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Coding: transforming healthcare diagnosis, procedures & equipment into universal medical alphanumeric codes

The global medical coding market size is expected to reach $25.4 billion by 2025, according to a new report by Grand View Research, Inc., registering a 10.0% CAGR during the forecast period. Rising need for a universal language to reduce fraud and misinterpretations associated with insurance claims is driving the market growth

Medical coding is the transformation of healthcare diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory and radiologic results, etc. Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.

Medical coding happens every time you see a healthcare provider. The healthcare provider reviews your complaint and medical history, makes an expert assessment of what’s wrong and how to treat you, and documents your visit. That documentation is not only the patient’s ongoing record, it’s how the healthcare provider gets paid.

The healthcare revenue stream is based on the documentation of what was learned, decided, and performed.

A patient’s diagnosis, test results, and treatment must be documented, not only for reimbursement but to guarantee high quality care in future visits. A patient’s personal health information follows them through subsequent complaints and treatments, and they must be easily understood. This is especially important considering the hundreds of millions of visits, procedures, and hospitalizations annually in the United States.

The global medical coding market size is expected to reach $25.4 billion by 2025, according to a new report by Grand View Research, Inc., registering a 10.0% CAGR during the forecast period. Rising need for a universal language to reduce fraud and misinterpretations associated with insurance claims is driving the market growth.

Presently, medical coding is in its initial phase with frequent introduction of advanced versions of classification systems. In addition, the number of coders is constantly rising as a result of career opportunities in this field. Escalating demand for coding services, coupled with the aforementioned factors, is driving the market growth.

Constant revisions in classification systems and their global acceptance are expected to result in lucrative growth during the forecast years. Rising demand for world-class healthcare services in developing regions is also anticipated to boost the adoption of medical coding procedures.

In the UAE, both the Governments of Dubai and Abu Dhabi have mandated the use of standardized medical codes as part of providers’ e-claim transactions. Medical coding is not only important in as far as regulatory compliance is concerned. It is also crucial in accurately capturing the medical services extended by the practice and in translating these services into billable items. Inaccurate coding due to untrained staff increases the chances of claims being rejected by payers.

AccuMed has a team of coding experts who are certified by some of the world’s most respected agencies, including the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC).

Dr. Ayham Refaat, Founder and CEO, ACCUMED tells the editor of Mediworldme, Ayesha Rashid, what is medical coding in detail and how it is used in the UAE?

Tell us in detail what is medical coding?

Medical coding is the process of transforming medical data which includes healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. In the healthcare industry there are standardized and internationally recognized numerical codes that describe diseases, injuries, and medical procedures.

The choice of the correct medical code is dependent on a detailed documentation of the patient’s medical history and current episode of care, supported by a deep knowledge of the medical coding, anatomy and physiology by certified medical coders.

How do coders take medical reports from doctors and turn them into a set of codes?

Medical coders must understand what each of the codes represent, and there are three types of coding: Diagnosis classifications which all follow the International Classification of Diseases, or ICD codes, developed by WHO. These are diagnostic codes that create a uniform vocabulary for describing the causes of injury, illness and death. Classifications for Procedures which are used to document the majority of the medical procedures performed in a physician’s office. Example of those would be the Current Procedure Terminology (CPT) developed by the American Medical Association, or the Australian Classification of Health Interventions (ACHI) developed by the University of Sydney, or more recently the Saudi Billing System for Private Health Insurance (SBSPHI) developed by ACCUMED.   Last type would be those classifications that are used to represent not only procedures like above, but also medical devices, consumables, supplies, medications and transportation services. Example of which would be the Healthcare Common Procedure Coding System (HCPCS), developed by Centers for Medicare and Medicaid (CMS) in the USA.

Why do we need to code medical reports?

Medical coding helps to uniform and collect accurate medical data from healthcare providers about episodes of care., Such data allows for governments and agencies to track health trends more efficiently which can help them understand their healthcare system needs better, set policies, understand the effectiveness of a treatment or the prevalence of a certain disease, and take informed data-backed decisions for the betterment of the health of their citizens

It also allows the use of modern technologies and big-data analytics to leverage automation and artificial intelligence to improve the clinical outcomes while reducing cost of healthcare services, thus leading to the transformation towards a value-based healthcare system in a country.

Accurate medical documentation is a critical aspect of billing within the revenue cycle process in the healthcare industry. Providers use these detailed medical records to validate their reimbursements to payers when a conflict with a claim has been issued. If a procedure or treatment is not properly documented in the medical record by a provider or their hospital staff, the health organization could face a denied claim. When records contain inaccurate information or are incomplete, an immense amount of time and money must go into correcting the flaws within the document. When this issue is happening on a grand scale, the stress put on the revenue cycle process can have major consequences for the provider’s bottom line.

By ensuring that documentation is correct before it is sent to the payer, the flow of the revenue cycle can go uninterrupted and healthcare administration costs can be kept at a minimum.

How it is closely tied to medical billing?

The main purpose of medical coding is the collection of accurate, meaningful and actionable clinical data. Using Classification systems for billing by assigning a financial value (price) to a service code is a proven method to ensure the availability and accuracy of coded clinical data. Tying medical coding to medical billing ensures physicians will be incentivized to document a patient’s visit to the highest detailing, and ensures coders assigning codes to the highest accuracy, so to guarantee the payment. Both outcomes being of extreme value to any healthcare system

Moreover, it facilitates the use of technology and the exchange of data between the healthcare providers, payers and regulating bodies electronically.

Tell us in detail about the billing process and how does it represent the ‘heart’ of the entire revenue cycle management?

Medical billing is an extremely complex process that accompanies a patient’s journey in a healthcare facility from beginning to end and is comprised of many steps at each level of the care delivery process.  Registering patients is the first step of the process during which a patient will need to share their personal and insurance details for the healthcare facility to establish eligibility of required treatment under the patient’s insurance policy.

Once eligibility is established, a patient will be seen by the physician who might require further diagnostic procedures to diagnose the case. This will trigger a multi-steps authorization process whereby clinical information about the case has to be coded and sent to the insurance company for their review and decision.

If approval is granted and after the service is provided, the final medical report is sent again to the medical coder to transform the data into codes, the report which is translated into codes and contains personal information about the patient and their medical history is called the ‘superbill’, once the medical coder is done, he would then send the ‘superbill’ to the medical biller, the medical biller would then put it either into a paper claim form, or into the proper practice management or billing software, and transmit claims. One the claim is received by the payer (Insurance company) it goes under the adjudication process where the payer evaluates the medical claim and decide if the claim is approved or denied and how much of the claim will be reimbursed. The payer would then send a report to the biller who has to create a statement for the patient.

Denied claims will then have to be reviewed by the healthcare facility specialized team to understand reasons for rejection and resubmit the case with proper justifications.

Further processes related to collection of payment from payer, collection of co-payments from patients, and final reconciliation has to be performed as well to avoid revenue leakage and ensure the billing cycle is closed efficiently.

Depending on the country, it takes a healthcare provider any time between 90 – 180 days from the day the patient visited the facility, till the time the payment against that visit is received. If claims are denied and has to be resubmitted, this could take the timeframe up to 300 days.

How do you safeguard patient information in terms of coding and billing? Please provide us with details about measures taken to safeguard patient’s data

Data confidentiality should be a top priority for healthcare providers, as well as Revenue Cycle Management companies who are using these data for coding and billing purposes. In ACCUMED, our systems automatically block all personal information of a patient and anonymize the claim. Staffs working on the case can only see age and gender (both required for accurate coding) but do not know who the patient is. The system then at the end of the process inserts the patient data before transmitting to the payer in an automated format. All computers are blocked for any print, download or use of external hardware. Moreover, staffs are requested to leave their mobiles in safety boxes when arrived at the office before they start their work to avoid taking photos of the screen.

Paper claims pose more challenge in data confidentiality which is why we always advice healthcare providers to use Electronic Medical Records. Still, in the absence of EMR, we have a dedicated department that receives the paper medical records and anonymize the patient’s data using markers. The department is fully secured to avoid any leakage. The information is then entered to our system to create and electronic claim and the process is continued digitally as explained above.

In the UAE, why is medical coding mandatory? How does it help the government?

In the UAE, both the Governments of Dubai and Abu Dhabi have mandated the use of standardized medical codes as part of providers’ e-claim transactions.

Medical coding is crucial as it helps uniform and collect accurate medical data from healthcare providers, and it provides governments with data that helps them make better informed decisions and track medical trends and have a better control over medical costs and manage the health care industry in general. The medical reports also allow governments and healthcare institutions track medicines and how affective they are.

Kinds of technology used in medical billing and coding?

We at ACCUMED have an RCM focused billing platform which is designed specifically for the GCC healthcare market and based on best global practices and aims to achieve operational and financial excellence. The platform is able to integrate with any existing hospital management system or RCM software. The platform can find and remove any operational issues and bridge billing gaps. And the billing system compiles with regulation policies, payer policies, medical Rules and ICD/CPT Crosswalks, provider Business Rules

Automation is key to us as it helps us minimize errors and reduce costs. We have also developed artificial-intelligence based claims scrubbing tools used to ensure accuracy of coding nd compliance with regulators and payers requirements. We also provide dedicated technology solution to small size clinics and medical centers to aid them in transforming into paperless environment. This solution is comprised of a cloud-based Electronic Medical Record, Practice Management Software and a our Billing platform; all integrated into one solution that can be availed on prescription basis at nominal cost with zero upfront investment (both time and money) in hardware and software complicated setups.

In your opinion why is proper medical coding important for ensuring accurate payment and patient care history?

As mentioned, every symptom or patient status has a special medical code created to reflect it. The main purpose of having a medical coding is to collect accurate clinical data that is meaningful and actionable. The medical codes are used to record and track the medical history of the patient as well as collecting claims. If there are any errors made while coding, then the medical history of the patient is compromised directly impacting the future health of any individual. In addition to patient’s health, errors in medical codes also impacts medical billing leading to possible delays or rejections in payments or claims resulting in loss of revenue.