In some small clinics, the same person may handle both the billing and the coding, but medical billing and medical coding are two distinct careers you can train for. Medical coding involves using diagnostic information provided by the physician to assign a particular code for insurance billing purposes. These codes, currently called ICD-10 codes in the U.S., are used internationally (with some countries using the ICD-11 version) to tell the insurance company the patient’s specific diagnosis. This allows the company to verify that the corresponding procedural code or office visit code, known as a CPT code, and the related charges are appropriate for the diagnosis. Although medical coding is often integrated into patient chart software, there may still be a need to review codes before submitting them for reimbursement by insurance companies.

Medical coding differs from medical billing in that a medical coder works directly with healthcare professionals but does not always interact with patient records. In contrast, medical billing is done in an office separate from the providers, where patient medical records are frequently viewed.

Here is an example of when a medical biller and a medical coder would be involved in a patient visit:

Sarah hurt her ankle and went to see her primary care doctor. The doctor worked with the medical coder to provide an appropriate diagnosis that would allow insurance to cover imaging and necessary treatment for Sarah’s ankle. After the visit, the diagnosis codes and the procedural codes, including those for the office visit and the X-ray, are submitted to the medical biller for processing and submission to Sarah’s insurance company. Once the insurance company returns payment, the medical biller will enter the payment information into the system and create a statement to send to Sarah, explaining how much she owes on the balance. If the insurance company denies payment of the claim, the medical coder can review the charge to ensure that it most accurately reflects the patient encounter. Correction and resubmission after a claim denial can lead to a reversal of the original denial, providing payment to the doctor and the clinic for their services. The medical biller can also work with Sarah to establish a payment plan or use charitable forgiveness funds if available.

While medical billing and coding are complementary fields, they may not always be performed by the same person. In the following section, we will discuss the varying options for certification and education in each of these specialties.

Career Opportunities in Medical Billing and Coding

While formal certification or licensure is not required in the field of medical billing and coding, many small practices may have office staff handle medical billing and coding without formal training. However, certification programs in both medical billing and coding can increase your marketability. These programs provide formal exposure to the worlds of medical coding and billing and often include introductory training in medical ethics, HIPPA requirements, and other patient service topics. Many certification programs can be completed in less than a year, making them popular among people looking to re-enter the workforce or change careers.

With a career in medical billing and coding, you can work in a variety of environments. Some people choose to work from home, contracting with different organizations or small clinics that purchase their services. Others may work within a clinical or hospital facility to meet the needs of a single organization. Since medical billing and coding interfaces with third-party payers, career opportunities also exist within insurance companies, where professionals process submitted claims (Bryan University, 2018).

As with many other medical support careers, medical billing and coding specialists are in high demand. For example, some medical coders and billers work specifically with oncologists and cancer treatment organizations to review patient records, pathology reports, and other diagnostic and procedural notes to ensure services are covered by the patient’s third-party payer. Other billing specialists, such as those working with anesthesiology practices, ensure the proper coverage and billing of services provided. This may involve coordinating with hospital billing and coding specialists, as some anesthesiologists have private practices that contract with hospitals for their services.

There are different levels of certification for medical coders. These include the certified coding associate (CCA), which requires a high school diploma; the certified coding specialist (CCS), which requires 1 year of experience after obtaining the CCA; and the certified professional coder (CPC), which demonstrates the highest level of expertise in CPT codes and billing. These certifications can be supported by programs at local community colleges and do not require a degree. However, Health IT degrees from two-year or four-year colleges can provide additional training that improves your chances of passing certification exams.