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Medical Billing and Coding

Medical billers and medical coders are the healthcare professionals in charge of processing patient data such as treatment records and related insurance information. Medical insurance billers and coders are tasked with coding a patient's diagnosis along with a request for payments from the patient's insurance company. Both medical billing and medical coding professions are involved in the medical reimbursement cycle, which ensures that healthcare providers are accurately and efficiently paid for the services they perform.

Increasing demands on providers with decreasing reimbursement requires medical offices to invest in highly skilled medical billers. An intimate understanding of medical insurance, the claims process, the appeals process, and the impact on the practice's revenue gives the medical biller the necessary knowledge to successfully optimize and maximize a practice's revenue performance. The financial health and fitness of a practice largely depends on the effectiveness and overall performance of the billing office.

Medical Billing and Coding

Roles and Responsibilities

The primary role and responsibility of a medical coder is to review clinical statements and assign standard codes using CPT®, ICD-10-CM, and HCPCS Level II classification systems. Medical classification, or medical coding is the process of translating medical reports into a code used within the healthcare industry. The use of medical codes helps summarize medical services and reports. These medical code sets help medical coders document the condition of a patient and describe the healthcare procedure(s) performed on a particular patient in response to their condition.

Medical billing is the act or process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider. The medical biller needs to understand how to read medical records and, like the medical coder, be familiar with CPT®, HCPCS Level II and ICD-10-CM codes. Medical billing translates a healthcare service into a medical billing claim. The responsibility of the medical biller in a healthcare facility is to follow the claim to ensure the practice receives proper reimbursement for the work the providers perform. While a medical biller’s duties vary based on where they work, their duties generally include: charge entry, claims transmission, payment posting, insurance follow-up, and patient follow-up.

Evolving Standards

Starting in late 2015, the United States began transitioning from the International Classification of Diseases version 9 (ICD-9) coding standards to ICD-10 standards. AAPC, the largest medical coding and billing training and certification association in the world, has led the charge and education on ICD-10 by offering courses, taught by industry experts, that prepare medical coders and billers for the new disease classifications.

There is tremendous demand for skilled medical billing and coding professionals in healthcare, the largest industry in the U.S.. In fact, employment in this field is projected to grow 15 percent from 2014 to 2024, much faster than the average*. As the U.S. population ages, the demand for healthcare services is projected to increase substantially. At the same time, many healthcare organizations are still converting to electronic medical records (EMRs) and will be continually challenged to stay current with healthcare advancements.

Work Environment

Medical billing and coding professionals work in a wide variety of settings, including:

  • Physicians offices
  • Hospitals
  • Medical billing services
  • Emergency rooms
  • Ambulatory centers
  • Insurance companies

Importance of Certification

Most employers prefer hiring certified medical billing and coding professionals. Certified medical professionals generally earn more and are better trained than non-certified professionals.

Medical coding standards are increasingly more complex and require ongoing education and training for medical coding professionals. Medical coders achieve certification through specialized education, experience in an area of specialty, and qualifying exam(s). Certification is a professional’s official recognition of achievement, expertise, and judgment. Certification is a high level of professional achievement that requires continued learning and skill development to maintain.

AAPC Medical Billing and Coding Training

AAPC established the training and certification standard for medical billing and coding. AAPC has 165,000 members with 115,000 actively certified.

AAPC provides industry leading training and certification and is recognized as the largest medical association representing medical coders, billers, auditors, compliance, and practice managers. AAPC certification is the most recognized and respected certification in the industry. AAPC members have access to the largest peer-network for medical coding and billing professionals with over 165,000 members worldwide.

Certified Professional Biller (CPB™)

The Certified Professional Biller (CPB™) certification prepares medical billers with the technical knowledge and skills to maintain all aspects of the revenue cycle. Without deep knowledge and expertise in medical billing and the unique understanding of payer requirements, reimbursement may be denied, delayed, or incomplete.

Certified Professional Biller’s have proven knowledge of how to submit claims in accordance with government regulations and private payer policies, follow-up on claim statuses, resolution of claim denials, appeals submission, posting of payments and adjustments, and collections management.

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Certified Professional Coder (CPC®)

The Certified Professional Coder certification (CPC®), is the established standard for medical coding in physician office settings. Over 155,000 certified professionals help maintain compliance and profitability within healthcare practices through accurate medical coding and documentation. CPC’s have demonstrated mastery of all medical code sets, evaluation and management principles, surgical coding, and adherence to documentation and coding guidelines through rigorous examination and experience.

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Want to learn more? Contact an AAPC Career Counselor for a free consultation to learn more about medical billing and coding. You can contact AAPC online, via email, or by calling 800.626.2633.

*Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2016-17 Edition, Medical Records and Health Information Technicians, gathered from http://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm on June 2016.

Which certification is right for you?

Call 877-290-0440 or have a career counselor call you.

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