Medical billing and coding
- Medical billing and coding is the process of converting patient charts and clinical data to medical claims, which are then submitted to payers for reimbursement.
- Medical billers and coders convert patient treatment and diagnosis information into numerical codes that payers use to make reimbursement decisions.
- Medical billing software helps streamline processes for newcomers, longtime billers, and coders.
- This article is for entrepreneurs starting a medical billing and coding career, and current billers and coders looking to improve their procedures.
How patient charts and clinical data become medical claims.
The U.S. Bureau of Labor Statistics has predicted that the medical billing and coding field will grow by 22% through 2026. This fact alone makes investing in a more robust medical billing and coding set up a smart plan. It also suggests that there’s never been a better time for you to enter the field.
Learn about the position and how medical billing software improves it.
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What are medical billing and coding?
As a medical biller and coder, you would convert patients’ encounters into numbers and formats that payers – including insurance companies and government agencies – can use to reimburse the providers you represent. It requires the transcription of the diagnoses, exams, procedures, and treatments in patients’ charts into two types of codes. The first code is the International Classification of Diseases, 10th Revision (ICD-10), which describes diagnoses. The second is Current Procedural Terminology (CPT), which depicts services.
What do medical billers and medical coders do?
Medical billers and coders oversee the process of converting clinical data from patients’ charts into standardized codes that government and private payers can differentiate. Medical billers and coders also record a patient’s insurance information alongside codes for proper claim filing and reimbursement.
After creating and filing accurate claims, medical billers and coders work with payers to ensure that their practice receives timely, full reimbursement. Billers and coders also oversee the resubmission process if claims are rejected and the appeals process if claims are denied. However, it’s becoming less common for medical billers and coders to manually check errors for claims, as automated claim scrubbers complete this task faster.
On one level, medical billing is as simple as it sounds: medical billers take the information from the medical coder and make a bill for the insurance company, called a claim.
Of course, as with everything related to the health care system, this process isn’t as simple as it seems.
To get a better look at medical billing, let’s rewind the example we used earlier. Our same patient has a cough, a fever, and is producing lots of mucus. This patient calls the doctor and schedules an appointment. It’s here that the medical billing process begins.
The medical biller takes the codes, which show what kind of visit this is, what symptoms the patient shows, what the doctor’s diagnosis is, and what the doctor prescribes, and creates a claim out of these using a form or a type of software. The biller then sends this claim to the insurance company, which evaluates and returns it. The biller then evaluates this returned claim and figures out how much of the bill the patient owes, after the insurance is taken out.
If our bronchitis-afflicted patient has an insurance plan that covers this type of visit and the treatment for this condition, their bill will be relatively low. The patient may have a co-pay, or have some other form of arrangement with their insurance company. The biller takes all of this into account and creates an accurate bill, which is then passed on to the patient.
In the case of a patient being delinquent or unwilling to pay the bill, the medical biller may have to hire a collections agency in order to ensure that the healthcare provider is properly compensated.
The medical biller, therefore, acts as a sort of waypoint between patients, healthcare providers, and insurance companies. You can think of the biller, like the coder, as a sort of translator—where the coder translates medical procedures into code, the biller translates codes into a financial report. The biller has a number of other responsibilities, but for now you should simply know that the biller is in charge of making sure the healthcare provider is properly reimbursed for their services.
Medical billing and coding training, and skill requirements
Medical billers and coders must have a relevant degree or certification to work with healthcare information systems. Other credentials are highly recommended. Additionally, there are several skill sets that predispose a person to being a sufficient medical biller and coder. These three considerations are outlined below.
1. Medical billing and coding educational requirements
To work in medical billing or coding, you need one of the following degrees or certifications. A trustworthy program in any of these areas will boast an AHIMA, CAHIIM, or AAPC accreditation.
- Medical billing and coding certificate: If you are aiming to enter the medical billing and coding field quickly, certificate programs are ideal. Many programs take less than a year, and cover medical terminology, treatments, procedures, biological systems, and the basics of ICD-10 codes. Most certification programs provide hands-on training with leading medical software and establish billing and compliance basics.
- Associate’s degree: Over the course of two years, associate’s programs in health information management will teach you the same curriculum as a certification program. However, practices and medical billing companies may be more inclined to hire you if you have earned a degree over a certificate. Additionally, associate’s degrees can count as the completion of several undergraduate credits.
- Undergraduate degree: Some universities offer traditional four-year bachelor’s programs in medical billing and coding, healthcare administration, and health information management. These longer, more in-depth programs will teach you about data analysis, health policy, project management, human resources, and compliance.
2. Medical billing and coding credentials
Upon graduating from any of the above programs, you can – and should – take one of the following AHIMA credentialing exams.
- Certified Coding Associate (CCA): This certification indicates you are capable of tactfully, diligently managing healthcare information. If you graduate from an AHIMA-accredited program, you can take the certification exam immediately upon graduation. Otherwise, six months of work experience is highly recommended as a replacement to qualify for the exam.
- Registered Health Information Technician (RHIT): To qualify for this exam, you must graduate from a CAHIIM-accredited health information management associate or undergraduate program. You do not need prior work experience to take the RHIT exam.
After you work as a medical biller or coder for two years (or one year with either of the above credentials), these two AHIMA credentials become available:
- Certified Coding Specialist (CCS): This credential is highly recommended if you are seeking to work as a medical biller and coder in a hospital setting. A CCS credential indicates proficiency in medical terminology, pharmacology, disease processes, and ICD-10 and CPT coding.
- Certified Coding Specialist – Physician-Based (CCS-P): The CCS-P signifies you are proficient in physician-level billing. It covers all the same areas as a CCS credential plus HCPCS Level II coding. It is considered the highest possible indicator of medical billing and coding excellence.
In all the above cases, you must recertify every other year as a medical biller and coder. To recertify, you need to take 20 Continuing Education Units (CEUs) and complete two annual coding self-reviews, which each count as five CEUs. AHIMA explains additional recertification criteria and CEU options in its recertification guide.
3. Medical billing and coding skills
Although medical billing and coding courses are theoretically open to anyone, you may be more likely than others to succeed in the field if you have acquired these skill sets:
- Attention to detail: Since medical coding systems comprise seemingly infinite strings of five- and six-digit numbers, you will need a keen eye to spot numerical errors. Without adequate attention to detail, you are more likely to encounter claim rejections.
- Computer proficiency: Most of the medical billing process now takes place digitally instead of in paper form. If you are computer savvy, you may have a natural tendency to complete medical billing and coding tasks efficiently.
- Organizational skills: Medical billing and coding requires you to complete many forms for a number of patients. Failing to properly organize these forms can lead to operational hiccups that make the billing process painful for both the patients and practice.
- Ability to maintain data privacy: Under HIPAA laws, you are required to keep healthcare information confidential at all times – except to obtain payer reimbursement. As a medical biller or coder, you will need to respect others’ privacy. Consequently, you will not be able to discuss details of a patient’s information with team members who aren’t working on their case.
- Data analysis: You should be able to look at groups of codes and quickly assess whether they make sense based on the patient’s charts. You should also know how to rectify errors you spot during data analysis.
- Anatomy and physiology: To know whether groups of codes make sense together, you should be aware of anatomy and physiology basics. No biller or coder is quite an expert in any scientific field, but you should be capable of understanding bodily systems, medical processes, and their interactions.
How medical billing software helps medical billers and coders
Medical billing software makes a huge difference for medical billers and coders. Even though the certification options qualify billers and coders to get the job done, software expedites the processes.
For example, medical billing software – such as DrChrono – provides a backbone for all of the steps you complete in medical billing and coding. That backbone includes claim creation, filing and scrubbing, an integrated clearinghouse, and denial management tools. Read our review of DrChrono to learn more about how the software expedites the billing process.
If you work for a practice, you can also benefit from medical software such as athenahealth, which facilitates all of a biller’s claim-related tasks. Read our review of athenahealth to learn more about the company’s consultative approach to billing.
Visit our medical billing service best picks page to find a variety of software platforms that improve the medical billing and coding process – from start to finish.