Most professional coders and billers work in the outpatient physician office setting. This is because every doctor needs to send out his or her own bills to insurance companies, government healthcare agencies, or to patients. The number of private physician practices outnumbers all other healthcare facilities combined. When a physician provides services to his or her patient in the inpatient hospital setting, in an outpatient facility, or in an acute care clinic, radiology clinic, or sleep study lab, the physician bill for professional services is separate from the bill generated by the technical service provided by the institution.
Professional Medical Service Coding
Many Common Procedural Terminology (CPT) codes and Level II Health Care Procedure Codes (HCPCS) consist of a technical component and a professional component. The technical component is billed by facilities that provide the supplies, the support staff, and the physical space to perform a medically necessary service. The professional component of a code is used to describe and bill a licensed healthcare provider’s expertise in interpreting results and managing a patient’s treatment plan.
Surgeons, radiologists, and pathologists, among other specialists, often utilize codes that contain both a technical and professional component. When services are provided outside of these physicians’ offices, only the professional component is coded and billed by appending the modifier -25 to the procedural code. The outside facility bills the same code, provided by the physician, with the modifier -TC. When the service is provided in the physician’s office, it is billed universally; both components are billed and coded without an appended modifier.
Some medical services consist only of a professional component. Physician medical billers and coders are familiar with these Evaluation and Management (E/M) codes. They are the codes used to describe and bill office visits, hospice and skilled nursing facility (SNF) visits, home visits, and consultations.
Physician Office Medical Coding and Billing
Because most physician-setting medical billers and coders are employed by smaller medical practices, they often fulfill both roles. In the small office setting, physicians cannot employ a large support staff to ensure accurate code assignment that complies with government and commercial payer contractual requirements and guidelines. A well-informed physician medical biller is aware of all the nuances of medical coding. A certified medical coder who works in a physician office codes procedures and submits bills, posts reimbursements, and discusses financial obligations with patients. A professional physician medical biller, or a certified medical coder with physician office experience, is a small medical practice’s first line of defense against legal charges of fraud and abuse of the healthcare reimbursement system.