8.2 Medical Billing and Coding
Katie Baker
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.
A Day in the Life of a Medical Biller
Gina, 26, starts her day as a medical biller and coder in a neighborhood medical office with 10 providers. She heads to work on the bus, thinking about the projects she is working on in addition to her regular tasks. This month, she has been collaborating with her office manager on a project to increase efficiency and accuracy in their group’s billing performance by reviewing customer feedback.
At work, Gina greets her coworkers and sits down in her cubicle with a cup of tea to get started. She spends the morning processing superbills from her assigned providers’ visits the previous week. A superbill is a form (paper or electronic) that includes the patient’s identifying information, such as their name, date of birth, and patient number, as well as the codes for the patient visit and diagnoses. The visit codes will include a CPT code for the visit itself, any procedures or tests performed, and any modifiers (codes that are required to add procedures and tests to the visit code). Gina double-checks the superbill to ensure that the provider has included all of the correct modifiers. If any modifiers are left out or incorrect, the insurance company will not pay for the additional procedures or tests performed on the day of service.
All of her work is done through a shared electronic medical records (EMR) software, which allows her to view the chart and the patient’s protected health information (PHI) alongside the superbill. She also looks for common errors and compares the visit codes to the diagnosis codes to ensure they align. Finally, she confirms that the insurance information in the patient file matches the information on the superbill and checks for any changes in the file that might affect the claim processing.
After completing her review of each superbill, Gina creates claims using the EMR and sends them electronically to the various insurance companies. For smaller insurance companies, she prints the proper claim form and either faxes it or mails it.
Her morning work done, Gina heads out for lunch and a walk around the block. She makes sure to stretch after spending the morning sitting at her desk.
In the afternoon, Gina processes incoming mail, including insurance payments and payments from patients. She also scans patient payments made through the practice’s online portal, which automatically links payments to patient accounts. She enters any physical payments along with the insurance information about payment adjustments and allowed amounts. Any denied claims are set aside for Gina to follow up on with the insurance companies the following morning.
Since it is the end of the month, Gina also creates billing statements for patients and and prepares them for mailing the next day. At the beginning of the next month, patients whose payments are more than 90 days overdue will receive a phone call from Gina or one of her colleagues before being referred to collections.
Before heading home, Gina reviews the day’s customer feedback surveys and notes a few common issues to discuss with her manager during their weekly meeting. They will brainstorm ways to improve patient satisfaction and retention while ensuring that bills are paid on time. Finally, Gina shuts down her computer, says good night to her coworkers, and heads home, reflecting on all of her hard work as she looks forward to relaxing with a movie.
A career that encompasses submitting insurance claims and bills to insurance providers and patients, following up on rejected claims and payment balances and processing payments.
Converting diagnosis and treatment information into billing codes to submit claims.
Health Insurance Portability and Accountability Act, passed by Congress in 1996, protecting patient information from being disclosed without proper consen.