Medical Billing vs Coding

If you’ve decided to dive into the world of healthcare administration, one of the first things you’ll encounter on this journey is the terms “medical coding” and “medical billing.”

Now, you might be scratching your head, wondering, “Aren’t they the same thing?” Trust me, you’re not alone in that confusion.

Many folks entering this field find themselves confused trying to distinguish between the two.

In this article, we’re going to discuss exactly that. We will elaborate on what is medical coding and medical billing, how they are different, how their salaries differ, and so much more.

So, let’s break it down, shall we?

What is Medical Coding?

Let’s start by discussing what medical coding is.

Imagine this: You go to the doctor, and they diagnose you with something like a cold. But that diagnosis isn’t just discussed casually. It’s translated into a special language understood by the healthcare team. That’s where medical coding comes in.

Medical coding is like turning all the details of your doctor’s visit—diagnosis, treatments, medications—into standardized codes. These codes represent something specific about your health journey. They’re important for accurate billing, research, and even tracking diseases.

What Do Medical Coders Do?

Medical Coders have a range of duties within different healthcare settings.

Let’s take a look at what these professionals do:

1. Reviewing Medical Records: Medical coders start by carefully examining patient medical records, which include physician notes, test results, prescriptions, and other relevant documentation.

2. Identifying Key Information: They extract crucial details from these records, such as diagnoses (what’s wrong with the patient), procedures performed (what was done during the visit or treatment), medications prescribed, and any additional services provided.

3. Assigning Codes: Using specialized code sets like ICD-10-CM (for diagnoses) and CPT (for procedures), they match each piece of information to the corresponding code. This step requires a deep understanding of medical terminology, anatomy, and coding guidelines.

4. Ensuring Accuracy: Medical coders must ensure that the assigned codes accurately reflect the patient’s condition and the services rendered. Mistakes can lead to billing errors, reimbursement issues, and even potential legal consequences.

5. Staying Compliant: They must stay updated with evolving coding regulations, guidelines, and industry standards. Compliance with HIPAA (Health Insurance Portability and Accountability Act) and other privacy laws is also crucial to safeguard patient information.

6. Supporting Billing Processes: Accurate coding is essential for healthcare providers to receive proper reimbursement from insurance companies or government payers. Medical coders play a vital role in this revenue cycle management process.

7. Facilitating Data Analysis: Coded data is used for various purposes beyond billing, including tracking patient outcomes, analyzing healthcare trends, conducting research studies, and informing public health initiatives.

8. Collaborating with Healthcare Teams: Medical coders often work closely with healthcare professionals, including physicians, nurses, and administrative staff, to clarify documentation and ensure accurate coding.

9. Maintaining Documentation: They maintain detailed records of coded information, ensuring that it’s easily accessible for audits, quality assurance purposes, and future reference.

How To Become a Medical Coder

Becoming a medical coder requires a few simple steps.

Education Requirements:

Obtain a high school diploma or equivalent.

While not always mandatory, completing some form of training in healthcare-related fields such as medical coding, health information technology, or medical billing can be beneficial.

Gain Knowledge and Skills:

Develop a strong understanding of medical terminology, anatomy, physiology, and pharmacology by completing some form of formal medical coding training.

Familiarize yourself with coding systems such as ICD-10-CM, CPT, and HCPCS Level II.

You can achieve this by either enrolling in an associate degree or diploma from a university or community college or through online programs.

Certification:

Pursue certification through reputable organizations such as the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).

Common certifications include Certified Professional Coder (CPC), Certified Coding Specialist (CCS), and Certified Coding Associate (CCA).

Certification demonstrates your competency and commitment to the profession, increasing your marketability to employers.

Gain Practical Experience:

Look for entry-level opportunities such as medical coding internships, externships, or entry-level coding positions.

Gain hands-on experience working with medical records, coding software, and healthcare coding guidelines.

Seek opportunities to work in various healthcare settings, such as hospitals, physician offices, clinics, or insurance companies, to broaden your experience.

What is Medical Billing?

Now that you know all about medical coders, who they are, what they do, and how to become one, let’s move on to an overview of medical billing.

Let’s imagine this scenario: You’ve just had a medical appointment. The doctor checked you out, maybe ran some tests, prescribed medication, and provided treatment. Now, it’s time for the administrative side of things, and that’s where medical billing comes into play.

Medical billing is the process of translating all the services provided during a patient’s visit into a bill that can be sent to the patient, their insurance company, or a third-party payer (like Medicare or Medicaid).

It involves creating claims based on the services rendered, submitting those claims to the appropriate parties, and following up to ensure timely payment.

What Do Medical Billers Do?

As mentioned above, Medical Billers are an important part of the healthcare administration system.

Here’s a closer look at what’s involved in medical billing:

1. Creating Claims: The medical biller reviews the patient’s medical record and translates the services provided—such as examinations, treatments, procedures, and medications—into standardized codes. These codes, often using systems like CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System), accurately represent the services during the visit.

2. Submitting Claims: Once the claims are created, they’re submitted to the relevant parties for payment. This could be the patient’s insurance company, government healthcare programs like Medicare or Medicaid, or even the patient themselves if they’re self-paying.

3. Following Up: After submitting the claims, the medical biller monitors their progress. They track the status of each claim, ensuring that it’s processed promptly and accurately. If there are any issues or delays in payment, they follow up with the payer to resolve the issue and expedite payment.

4. Resolving Discrepancies: Sometimes, claims may be denied or rejected due to errors, incomplete information, or other issues. In such cases, the medical biller investigates the reasons for the denial, corrects any errors, and resubmits the claim for reconsideration.

5. Posting Payments: Once payments are received, the medical biller posts them to the patient’s account, reconciling them with the billed charges. They ensure that payments are applied correctly, accounting for any co-pays, deductibles, or adjustments as per the patient’s insurance plan.

How to Become a Medical Biller

The process of becoming a medical biller is similar to a medical coder, involving some basic steps.

Here’s a detailed guide on how to become a medical biller:

Educational Requirements:

Obtain a high school diploma or a GED. While not always mandatory, having a background in mathematics, computer science, or healthcare-related subjects can be beneficial.

Consider pursuing any type of educational training in medical billing and coding, health information management, or healthcare administration.

Gain Knowledge and Skills:

Familiarize yourself with medical terminology, anatomy, physiology, and healthcare documentation practices. Many community colleges and vocational schools offer certificate or associate degree programs in medical billing. Or you can even opt for online training program since they offer many perks.

Learn about medical billing software and electronic health records (EHR) systems commonly used in healthcare settings.

Develop strong computer skills, including proficiency in spreadsheet software and data entry.

Certification:

While certification is not always required, obtaining professional certification can enhance your job prospects and credibility as a medical biller.

Consider pursuing certification through organizations such as the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).

Common certifications include Certified Professional Biller (CPB) and Certified Billing and Coding Specialist (CBCS).

Gain Practical Experience:

Look for entry-level opportunities such as medical billing clerk, billing assistant, or billing coordinator positions.

Gain hands-on experience working with medical billing software, processing claims, and communicating with insurance companies and healthcare providers.

Consider internships, externships, or volunteer opportunities to gain practical experience and build your resume.

Similarities Between Medical Coding and Billing

So far we have discussed what medical billing and coding are, individually.

You might have discovered that even though both the terms are used together and sound similar, there are some differences between each particular career.

But do they also have similarities? Yes!

Let’s take a look at how the two careers are similar:

1. Integral to Revenue Cycle Management: Both medical coding and medical billing play important roles in the revenue cycle management process within healthcare organizations. Medical coding translates healthcare services into standardized codes, while medical billing ensures proper reimbursement for those services through accurate billing practices.

2. Dependence on Healthcare Documentation: Both medical coding and medical billing rely on accurate and detailed healthcare documentation. Medical coders use medical records to assign appropriate codes to diagnoses, procedures, and services, while medical billers use this information to create claims for submission to payers.

3. Importance of Compliance: Both medical coders and medical billers must adhere to strict coding and billing guidelines, regulations, and compliance standards. They need to stay updated with changes in healthcare laws, coding regulations, and insurance policies to ensure accuracy and compliance with industry standards.

4. Utilization of Coding Systems: Both medical coding and medical billing involve the use of coding systems to categorize healthcare services. Medical coders use code sets such as ICD-10-CM, CPT, and HCPCS to assign codes to diagnoses, procedures, and services, while medical billers use these codes to create claims for reimbursement.

5. Collaboration within Healthcare Teams: Medical coders and medical billers often work closely with healthcare providers, administrative staff, insurance companies, and other stakeholders within healthcare organizations. They collaborate to ensure accurate documentation, coding, and billing practices, as well as to resolve issues related to claims processing and reimbursement.

6. Focus on Accuracy and Efficiency: Both medical coding and medical billing require attention to detail, accuracy, and efficiency. Errors in coding or billing can lead to claim denials, delayed payments, revenue loss, compliance issues, and even legal repercussions. Therefore, both roles emphasize the importance of accuracy and efficiency in their respective processes.

7. Integration with Technology: Both medical coding and medical billing rely on technology, including electronic health records (EHR) systems, medical billing software, coding software, and claims processing platforms. These technological tools help streamline workflows, improve efficiency, reduce errors, and enhance communication within healthcare organizations.

Differences Between Medical Coding and Billing

As we mentioned before, even though both medical billing and coding are used together as one career, there are significant differences between the two careers.

Let’s see how:

Alright, let’s explore the differences between medical coding and medical billing.

Nature of Work:

Medical Coding involves translating healthcare services, diagnoses, procedures, and treatments into standardized codes using code sets like ICD-10-CM, CPT, and HCPCS. Medical billing involves creating and submitting claims to insurance companies or other payers for reimbursement based on the coded information provided by medical coders.

Primary Focus:

Medical Coding primarily focuses on accurately assigning appropriate codes to reflect the patient’s diagnosis and the services provided during their healthcare visit. Medical Billing primarily focuses on processing claims, ensuring they are complete, accurate, and compliant with payer guidelines, and following up on payments.

Skills and Knowledge:

Medical Coding requires a deep understanding of medical terminology, anatomy, physiology, and coding guidelines. Attention to detail and analytical skills are essential. Medical Billing requires knowledge of insurance policies, billing regulations, claims processing procedures, and reimbursement methodologies. Strong communication and organizational skills are important.

Certification:

Medical Coding certification options include Certified Professional Coder (CPC), Certified Coding Specialist (CCS), and others offered by organizations like AAPC or AHIMA.

Medical Billing certification options include Certified Professional Biller (CPB) and Certified Billing and Coding Specialist (CBCS), also provided by AAPC and AHIMA.

Software and Tools:

Medical Coding involves using coding software and resources to assign appropriate codes based on medical records and documentation. Medical Billing involves using billing software, electronic health records (EHR) systems, and claims processing platforms to create, submit, and manage claims.

What a Day in the Life of a Medical Coder vs. Medical Biller Looks Like

A day in the life of a medical coder starts at their desk, surrounded by patient files waiting to be reviewed. They read through doctor’s notes, test results, and treatment plans, picking out important details to turn into codes.

Throughout the morning, they face different coding puzzles. Some cases are tricky and need careful thinking, while others just need checking against the rules. They work hard to make sure every code they assign is right for the patient’s condition and treatment.

In the afternoon, they handle questions from doctors and others about codes. They talk to colleagues and check online for the latest information to help them code accurately. As the day ends, they check over their work to make sure it’s all correct.

On the other hand, a medical biller dives into their emails and messages, sorting through claims and questions about bills, first thing when their day starts. They check patient insurance to make sure everything is right before sending the bills out.

Throughout the day, they do lots of different jobs. They send bills to insurance companies, check that payments match up with what’s been billed, and fix any mistakes they find.

In the afternoon, they keep an eye on the bills they’ve sent out, making sure they get paid. If there are problems, they talk to the insurance companies or others to sort things out.

Read: Best 4-Week Online Medical Coding and Billing Course

Conclusion

While both medical coding and medical billing are important components of the healthcare system, they play different roles in ensuring patients receive quality care and that healthcare providers are properly reimbursed for their services.

Each profession requires specific skills, knowledge, and attention to detail. Both medical coders and medical billers contribute to the smooth operation of healthcare facilities and ultimately play vital roles in supporting patient care.

Related Resources:

• What is Medical Billing and Coding?
• How Long is Medical Billing and Coding School
• Medical Billing and Coding Online Courses Cost
• Medical Billing and Coding Salary
• A Day in the Life of a Medical Coder
• Medical Billing & Coding Online Schools
• CPC Certification