Seven Steps of a Surgical Claim

medical billing and coding trainingUnderstanding insurance claims is an important part of medical billing and coding training

Students enrolled in the Health Claims Specialist program at the Harris School of Business spend a good deal of time learning the in’s and out’s of medical billing and coding. From learning about the Current Procedural Terminology (CPT) codes, to studying the International Classification of Diseases (ICD-9), students are frequently being exposed to new and challenging skills as they pursue their new career training.

At the Linwood, NJ campus, the staff has created a diagram to explain some of the responsibilities of a Health Claims Specialist when it comes to a processing surgical claims. The diagram takes you from the very beginning, starting with a new patient, to the end where all payments have been made.

Read more below:

The Life Cycle of a Surgical Claim

* = The asterisk indicates steps where the Health Claims Specialist is directly involved.

Step 1. New Patient Activities

  • Patient information form is completed
  • Financial Policy is reviewed and signed*
  • A medical chart is created*

Step 2. Initial Encounter

  • Co-payment is collected*
  • Doctor sees the patient and recommends surgery
  • Encounter form is completed*

Step 3. Surgery

  • Precertification request is submitted to insurance company*
  • Surgery is scheduled*
  • Doctor operates and dictates an operative report

Step 4. Coding

  • Coder reads and abstracts the operative report*
  • CPT procedure codes and ICD-9 diagnosis codes are assigned*
  • Codes are entered into practice management program*

Step 5. Claim Submission

  • A claim is created*
  • Claim is sent to the insurance company*
  • Insurance company adjudicates the claim, checking for accuracy and medical necessity

Step 6. Insurance Payment

  • Insurance company sends remittance advice to the doctor’s office
  • Payment is electronically transferred
  • Payment and adjustments are manually posted to the patient’s account*

Step 7. Patient Payment

  • A remainder statement is created and sent to patient*
  • Patient makes their payment
  • Payment is posted to the patient’s account and a receipt is given*

The Harris School wishes to thank the Linwood campus for sharing their diagram. For more information about the Harris School of Business, fill out our simple online form, and we will be happy to contact you.