splinted.

Medical assistants must pay close attention to detail. The selected codes and modifiers must be consistent with the actual services performed. During a billing review, auditors will look for missing or incorrect modifiers that justify denying the claim.

Bill Type

Based on the employer, medical assistants must select a bill type. This four-digit code conforms to the Fiscal Intermediary Standard System (FISS). Bill type tells the insurance company where the services were performed and allows them to determine applicable rules and reimbursement.

Every bill type starts with a leading zero. Medical assistants must then select a separate digit for the type of facility, type of care, and frequency. There are 40 possible digits for the combined categories. Medical assistants must be precise to ensure their claim is properly reviewed and processed.

Revenue Codes

Revenue codes are vital for hospital billing because they group related ICD-10, CPT, and HCPCS codes into a single line. Revenue codes include brief descriptions of the diagnoses and services.

They are a vital component of the process that helps insurers determine what department a service occurred in within the hospital. Revenue codes also help group the separate components of a single service. For example, they simplify the billing of an emergency room procedure by grouping the illness, treated body parts, and medical supplies used to administer relevant procedures together.

Final Thoughts

Now that you know how medical assistants use medical billing and coding guidelines, it is time to learn more about CyberTex. Take the first step toward a rewarding and challenging career as a medical assistant and contact us today to learn more.

Want to Learn More?

The Medical Assistant Training Program at CyberTex Institute of Technology takes great care of you by providing hands-on training, practical experience and the support it takes to get started in a medical assisting career without spending years in school. You will learn the basics of both clinical and administrative skills, and prepare to work in physician’s offices, hospitals, and other medical facilities.

Contact us today to learn more about our Austin and Killeen campuses.