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 exposu