coding simplified

Through the past two decades, the world of medical coding has evolved significantly. Documentation, in the 80s was either handwritten, transcribed or typed on a typewriter. Technological advances gave the public more access to resources and also made the process of billing less cumbersome and expensive. Medical office employees were usually trained as medical assistants whose work covered patient care, reception, transcription, coding, billing, filing, insurance verification, etc. Medical coders were relatively rare then as the world of coding was still evolving.

Coding was executed through a super-bill or a charge-master which was marked by the attending physician. Surgical services and procedures were fed into the medical billing software and claims were then mailed to the insurance companies. Payments, through insurance or patients, were fed into the same billing software and a monthly record was kept and mailed. Paper was the chosen method of doing business but it grew out of fashion once personal computers became more feasible and economically viable.

The Electronic Boom

Changes in technology meant that there would be changes in the management of information. Very few providers still utilize paper medical charts as electronic medical records have become the chosen method of billing. Programs can be specialized designed to meet the varied needs of individual medical offices and facilities. Information is now transmitted over the network of computers and data banks and instead of being locked physically, they are protected through secured logins and private network thus never exposing confidential patient information.

Patient information can be gained electronically before the appointment and information that is provided at the facility is fed into the same system thus centralizing the data. Coding was done manually through the crude ICD-9 CM diagnostic system and CPT procedural coding manuals. Encoding medical billing software now handles these operations and these software allow simple searches which are more detailed in nature in order for the program to bring the correct code quicker and cleaner. Dot-matrix printers were once the backbone of all administrative departments but they have been rendered useless through the electronic transfer of data through the internet to clearing houses. This allows for instantaneous updates.

Insurance payments still come through the common mail, however, even insurance companies have benefitted from the growth in technology and it has become easier for them to directly deposit payments into their clients’ accounts and also allow for electronic explanation of benefits and clauses. The reduction in paperwork allows for more employee time being spend in healthcare provisions than administrative claims duties.

Regulating Improvements

There are now modern HIPAA laws which secure patient information and keep them from prying eyes. Computer requirements have also been updated in order to ensure smoother flow of data between facilities, provides, insurance companies and government agencies. Many facilities now feature systems which allow for medical data and records to be pulled up at any time of the day regardless of whether the offices are opened or closed. This makes emergency treatment much easier and effective.

The most significant change is the change from the ICD-9 CM diagnostic data set to the ICD-10 CM diagnostic data set. This change is slated to happen in October 2014. ICD-10 will require coders to  have a functional knowledge of the anatomy and human organ systems and will require providers to document in further detail in order for more accurate and detailed codes to be provided. Medical necessity will be easier to prove with diagnostic coding and reporting being improved in greater detail. Insurance companies now require that healthcare providers prove that procedures and services were medically necessary. The entire process of pre-authorization revolves around the documented necessity of a medical procedure. Medical billing services have definitely received a significant boost with the sharp growth of technology in the sector.


George is a healthcare claims specialist who has been working in medical billing for the past twenty years. He has been an outspoken enthusiast for technological developments to be implemented into the billing industry in order to help healthcare providers become more efficient in their tasks.


October 22, 2014

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