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The Art of Medical Coding

Medical coding can be described as a form of art because:

In medical billing and medical care, we have many variables to deal or interact with. Insurance companies offer many types of plans to employers and members. At one time, they offered something simple known as a traditional plan. The traditional plan used to pay a fee for service, which meant you submit a claim for $100, they paid $100. Some insurance companies are a for profit company. To make a profit, you cut back on payments. Many years ago, Health Maintenance Organizations were developed for many reasons. One was to work on making people healthy by catching medical conditions early. As Andy Grifith would say, Nip it in the bud! But there were many problems with HMOs. Clinics were overloaded. There were too many rules and lawsuits. The HMO eventually changed and became just a simple health policy.

In Patient and Out Patient Medical Coding

There are different medical coding activities and procedures. Depending on the nature of care given they are assigned to either an out patient medical coder or an in patient medical coder. Medical coders in hospitals code for procedures that took place in a hospital, such as surgeries, intensive care, childbirth and other in-patient diagnostics and care, however most medical coding is done for outpatient care simply because most medical and health care delivery is done on an ambulatory or walk-in basis such as in doctor's offies, clinics and healthcare centers.


HMOs, PPOs and POS

HMOs, PPOs, and POS plans are practically the same with some minor differences. All three has the patient select a primary care provider All offer benefits, HMOs have more restrictions and requirements such as precertification and authorization.

medical coding bullets PPO and POS members are free to go out of network without authorization, but at a price. The PPO and POS may only be required to pay in network rates with the patient paying the balance or difference between the providers charges and carrier payment.

medical coding bullets HMOs may have a restriction that the HMO member remain in network when seeking care. The exception may be with emergency care as not all emergency doctors may be in network.

Not all HMO members may have the same benefits. Mr. Jones may have an HMO plan with ABC Insurance. Mr. Smith may have an HMO plan with ABC insurance. Mr. Jones may have eye care as a benefit but Mr. Smith may not have eye care as a benefit.

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