Coding and Billing

One of the biggest challenges to any business is cash flow. In a healthcare practice that boils down to just plain old coding and billing. Unfortunately this is something many of us did not learn in school.

For me, this is but one of the largest challenges that I’ve faced since opening their doors nine months ago. Initially, we had outsourced billing to a company that promised to submit her bills, follow-up on any denials, do the secondary billing and mail out statements to patients. We were also promised real-time access to data via their website. Unfortunately and despite us doing our to diligence, none of this was forthcoming. Six weeks into practice with very little money coming in, I sat down to learn how to bill. Imagine both my surprise and relief when within 10 days money started coming in. Today, I’m still doing the initial billing and my practice partner is doing the follow up.

While I had always heard “no one cares for your many like you do”, the whole truth of that can home to me.

If you are in planning or startup phase for your practice, think hard and long how you will achieve proper coding and billing. While seen enough patience is essential, it will do you no good if this essential step is missed.

As we move forward I hope to share with everyone my resources for coding and billing and practice management. In the meantime what are your questions, concerns, and frustrations about billing.

Comments 6

  1. I’ve always done my own billing. As a psychiatric nurse practitioner, the codes I use aren’t too numerous, so it was easy enough to learn them. Medicaid is the easiest to bill, oddly enough. It’s very user-friendly, on-line. Medicare is impossible, absolutely impossible (for psych. anyway) so I stopped taking Medicare very quickly. They simply never paid and always found something wrong with my submission. Community Health Plan was easy–I faxed them the bills, and they paid predictably. Uniform was easy–always written hard-copy bills, but they pay well providing the deductible has been paid. Regence ultimately wasn’t worth it–they didn’t pay enough for psych. Premera was a little better. (These are both Blue Cross/Blue Shield insurances.) If a client has Medicare and a supplemental insurance too, it’s even more impossible than just Medicare–I never ever got paid. I recommend a book called “Money and Outpatient Psychiatry” for psychiatric NPs.

  2. Laura and I know each other from another list and have been corresponding for several years now and collaborating on a project together with another professional from the list.
    Laura, What you say is definitely true! You know some of the battle I’ve had to put up with in billing. But the plot thickens as it were when yet another biller looks to have NOT done what she was supposed to do, pay bills, taxes, mail important papers, etc. This is devastating for my practice because we have no electronic billing done right now and it will be 6 weeks before we will be able to get started with our own billing. I know i’ll make plenty of mistakes, but i’ll also know that the books are right or know by default that that no one has stolen from me this time, but there is always tomorrow, next week, next month, etc. That’s not to say there won’t be another day of rampent stealing, but being an eternal optomist (most of the time) I know there are good people out there (just maybe not in my little hick town) but spotting, checking out references, having the person work a certain number of days to see if they are compatible with all other personnel, capable of doing a lot of work, working under pressure, and following directions without having to be reminded several times.
    Nina Ravey

  3. I’m not sure when I got savvy to billing and coding but it has always been a part of my practice. It all fell together for me when, in or around 1996, the changes were made to the documentation guidelines for patient encounters.

    I saw people who were hired as billers/coders try to interpret the chart data and try to decide what level of visit/charge to apply. I also watched these same folks try to pick through various ICD-9 codes to select the correct diagnosis code for the visit.

    Often they were wrong.

    Now that scares the begeezuz outta me because in the fine print of all of these credentialing packets that we sign, we agree that we are ultimately responsible for the billing. I watched biller/coders upcode, downcode and select incorrect diagnoses repeatedly. So I figured it out.

    Here is a link to Family Practice Management’s for coding E&M encounters:

    I particularly like:

    As I precept students in my practice, I try to teach them these concepts. I also try to teach them about ICD-9 diagnosis coding. I hand them a book and ask them to find the codes for the diagnoses that they want to use.

    The trick to diagnosis coding is that you have to think backwards and not everything we were taught has a diagnosis that is found in ICD-9. So “Acute frontal sinusitis” becomes “sinusitis, acute, frontal”.

    Many of the diagnoses have descriptive words with separate codes that delineate a certain characteristic of the disorder. The “ideal” is that you pick the most specific diagnosis codes and that your exam notes support the selection.

    For example sinusitis has a variety of codes (there may be more than what
    are listed here)

    461.1 Acute frontal
    461.0 Acute maxillary
    461.9 Acute NOS
    473.1 Chronic frontal
    473.0 Chronic maxillary
    473.9 Chronic, NOS

    Here is a website that helps you determine the best diagnosis code selection:

  4. I have always had a professional billing person. Well worth the expense. She is great, goes after the non-payers like a bulldog, deals with all of the insurance companies etc.

  5. Post


    I agree…a good biller is worth his/her weight in gold and then some. I’ve not been lucky in finding such a person. I spoke with another NP locally, and she was had already been through her THIRD biller. I went through one company and it was a disaster.

    How did you find this person? Does she work in your office, our do you outsource to her? And does she want more business? (Afterall, you’ve just given her a glowing reference!).


  6. I understand all of the frustrations attached to the prior response. I am a medical biller and i work with Nurse Practitioners. If anyone has any questions about billing or insurance payers I would be glad to help. You can send a question through my website at I also have information about a great medical billing software, there is information on my website.

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