Medical Billing and Coding

Common Errors

Medical assistants must avoid these errors related to medical billing and coding:

• Nerve injury: remove needle immediately if patient reports shooting pain
• Hemolysis: redraw, often caused by vigorous mixing or small-gauge needle
• Hematoma: apply pressure immediately
• Failing to verify patient identity using two identifiers before any procedure

Documentation

Documentation of medical billing and coding in the medical office uses ICD-10-CM: Diagnosis coding with alphanumeric codes, 3-7 characters, maintained by WHO/NCHS.

Examples: J06.9: Upper respiratory infection; E11.65: Type 2 diabetes with hyperglycemia; S52.501A: Fracture of lower end of radius, initial encounter.

All documentation must be timely, accurate, legible, and include the provider signature. Late entries must be labeled as such with the date of the original event.

Step-by-Step Procedure

Procedure: Respirations measurement (relevant to medical billing and coding).

Technique: Count without patient awareness (keep fingers on wrist), observe chest rise, count 30 sec x 2 or 60 sec if irregular

Normal values: Normal adult: 12-20/min. Tachypnea over 20, bradypnea under 12.

Clinical Significance

Medical assistants encountering medical billing and coding should be familiar with associated laboratory values. BMP reference ranges:

• BUN: 7-20 mg/dL
• Glucose: 70-100 mg/dL (fasting)
• Potassium: 3.5-5.0 mEq/L

Calculation Methods

Reference values and calculations for medical billing and coding. CBC normal ranges:

• WBC: 4,500-11,000/uL
• RBC: 4.2-5.9 million/uL
• Hemoglobin: 12-16 g/dL (F), 14-18 g/dL (M)
• Hematocrit: 37-47% (F), 42-52% (M)
• Platelets: 150,000-400,000/uL

Workplace Applications

Workplace application of medical billing and coding requires fluency in medical terminology: