Health Language Blog

Medical Billing and Coding:  Exciting Changes Ahead

Posted on 07/20/16


It’s an interesting time to be in healthcare, especially medical billing and coding! Over the next few years we will see major changes that will help us spend our healthcare dollars more wisely, and keep people healthier. These changes will have a profound impact on patients’ and physicians’ daily lives.

Let’s take a look at some of the biggest changes:

The Affordable Care Act The Affordable Care Act (ACA) is intended to make medical care accessible to all Americans, and with its passage on March 23, 2010 we are seeing an increase in medical procedures, and therefore an increase in coding and billing. Accuracy is even more critical today: the ACA has strict documentation rules in place, so medical coders need to be much more accurate when coding patient procedures. Inaccurate coding leads to denial of insurance or billing delays, creating more work and frustration for patients, facilities, and providers.

Electronic Health Records As of January 2014, all healthcare providers are federally mandated to use electronic health records (EHRs), also known as electronic medical records (EMRs). The idea is that digital records will improve patient care by allowing a patient’s entire medical history to be viewed in one place and easily shared with others.

ICD-10 and Other Coding Changes The transition from ICD-9 to ICD-10 on October 1, 2015, was perhaps the biggest change for medical billing and coding professionals:

  • ICD-10 has more than 87,000 procedure codes, and nearly 70,000 diagnosis codes, with the option for new codes.
  • ICD-9 had far fewer of both: 3,824 procedure codes and 14,025 diagnosis codes.

With the upcoming October 2016 update, there will be an additional 5,550 revisions to ICD-10-CM and ICD-10-PCS. With so many available codes in ICD-10, providers and medical coders need to be more specific and accurate in their work.

In addition to the new diagnosis coding system, the American Medical Association releases new Current Procedural Terminology (CPT) codes every year, so coders need to stay updated or risk inaccurate coding.

The Transactions and Code Sets Final Rule, as required by HIPAA, was issued in 2000 by HHS and named standard transactions to be used by "covered entities," defined as healthcare providers (including physicians), payers, and clearinghouses, when conducting specific administrative transactions electronically.

These are the administrative transactions named in the Transactions and Code Sets Final Rule:

  • Health claims or equivalent encounter information
  • Eligibility for a health plan
  • Healthcare payment and remittance advice
  • Health claim status
  • Referral certification and authorization
  • Enrollment and disenrollment in a health plan
  • Health plan premium payments

Most of us come in contact with medical coding standards at some point in our lives—whether as physicians, medical billers, or patients. When we do, it can be helpful to know the specific purpose of each different coding system. Here are some of the more common medical coding standards:

ICD – International Classification of Disease

The International Classification of Disease (ICD) is a widely recognized international system for recording diagnoses. It is developed, monitored, and copyrighted by the World Health Organization (WHO). Applied to any diagnosis, symptom, or cause of death, ICD consists of alphanumeric codes that follow an international standard, ensuring that the diagnosis will be interpreted in the same way by every medical professional both in the U.S. and internationally.

CPT Coding – Current Procedural Terminology

Current Procedural Terminology (CPT) is a U.S. standard for coding medical procedures, owned and maintained by the American Medical Association (AMA). Like ICD coding, CPT coding is used to standardize medical communication, but where ICD-9 and ICD-10 focus on the diagnosis, CPT instead identifies the services provided. CPT is used by insurance companies to determine how much physicians will be paid for their services.

LOINC – Logical Observation Identifiers Names and Codes

Logical Observation Identifiers Names and Codes (LOINC) was created in 1994 by the Regenstrief Institute as a free, universal standard for laboratory and clinical observations, and to enable exchange of health information across different systems. LOINC is a code system used to identify test observations.

SNOMED CT – Systematized Nomenclature of Medicine Clinical Terms

SNOMED Clinical Terms (SNOMED CT) is a comprehensive, computerized healthcare terminology—containing more than 300,000 active concepts—with the purpose of providing a common language across different providers and sites of care. As a core EHR terminology, SNOMED CT is essential for recording clinical data such as patient problem lists and family, medical, and social histories in electronic health records in a consistent, reproducible manner.

SNOMED CT can be mapped to other coding systems, such as ICD-9 and ICD-10, which helps facilitate semantic interoperability.

Visit again in coming weeks to learn more about these standards and how they can affect your everyday life.


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Topics: ICD-10, Coding Challenges, LOINC & SNOMED, EHR, CPT, ACA, billing, icd-9

About the Author

Kate Tierney - With more than 25 years of experience in the healthcare field, Kate has extensive clinical experience in private practices, outpatient clinics, healthcare education, and auditing. She spent three years as a medical coding, billing, and insurance instructor, and served on the AAPC National Advisory Board for District 7 from 2011–2013. She also served on the advisory board of the National Healthcareer Association from 2008-2011. She is a contributing author of the AAPC’s Official CPC Certification Study Guide, and has numerous coding certifications, including CPC, CPMA, and ICD-10 Trainer. Kate has been with Health Language for more than three years working with the clinical data analysts on client projects.