Who Should Answer When Your Patients Have Medical Coding Questions?

Scrutiny and analysis can go one of two ways. Either the subject matter becomes clear with a close and careful read, or the more time you spend trying to understand it, the more confused and frustrated you become.


Patients are scrutinizing their medical bills with a closer eye due to increasing out of pocket expenses. Simultaneously, healthcare organizations are moving away from providing extremely detailed information on patient statements in an effort to simplify communication. So when questions arise, the patient must call for clarification on the bill. And when those questions are coding-related, confusion often prevails.

Are your patient representatives prepared and trained to answer coding-related questions from patients? Probably not. Medical coding is a highly specialized discipline — it’s complex, and historically, it hasn’t been patient-facing.


But that begs the question: Should your coders be speaking directly with your patients regarding questions and coding-related account reviews? Here are a few things to consider.

What’s the question?

For common questions with standard responses, patient account specialists can be trained not only to answer correctly, but also to understand the “why” behind the explanation so that the conversation with the patient is natural, not overly-scripted.

For example, most patients understand that their payer covers an annual physical/well visit to a primary care provider (PCP). They believe they shouldn’t have an office visit copay, and that’s that. But, the patient won’t necessarily know when a preventative visit becomes a diagnostic visit and therefore warrants a co-payment. Most don’t know that codes, and therefore charges, are unique for each situation, so they are surprised when the statement from the provider indicates a charge has been applied. While these common situations may warrant a review by coding, in most cases the patient specialist should be able to handle the call.

For more complex questions, the first and natural assumption is that calls requiring an in-depth coding review or a detailed explanation should be directed to and answered by a medical coder. Was the coding correct to begin with? Did the physician enter the diagnosis code wrong, and/or does it need an amendment? Is it the payer who made an error? Or is the statement correctly showing the patient balance? In these cases, involving a coder eliminates the risk of the truth getting lost in translation. Not taking this step potentially confuses and frustrates the patient and may lead to additional patient calls to resolve the same issue. That’s costly, both in dollars and patient satisfaction.

What’s the process?

When patient inquiries need coder attention, how is the coder notified? It is imperative to have a clear process whereby items for review are routed to a coder, then tracked and monitored to ensure proper resolution. Working in your information system through task lists or work queues is preferred. Set the expectation with the patient that it will take some time to review the medical record and research the issue. In most cases, the patient specialist can relay the information back to the patient, but in some cases, it may be prudent for the coder to speak directly to the patient.

Who communicates best?

The plain and simple truth is that not every coder is the “right” coder to be patient facing. For coders who are natural communicators, speaking with patients to explain and resolve billing questions is fulfilling. The “right” coder for patient conversations is compassionate and respectful and has the unique ability to translate coding and healthcare language into a verbal explanation that the patient can easily understand.

What about costs?

Dedicating coding staff to patient inquiries may increase costs. But it’s no place for short cuts. Consider the cost of losing your patients if issues are not resolvedto their satisfaction.

The bottom line

While five, even ten, years ago you may not have needed a plan to handle coding questions from the patient, today you absolutely do, and the process you settle on should involve coding staff. Investing time and resources to train medical coders who are empathetic with a high emotional intelligence will improve patient satisfaction and ultimately impact revenue goals.

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About Cynthia Sherman, Director, Coding Services

Cynthia Sherman, Director, Coding Services

Cynthia leads all aspects of Coding Services at MediRevv, including the day to day management of coding operations and client account management. As Director of Coding she has grown division from a staff of one to forty. She is certified CCS-P (2002) through AHIMA.

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