medical billing and coding definition
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What is Medical Billing and Coding?

Medical Billing and Coding is an essential and emerging area of the healthcare field. Its key role is to streamline the reimbursement cycle of the healthcare system, ensuring that medical providers (such as physicians) are paid for the services they perform. Medical billing and coding are actually separate, yet closely-related practices that are often combined into one profession: the Medical Biller and Coder. To help you gain a better understanding of the field at large, we’ll start by defining the two separately.

Medical coding, also called medical classification, is a lot like translation. This practice involves converting health information and patient data – the diagnosis, procedures, medical services, equipment used – into a universal, medical, alphanumeric code. Data is gathered from patient records, physician’s notes, lab results, and other documentation, then later transformed into a code that insurance companies can clearly interpret and understand. For every diagnosis and medical procedure, there is a corresponding medical code.

This means there are thousands of medical codes out there, each matching with a different procedure or service, illness or injury. There are specific codes for the type of visit (inpatient, outpatient, etc.), the symptoms that a patient is showing, the tests that are performed, and the diagnoses decided upon. These codes act as the universal language between clinicians, medical facilities, insurance companies, government agencies, and other health-related organizations. They are created using specific coding classification systems, such as CPT®, ICD-10-CM, and HCPCS Level II.

Once codes are determined and confirmed for accuracy (by a Medical Coder, or Medical Biller and Coder), they are entered into a system and passed onto the Medical Biller. It is these codes that help healthcare providers bill accurately, and turn a profit efficiently.

Medical billing is a lot like its name implies. It involves taking the medical codes and creating a bill for health insurance companies, commonly known as an insurance claim. Medical billing is the process of submitting these claims to patients’ insurance companies, so that a healthcare provider can get compensated for the services rendered. Medical Billers are also responsible for following up on insurance claims, to ensure the reimbursement is granted. Medical billing is an important facet of the healthcare facility, in that it safeguards and optimizes revenue.

Sometimes, health insurance companies are not involved in this reimbursement process, and a Medical Biller will invoice a patient for the services received. Healthcare facilities must bill in order to pay their providers, as well as to continue offering their services and maintaining clean, up-to-date equipment.

As you can see, Medical Billing and Medical Coding are unique entities. However, they are integrated in that the common goal is reimburse healthcare providers for patient services. While it may seem like going to the doctor for an appointment is a simple, 1-to-1 encounter, it actually involves a variety of different parties and processes to get that appointment paid for. That’s where the Medical Biller and Coder comes into play.

What does a Medical Biller and Coder do?

A Medical Biller and Coder is responsible for taking health information, and further converting it into codes that allow the provider to receive reimbursement from health insurance companies. Usually, this person is the main entity in interpreting and coding patient data, entering it into the system, and then submitting the codes and claims to insurance companies. The Medical Biller and Coder is often one person; however, this role can also be conquered by two separate professionals, one Coder and one Biller, that work together to ensure invoices are properly paid.

On the medical coding side of things, the professional would be responsible for reviewing clinical statements, patient records, transcribed notes from the physician, and lab or radiology results, and assigning standard medical codes to each service or diagnosis, using a classification system.

On the billing side of the job description, a Medical Biller would then translate the code into medical claims, to send to insurance companies or other payers like Medicare in a timely manner. This person will then follow the claim, to ensure the provider receives proper reimbursement for the work performed.

A Medical Biller and Coder can generally be found:

  • Reviewing patient data and health information
  • Assigning codes to the symptoms, diagnoses, treatment, and other relevant information from a patient visit, using classification software
  • Ensuring the accuracy, appropriateness, and completeness of this data
  • Entering charges into a system, form, or report to create a claim
  • Transmitting claims to the appropriate payer
  • Posting payments as they are received
  • Following up with payers, such as insurance companies and patients

It is the job of the Medical Biller and Coder to tell the whole story of a patient’s encounter with a provider from start to finish, and to ensure the provider gets reimbursed for the services that took place. Medical Billers and Coders often work in physicians’ offices, hospitals, nursing homes, and other clinical facilities. In essence, a Medical Biller and Coder is a medical reimbursement consultant to practices, physician billing services, insurance companies, software companies, healthcare agencies, consulting firms, and State and Federal Government Agencies.

Where to Begin a Medical Billing and Coding Career

It is typically a standard requirement for Medical Billers and Coders to have at least a postsecondary certificate, and professional certification, before entering the field. Though not required in all states, these prerequisites are preferred by most employers today. It is through this level of training that you will gain a full understanding of medical coding processes and classification systems, electronic health records (EHR), the ins and outs of insurance claims, as well as the fundamentals of medical office management and terminology.

If you would like to become a Medical Biller and Coder, you can rest assured that the road to this career is not long-winded like many other careers in this field. There are flexible, certificate programs out there that can get you to a successful career in just a matter of months.

At Goodwin College’s Medical Billing and Coding School, for example, you can get trained, certified, and working in the field in as few as 12 to 18 months — faster than many other medical billing and coding schools in the region. Students must sit for the Certified Professional Coder (CPC) exam in order to become certified, which you will prepare for during your time in training.

Learn more about the field of Medical Billing and Coding today by visiting us online at www.goodwin.edu/landingpages/mbc. You may also call Goodwin College at 800-889-3282 to learn more about our Medical Billing and Coding program in Connecticut.