Terminology for Medical Billing & Coding

Specialized terminology plays a key role in billing and coding: It's part of the language of the healthcare system. Medical billers and coders frequently communicate with medical providers, hospitals, insurance companies, pharmacies and collection agencies, especially when a claim is denied. To do their jobs effectively, they must understand the terminology of billing and coding.

Significance

• Billers and coders review medical documents to assign codes, maintain records and identify the data needed to submit and process claims. Medical terminology concerns information regarding a patient's condition/diagnosis, medication, symptoms and services rendered. Insurance terminology consists of language pertaining to policies, reimbursement procedures, coverage, etc.

Anatomy & Physiology

• To comprehend medical data and locate corresponding codes, you must be familiar with the human body, its structures and systems. These are: cardiovascular, digestive, endocrine, hemic and lymphatic, musculoskeletal, nervous, male and female genital/ reproductive, respiratory, skeletal and urinary.

Health Insurance Carriers & Policies

• Insurance carriers (Medicare, Medicaid, GHI, Blue Cross/Blue Shield) offer different types of plans, including indemnity plans and managed care plans (HMO, PPO, POS and EPO). Coding and billing methodologies must comply with all federal and legal laws, as well as each provider's guidelines.

Insurance Billing & Reimbursement Terminology

• Key vocabulary within this area includes: benefits, bundling, charge capture, coinsurance, claims, co-payment, cost sharing, covered expense, deductible, eligibility criteria/eligible payment amount, fee schedule. The vocabulary of billing also includes: Health Insurance Portability and Accountability Act, internal control number, medical necessity, network, pre-authorization, premium, prospective payment system, revenue code, submitter ID and supplemental plans.

Diagnostic & Procedural Coding Systems

• The International Classification of Diseases is a diagnostic coding, while Current Procedural Terminology and the Healthcare Common Procedure Coding System are for procedural coding. Each system involves unique conventions, guidelines and an overall scheme. Coders and billers review these systems, when they're used and the services they cover.