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HCM 345- 2-1 Short Paper: Compliance, Coding, and Reimbursement

Sep 5, 2023

How do medical billing and coding regulations affect reimbursement in a healthcare organization? After reviewing the steps in the revenue cycle, what are the various tasks that the different healthcare departments do to drive the reimbursement process?

2-1 Short Paper: Compliance, Coding, and Reimbursement

Even though coding and billing are two different procedures, both are crucial for receiving payment for healthcare services. The extraction of significant and relevant data from patient records and clinical documentation is known as medical coding, whereas insurance claims and patient bills are created using these codes by medical billing. The core of the healthcare revenue cycle is composed of medical coding and billing, which come together at the time a claim is created. Patient registration is the first step in the process, which is completed once the provider has received full payment for all patient services.

The complexity of the services provided, how claim denials are handled, and the organizations in charge of collecting a patient’s financial responsibility all affect how long a medical billing and coding cycle takes to complete. Provider organizations should make sure that their staff members are familiar with the fundamentals of medical billing and coding in order to aid providers and other staff in managing a smooth revenue cycle and recovering all reimbursements due to offering high-quality care. Medical billing is similar to medical coding in that it appears to be a drawn-out and difficult process but is a simple eight-step process (Bodei et al.2022, p.19).

There are several steps involved, including registration, determining who is responsible for paying for the visit, checking for coding and billing adherence, checking for payer adjudication, and patient check-in and check-out, some responsibilities include preparing and transmitting claims, Preparing the patient’s billing or statement and then providing the details of the payment and the total amount that the patient Has to pay and the last step is to collect from the patient or whoever is with the patient. There are no such responsibilities as “front-of-house” and “back-of-house” responsibilities in health care billing.


A patient is required to pre-register to visit their doctor before the time they call the healthcare provider to book an appointment. The patient only needs to explain the nature of their visit if they have earlier visited the provider and their information is already on file. In order to confirm that the patient is qualified to receive services from the provider, they must provide the provider with personal and insurance information if they are a new patient.


Who is liable for what during a specific doctor’s visit is defined by financial responsibility. The patient’s insurance plan’s covered services can be identified by the biller once it has the patient’s information. The biller should verify the health or life insurance coverage carefully to accurately generate the bill because insurance coverage varies so greatly between organizations, people, and plans. All insurance plans do not provide coverage for all services or prescription medications. If the notification that the entire cost will be covered is given to the patient’s insurance company.


The procedures for checking in and outpatients are some of the easiest front-of-house jobs to finish. If the patient is seeing the doctor for the first time, some pepper work is needed in that case. Otherwise, some information will be asked to match the data that are recorded on the doctor’s file for confirmation. The patient must provide correct government-authorized identification details, such as a driver’s license or passport, in addition to a current insurance card. The provider’s office will also take copayments from patients as they check in or out. The patient may be asked to pay the copayment after the visit, but it is always taken in advance by the provider.

Once the patient has left, the medical code receives the reports from that visit. Who extracts and transforms the data from the report into precise, useful medical code? The “super bill” is a report that gives information on the patient’s background in medicine as well as their demographics (Bajowala, Milosch & Bansal, 2020, p.8). The super bill contains all the necessary details about the medical services rendered. Names of the provider, doctor, patient, procedures carried out, codes for procedures and diagnoses, and other pertinent medical data are included. The development of a claim depends on this data. Once finished, the super bill is typically sent to the recipient using a piece of software.


After receiving the super bill from the medical coder, the medical biller enters it either manually or entering data digitally into the appropriate practice management billing software the biller will also include the procedure’s costs in the claims. Instead of sending the full cost to the payer, they will send the amount they expect the payer to pay, as stated in the payer’s contract with the patient and the provider. After the medical claim has been created, it is the biller’s responsibility to ensure that it complies with compliance standards for coding and format. Although the biller does review the codes to make sure the procedures coded are billable, the coder is typically in charge of the accuracy of the coding process. Whether a procedure is billable depends on the payer’s policies and the patient’s insurance plan.

Even though claims may have different formats, the same crucial information is present in all of them. Each claim includes information about the patient, including their demographics and medical history, as well as the procedures they underwent (in CPT or HCPCS codes). Each of these procedures comes with a diagnosis code (an ICD code) proving the need for it in medicine. Also given is the price of these procedures (Meyer et al. 2021, p.27). Claims also contain details about the provider, who is designated by an NPI number from the national provider index. A facility type code that indicates the type of facility where the medical services were provided, will also be included in some claims. Billers must also make sure the bill complies with billing compliance requirements. Typically, billers must abide by the rules established by the Health Insurance Portability and Accountability Act (HIPAA) and the Office of Inspector General (OIG). We won’t go into great detail about OIG compliance standards here for the sake of space and efficiency. They are simple but lengthy.


With some exceptions, HIPPA, the Health Insurance Portability and Accountability Act, was passed in 1996. (HIPAA) has required all health entities that fall under its jurisdiction to submit their claims electronically since 1996. HIPAA protects the majority of payers, clearinghouses, and providers. It should be mentioned that HIPAA does not mandate that medical professionals carry out all of their business electronically. Electronic completion is required only for transactions covered by HIPAA regulations (Robinson et al. 2019, p.15). One illustration of such a transaction claims. Billers may still submit manual claims, but doing so has several drawbacks. Manual claims take a very long time to reach payers, are inefficient, and are prone to errors. Billing electronically reduces human or administrative billing errors and saves time, effort, and money.

Billers have the option of directly submitting claims to high-volume third-party payers like Medicare or Medicaid. A cleaning house will likely handle a claim that a biller does not send directly to one of these important payers.

A clearing house is an independent business or organization that receives, formats and sends claims to payers on behalf of billers. Some payers have very specific formats in which claims must be submitted. By gathering the data needed to create a claim and submitting it in the proper format, the Clearinghouse lessens the burden on medical billers. Think of it this way. Each insurance payer has its own set of claim submission guidelines, and ten claims may be submitted to ten different insurance payers by the practice. Instead of formatting each claim individually, a biller can send the relevant data to the clearing house, which will then take on the responsibility of reformatting those ten different claims.

Following a review of the revenue cycle steps, the following tasks are performed by various healthcare departments to drive the reimbursement process: –

There Were Numerous Activities To Choose From. 1. Request that your client register, 2. Verify accountability of financial information, 3. Patient check-in and check-out, 4. Claims payment and verification of compliance and 5. Combine submissions and send them in

A patient is registered, given payment details, and given financial responsibility when they arrive at the clinic. They are also examined by the payer’s adjudicators to see if they are billing code-compliant, prepared to submit a claim, and under observation. The patient is then given their bill or statement, which is prepared after that.


Bajowala, S. S., Milosch, J., & Bansal, C. (2020). Telemedicine pays billing and coding updates. Current Allergy and Asthma Reports, 20(10), 1-9.

Bodei, L., Herrmann, K., Schöder, H., Scott, A. M., & Lewis, J. S. (2022). Radiotheranostics in oncology: current challenges and emerging opportunities. Nature Reviews Clinical Oncology, 19(8), 534-550.

Meyer, B. C., Friedman, L. S., Payne, K., Moore, L., Cressler, J., Holberg, S., & Longhurst, C. (2021). Medical understanding through telemedicine: a model enabling rapid telemedicine deployment in an academic health center during the COVID-19 pandemic. Telemedicine and e-Health, 27(6), 625-634.

Robinson, H., Buccini, G., Curry, L., & Perez‐Escamilla, R. (2019). The World Health Organization Code and exclusive breastfeeding in China, India, and Vietnam. Maternal & child nutrition, 15(1), e12685.

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