Medical Coding Workflow Explained: From Patient Visit to Payment

In today’s healthcare industry, medical coding is the backbone of the revenue cycle. It bridges the gap between healthcare providers and insurance companies — ensuring that patient care translates into proper reimbursement. But how exactly does the process flow from a patient’s visit to final payment?

Let’s break down the medical coding workflow step-by-step. Know More

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1️. Patient Visit and Data Collection

Everything begins when a patient visits a healthcare facility — whether it’s for a routine check-up, a diagnostic test, or a treatment.

During this visit, the front-desk team gathers essential details:

• Patient demographics (name, DOB, insurance info, contact details)
• Reason for visit or symptoms
• Referrals or authorizations (if applicable)

This data forms the foundation for the billing and coding process that follows.

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2️. Provider Documentation

After the consultation or procedure, the healthcare provider documents every aspect of the encounter in the Electronic Health Record (EHR). This includes:

• Patient’s diagnosis
• Procedures performed
• Prescribed medications
• Test results and clinical notes

Accurate and detailed documentation is critical — because coders rely on this to assign the correct codes later.

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3️. Medical Coding

Once documentation is complete, it’s the medical coder’s turn to step in.

Coders translate the provider’s notes into standardized medical codes using coding systems such as:

• ICD-10-CM – for diagnoses
• CPT (Current Procedural Terminology) – for procedures and services
• HCPCS Level II – for supplies, equipment, and additional services

These codes ensure uniformity across the healthcare system and help payers understand what services were provided and why.

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4️. Charge Entry and Claim Creation

After coding, the charges for each service are entered into the billing system. The coder or billing specialist ensures that:

• The codes match the services rendered
• The provider’s NPI, patient details, and insurance information are correct
• Any modifiers (for complex or multiple procedures) are applied correctly

Once verified, a claim is generated — either electronically (via clearinghouse) or manually — and submitted to the insurance company (payer).

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5️. Claim Scrubbing and Submission

Before a claim reaches the payer, it goes through a process called claim scrubbing.
This step checks for:

• Missing information
• Invalid or mismatched codes
• Compliance with payer-specific rules

A “clean claim” has a much higher chance of first-pass approval, minimizing delays and denials.

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6️. Payer Review and Adjudication

When the payer (insurance company) receives the claim, it undergoes adjudication — the review process that determines payment.

During adjudication, the payer will:

• Verify patient eligibility and coverage
• Confirm medical necessity
• Check coding accuracy
• Calculate the amount to reimburse

If the claim is approved, payment is processed. If denied, it’s returned with an Explanation of Benefits (EOB) detailing the reason.

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7️. Payment Posting and Reconciliation

Once payment is received, the billing team posts the payment in the patient’s account and reconciles it with the claim.

If the payment doesn’t match the expected amount (due to adjustments, co-pays, or denials), the discrepancy is noted for further action.

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8️. Denial Management and Follow-up

Not all claims get paid smoothly.
Some may be denied or underpaid due to:

• Coding errors
• Missing documentation
• Authorization issues

In such cases, the denial management team investigates, corrects the issue, and resubmits the claim — ensuring the provider gets the rightful reimbursement.

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9️. Patient Billing (If Applicable)

Finally, if there’s a balance remaining after insurance payment (like deductibles or co-pays), the patient receives a bill statement.
Clear communication at this stage helps maintain trust and transparency between the provider and patient.

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✅ The Importance of an Accurate Workflow

A well-structured medical coding workflow ensures:

• Faster claim approvals
• Fewer denials and rework
• Accurate reimbursement
• Compliance with regulatory standards
• Improved financial health for the practice

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💡 Final Thoughts

The journey from patient visit to payment may seem complex, but when every step — from documentation to denial management — works seamlessly, it leads to efficient revenue cycles and satisfied patients.

In a world where accuracy and compliance are key, medical coders play a vital role in keeping healthcare organizations running smoothly and financially stable.