What Do Medical Coders and Billers Do?

Zack Williamson

Zack Williamson

Zack Williamson is a co-founder and CEO of ClarkStaff.com, a remote staffing and business management consulting firm with offices and partners in the US, UK, The Philippines, New Zealand, and Australia. Zack enjoys writing about a wide range of topics from business process consulting and International manpower logistics to digital media and internet marketing. That being said, some people visit his blog to check out the occasional rant about politics, health, music, and more.

The task of a medical biller and coder is to translate health information into codes so the provider can be reimbursed by health insurance providers. This person is typically in charge of examining and interpreting patient data, coding it, putting it into the system, and submitting the codes and claims to insurance providers.

The medical biller and coder are frequently a single person, but this position can also be held by two independent professionals; one biller and one coder – who collaborate to make sure invoices are paid in a timely manner. Medical billing and coding come together in the process of creating claims to create the foundation of the healthcare revenue cycle.

male doctor looking at the medical file in hospital. In the background, diverse colleagues are chatting in the hallways.

Medical Coders

Medical coding focuses primarily on patients’ medical records. The accuracy of coding their data helps in preventing misleading notes or diagnoses. It involves speaking with medical staff like doctors, nurses, and other healthcare professionals to classify the services a patient has received.

Coders enter the data through special software called Electronic Health Records (EHR) and Electronic Medical Records (EMR) that is used in hospitals and other medical centers. They also need to be updated with the latest revisions in coding standards and regulations.

Medical coders examine operative reports used during surgery and make sure patient charts and histories are accurate as this will reflect the patient’s medical condition.

Since coding is a translation of the patient’s status, there are jargons used by medical professionals, insurance companies, government organizations, and other health-related organizations that correspond to a specific code and every diagnosis. Here are some of the codes used during this process:

ICD-10 Diagnosis Codes  

As stated on aapc.com, ICD-10 refers to the tenth edition of the International Classification of Diseases (ICD), a medical coding system that was designed by the World Health Organization (WHO) in order to classify health diseases under detailed conditions. There are national variations of ICD-10 which are modified to align with the healthcare infrastructure of each country. 

ICD-10-PCS (Procedure Coding System) is the procedure code set used only for hospital inpatients. ICD-10-CM (Clinical Modification) categorizes diseases in mortality data from death certificates, expanded injury codes, and the creation of combination diagnosis or symptom codes. The health of the patient, the location and seriousness of an injury or symptom, and whether the visit is related to an initial or follow-up encounter are all indicated by ICD codes.

Front view of diverse medical team with stethoscopes around the neck shaking hands at table in the hospital. Coffee cup, water glass, laptop, and digital tables are on the table.

CPT (Current Procedure Terminology)

Current Procedural Terminology, or CPT, as it is more widely known, is a system of medical codes used to define the operations and services that are provided by doctors, allied health professionals, non-physicians, hospitals, outpatient facilities, and laboratories.

There are modifiers for CPT codes that provide more detailed descriptions of the services. CPT modifiers provide the basis for a service, the placement of the procedure on the patient, and whether or not the provider performed several procedures. Using CPT modifiers ensures that providers are paid correctly for all services.

Medical Billers

Compared to medical coders, billers frequently perform more customer-facing duties. Their tasks involve entering data with the help of proprietary billing software, submitting claims, following up with patients, managing account payments and invoices, investigating denied or rejected claims, and verifying the accuracy of the codes used by medical coders to categorize services and products.

Front End Medical Billing

The staff informs the patients of any costs they might encounter during the front-end billing process. Typically, while scheduling appointments, offices can accept copayments from clients. Coders receive the medical records from the check-out patients and translate the data into codes.

Health Insurance

Backend Medical Billing

After the patient is released and sent home, back-end medical billing takes place. Medical billing specialists develop billable codes using the patient’s medical records before submitting claims for payment.

Conclusion

Medical coding and billing are crucial steps in the healthcare revenue cycle. The seamless operation of the medical billing and coding cycle guarantees that providers are paid for the services provided and that provider organizations are able to continue providing care to patients.

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