Medical Billing Coding Rules and Regulations

Rules Medical Billing Coding

PHI or protected health information is necessary for Medical Billing coding rules and regulations companies to perform their tasks lawfully. HIPAA rules are there for medical billing companies to work accordingly.

  1. Title II of HIPAA
    Title of HIPAA

Title II of HIPAA avoids any fraudulent or abusive administration of medical billing companies. It allows appropriate use of protected health information or PHI. This simplifies the billing process and claims management. It keeps the records electronic and updated and makes the sharing of records smooth. The OIG or Office of the Inspector General is in charge of inspecting and taking legal action against healthcare providers and fraudulent insurance companies.




Privacy Rule

  1. Privacy Rule

This rule dictates the companies on the entitlement to information sharing. These rules tell the medical billing companies whom they are allowed to share their data. The data includes the following aspects:

  • Medical history
  • Fees and insurance paid by the patient
  • Healthcare provider’s location


  1. Security RuleSecurity Rule

The security rule is also similar to the privacy rule. It gives details about the aspects of how the companies are protecting the PHI they have given access to. The managerial, physical, and technical safeties can be implemented to keep the secrecy, accessibility, and reliability of PHI.

  • Physical security: Security systems, alarms and cameras in the storage location of PHI.
  • Technical security: Cyber-security via data backup, firewalls and encryption of your business’s PHI
  • Managerial security: Includes trained professionals to handle all kinds of security containing strategies and measures needed


  1. CPT Codes:CPT Codes

The CPT or Current Procedural Terminology codes are the numbers allocated to track and bill medical services. They are five-digit codes containing all digits or four digits and one alphabet e.g. 99213 and 99214 are used for common check-ups.

American Medical Association or AMA has given and maintains these codes. This organization keeps updating the rules and codes as per the new advancements in the medical world. These codes just outline the contract between the provider and client, the pay and services have to be discussed between the two parties themselves.

The different categories of CPT include:

  • Processes, facilities, strategies, and medications etc.
  • Work procedures and quality of care etc.
  • Processes consuming developing technology


  1. Uses of CPT coding:CPT coding

These codes determine the number of expenses a patient has to pay for the medical bills. That’s why an error-free code assignment is necessary.

  • Primary Coding

The healthcare providers initiate the coding process. They assign your CPT codes and you will be notified of them via the EHR or electronic health record.

  • Confirmation and Compliance

The assigned medical codes are authenticated and validated after you complete your visit and submitted to your name. They then start allocating the services of the code

  • Claim Handling

Your claims are then processed under the roof of your assigned code to avoid any errors.

  • Research

Coding data is used to calculate the upcoming health care expenses of patients. They also use them to track drifts in medical care to maintain their budget.

  • Release documents:

You will get the release or discharge documents after every appointment and procedure including the specific codes. The medical bill includes a CPT code for every service provided. EOB or explanation of benefits from the insurance company or the payer will give charge of each service, paid on your behalf, with a CPT code.


This was a summary of Medical Billing coding rules and regulations codes and procedures. Book an appointment to check your eligibility criteria and outsource your medical billings now.

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