Medical billing and medical coding are crucial aspects of the medical revenue landscape. Both jobs ensure health care providers get paid for their services. Medical coders read the providers’ operative or procedural notes and code them so providers receive proper payment for their services. Medical billers submit these notes and follow up on health insurance claims for timely payment. Medical billers also appeal claim denials.
Both billers and coders work in almost every type of clinical location, including hospitals, healthcare provider offices and outpatient care centers. Sometimes – particularly in smaller offices – one individual handles both codes and bills. Jobs in medical coding and billing are expected to grow 9% by 2030, according to the Bureau of Labor Statistics.
Healthcare providers send medical coders their unbilled reports, and coders translate these notes into code to create a succinct record of the patient’s visit. These operative or procedural notes include surgical records, office notes, laboratory notes, pathology findings and more, spanning the full spectrum of healthcare departments. Once finished, medical coders send their coded claims to medical billers for processing.
Medical coders use three main types of coding:
“ICD” stands for the International Classification of Diseases, and “10” refers to the 10th revision. Each ICD code is seven characters.
ICD-10 diagnosis codes describe the patient’s condition. A coder may assign more than one diagnosis code on a patient visit.
ICD-10 diagnostic codes fall under two systems:
Treatment codes describe the treatment or services performed on the patient to address their condition.
There are two treatment code levels defined by the Healthcare Common Procedure Coding System (HCPCS):
Medical coders use modifiers when a procedure has been performed differently than described in the standard five-digit code. Modifiers usually indicate one of the following variations:
If one of these situations occurs, coders add a two-digit alphanumeric modifier to the code. For example, the code might be 99203 for an initial office visit, while 99203-57 describes an initial office visit with a decision for surgery.
The process for telemedicine billing is the same as billing for in-office patients.
Let’s say a medical coder, Jim, received the following information:
A patient is seen in the office for a chief complaint of shortness of breath and fatigue. The physician performs a detailed history, detailed examination, and medical decision-making of moderate complexity. Final diagnosis – pneumonia. In the office, the physician provided and interpreted a two-view chest X-ray.
Jim would encode that report using the following process:
Medical billers use patient, provider, and health care organization information and treatment details to fill out two medical claim forms: the CMS-1500 and UB-04 (the uniform billing form for institutional providers). Billers then submit these forms to the relevant insurance companies, bill them for the healthcare or doctor’s services, and follow up if the healthcare organization or doctor hasn’t been paid.
If insurance denies a claim, the medical biller would file an appeal and do all they could to ensure the healthcare organizations and providers receive all the proper reimbursements. Billers work with insurance portals and make calls, and sometimes mediate between insurer and client, explaining to clients why their insurance claim was rejected.
Medical coders must be familiar with medical terminology and anatomy to understand what they read. They must also become familiar with frequently used procedures and codes for their specialties and keep up with coding changes. Medical coders handle medical records, documentation requirements and compliance.
Medical billers use a different skill set. These professionals must know various insurance providers, their policies and filing details, how to appeal, and much more.
Medical billers and coders work across healthcare facilities, including hospitals, dentists, doctors’ offices and outpatient centers. Some practices limit medical billers to specific insurance companies or specialties. Sometimes one person does both jobs, depending on case complexity and organization size. Other times, billers and coders interact, working together to adjust rejected claims for insurer review.
If you want to outsource your medical billing needs, the best medical billing services can handle coding, billing, submissions, denial management and more. Investigate any potential partner for its transparency, technology, experience in your specialty and compliance reputation.
Check out our in-depth reviews of top medical billing services to find one that fits your needs and budget: