Few things compare to the fulfillment that comes from healing sick or injured patients. But let’s face it—you can’t run a practice on warm fuzzies alone. And that’s the path you’re on if your patients’ bills remain unpaid.
You also need to run the business. And that’s where medical billing and coding come in.
In this guide, I’m diving right into the heart of this crucial field. I’ll break down all the details you need to know while equipping your specialists with an arsenal of tools and programs to kick-start their journeys.
Let’s get you and your medical team paid!
What Is Medical Billing and Coding?
Medical billing and coding is the process of converting diagnoses, medical tests, treatments, and procedures into standardized codes. These codes are then used to bill patients, insurance companies, and government entities.
While they’re often used together, medical billing and coding are two separate jobs.
Let’s say someone has a pounding heading and visits a doctor. The doctor orders a CT scan. A medical coder will assign specific codes representing the diagnosis (headache) and test (CT scan). If the doctor orders lab work to be done, that gets its own code, too.
After the visit has been coded, a medical biller turns it into a bill. And when the payment hits, they make sure every penny’s in its place.
In a nutshell, medical coders and billers are all about ensuring healthcare providers are correctly compensated for the services they provide.
Medical Billing and Coding 101: Roles, Responsibilities, and More
With more and more folks hitting their golden years, the demand for medical care is increasing. And as your practice grows, so does the challenge of dealing with finances.
That’s why it’s important to get a complete understanding of how the medical billing and coding field works. Your know-how will help your practice thrive.
Essential Skills for Success
Ready to find a billing and coding expert for your practice? Here’s what to keep an eye out for:
Fluency in medical terminology: Your professionals need to be fluent in medical lingo to excel in medical billing and coding. After all, how else can they flawlessly translate all the diagnoses, treatments, tests, and procedures that your doctors prescribe?
Mastery of coding systems: These systems include ICD-10-CM/PCS, CPT, and HCPCS, and I’ll dive deeper into them below.
Attention to detail: Your experts need to be detail-oriented and precise when assigning codes. One tiny coding slip can seriously affect patient care outcomes and your finances. In worst-case scenarios, the federal government can even get involved.
One endocrinologist found this out the hard way when he was fined $447,000 for billing routine blood draws as critical care blood draws.
Analytical skills: Given the complexity of medical records, billing and coding experts should be able to sift through data, spot the crucial information, and assign codes accurately.
Familiarization with coding guidelines and regulations: These include those from the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), and the Health Insurance Portability and Accountability Act (HIPAA). Guidelines and regulations change all the time, so closely monitoring them is a must.
Those skills are some of the most important, but it doesn’t end there. Here are more to tick off when scouting for the perfect medical billing and coding pros:
- Communication skills
- Ethical and professional conduct
- Time management and organization
Career Paths and Specializations
A medical billing and coding position can lead to other roles in your practice and beyond. Let’s explore the possibilities.
Certified Professional Coder (CPC): These coding experts are certified by the American Academy of Professional Coders (AAPC). CPCs often earn more than non-certified medical coders, which is something you’ll want to consider when adding one to your team.
Certified Professional Biller (CPB): Like CPCs, CPBs are certified and verified by the AAPC. They also earn more than their non-certified colleagues.
Medical coding auditor: These individuals comb through coders’ and billers’ work to make sure it’s accurate and compliant with healthcare regulations.
Compliance officer: These professionals make sure your practice is compliant with government regulations and internal policies.
Revenue cycle specialist: As their title implies, revenue cycle specialists are in charge of the practice’s revenue cycle, from patient registration and insurance verification to coding, billing and reimbursement. Ultimately, they help your team get paid.
Other roles coders and billers can dive into (with proper training, of course) include the following:
- Medical coding educator
- Health information technician
- Medical claims analyst
- Medical compliance specialist
- Medical documentation specialist
- Clinical data analyst
- Medical revenue manager
- Coding compliance manager
- Health information management (HIM) director
Pay and Salary Expectations
Naturally, a medical biller and coder’s salary hinges on a variety of factors. These include your medical specialty, your location, the type of practice you’re running, and the professional’s certification status and experience.
According to a 2022 AAPC survey, specialists without certification earn an average of $46,321 per year. Their certified counterparts, however, enjoy 17.7% more, averaging $56,290.
These variables hold significant weight when you’re on the lookout for the right medical billing and coding hire for your practice.
The 3 Code Sets Specialists Must Know
The three coding systems your medical billing and coding specialists must be familiar with are:
ICD-10-CM is short for International Classification of Diseases, 10th Edition, Clinical Modification. Healthcare providers across the US use this code set for diagnosis coding. It employs three to seven alphanumeric digits, consisting of a staggering 68,000 codes.
Here are some examples of ICD-10-CM codes:
J10.00: Influenza due to other identified influenza virus with unspecified type of pneumonia. Beware that only influenza A (non-novel), influenza B, and influenza C are included in this code. Other cases of influenza, such as influenza due to swine flu, are excluded and have their own codes.
J45.31: Mild persistent asthma with (acute) exacerbation. Again, some cases of asthma are included, while others are excluded, so it’s important to use the right codes for the right situations.
L70.0: Acne vulgaris. This code excludes acne keloid (L73.0).
CPT stands for Current Procedural Terminology. The American Medical Association (AMA) crafted it back in 1966 to standardize medical, surgical, and diagnostic services and procedures given to patients in both inpatient and outpatient settings. This system uses five alphanumeric characters, and there are roughly 10,000 codes currently in use.
Here are just a few of them:
77424: Radiation oncology treatment. For this particular code, a medical provider delivers a high dose of radiation in the form of X-rays directly to a patient’s tumor while sparing nearby healthy tissue. This is completed in a single session.
55250: Vasectomy, otherwise known as male sterilization.
80048: Basic metabolic panel (BMP). A BMP is a blood test that measures the body’s metabolism by checking on kidney function and monitoring the patient’s fluid, electrolyte, and glucose levels.
HCPCS stands for Healthcare Common Procedure Coding System, and there are two medical code sets—HCPCS Level I and HCPCS Level II.
Level I consists of the CPT code set, which I’ve outlined above, while Level II is your go-to for everything that’s not covered by Level I, such as non-physician services like ambulance rides, drugs, supplies, and equipment like wheelchairs and walkers.
This system also uses five alphanumeric digits; however, unlike CPT codes, it always begins with a letter followed by four numbers.
Let’s take a look at a few examples of HCPCS Level II codes:
A0100: Non-emergency transportation; taxi.
K0813: Power wheelchair, group 1 standard, portable, sling and solid seat and back, patient weight capacity up to and including 300 pounds. Other wheelchairs have their own codes.
M1067: Hospice services for patients provided at any time during the measurement period.
Bonus Code Set: ICD-10-PCS
ICD-10-PCS is short for International Classification of Diseases, 10th Edition, Procedure Coding System. It’s used for inpatient hospital settings only and includes seven alphanumeric digits.
Here are a few of these codes:
2W1AX6Z: Compression of right upper arm using pressure dressing.
BT39ZZZ: Magnetic resonance imaging (MRI) of kidney transplant.
GZ52ZZZ: Individual Psychotherapy, Cognitive.
Where Do Coders and Billers Work?
There are many places where medical coders and billers can work. The highest percentage (29%) work in hospitals, followed by physician’s offices (19%). That being said, working remotely is also on the rise.
Here’s how these three settings compare:
Working at a Hospital
Hospitals provide both inpatient and outpatient services, and medical billing and coding look different in each of them.
Here’s a brief comparison:
Inpatient Medical Billing and Coding
Inpatient billing and coding deals with complex cases in which many healthcare services may be performed during the patient’s hospital stay.
For example, a patient who requires open heart surgery won’t just be in the hospital for the surgery itself. They may also need chest X-rays, blood tests, and an IV drip.
Details matter for inpatient coders and billers. These professionals must carefully go through medical records, surgical notes, and doctors’ notes so they can assign an accurate code to each service provided.
And that’s not all. When a patient checks in, the inpatient coder and biller must closely follow their journey, adjusting codes and billing details as the patient’s situation changes.
Inpatient medical billers and coders need a solid grip on not only ICD-10-PCS but also the other three coding sets.
Outpatient Medical Billing and Coding
Outpatient coders and billers deal with more cases than their inpatient colleagues, but those cases are usually less complex. Still, efficiency remains a key factor for success.
On a daily basis, outpatient billers and coders craft codes and put together bills for a variety of healthcare services. The challenge, then, lies in accurately assigning codes based on patients’ medical histories.
Let’s consider a patient scheduled for skin cancer removal surgery at a hospital. The coder and biller need to carefully research factors like past visits to a dermatologist and a previous skin cancer diagnosis. This knowledge helps them assign the most accurate code for the surgery.
Billing and coding in a hospital is considered advanced compared to other settings. And for good reason, since dealing with numerous different codes and handling many patients at the same time is demanding.
Working at a Medical Practice
A medical billing and coding specialist’s day-to-day is shaped by the unique way their practice tackles these tasks.
A family practice’s methods, for instance, will differ from those found in a therapist’s office. Still, many factors are universal for coders and billers, no matter where they work.
For instance, these professionals must all use the correct coding systems, such as ICD-10-CM for diagnoses and CPT for medical procedures. They must also use accurate codes since not doing so can result in negative healthcare outcomes and legal or financial penalties.
For instance, a psychiatrist was fined $400,000 and permanently excluded from taking part in Medicare and Medicaid. Why? Because he billed patients for 30–60-minute therapy sessions when he only provided 15 minutes’ worth of medication checks.
In some practices, billers and coders take on more than just codes and bills. They’re the go-to guys for checking up on insurance and making sure claims get sorted. And when patients have questions or concerns, these specialists step in to tackle those, too.
Even medical coders and billers are embracing the home office. And while this arrangement offers flexibility, it also comes with risks—mostly due to the digital nature of the work.
First, at-home medical billers and coders use technology and remote tools, which means security is a big deal. Are their remote work environments meeting security standards? They’d better be since the worker is accessing sensitive patient data online.
I’m talking about medical records, coding systems, and physicians’ notes—even addresses and payment info. That’s also why strict adherence to HIPAA guidelines and other data security regulations is so important; they are there to protect patient privacy and the confidentiality of medical info.
Working remotely often means working independently, too. While time management and self-motivation are skills all professionals should have, they’re the secret sauce for remote work. Without colleagues and supervisors around, it’s up to the individual to ensure they get their work done.
Useful Medical Billing and Coding Tools
I know that’s a lot of tech to get used to, especially for those who aren’t particularly tech-savvy. And believe me, there are plenty of non-tech-savvy billers and coders out there. That’s why it’s important that your specialists use these tools correctly. Even one misstep, no matter how small, can cost your practice money.
With that said, here are some tips on how to use these tools correctly:
First, make sure your billers and coders familiarize themselves with the tools they’re using, especially EHR systems. All your patients’ sensitive medical data is on there, so you want to stay compliant with regulations.
Next, ensure proper documentation. That means entering all patient data, including demographics, medical history, physicians’ notes, and test results, correctly in the EHR.
But medical billing and coding is about more than just getting patient data right. It’s also about documenting start and stop times for timed procedures, such as infusion and hydration. And a procedure that demands a little more work must have proper documentation to explain why before the patient is charged extra for it.
Don’t just take my word for it, though. The AMA is adamant about documentation.
The last tip is to stay on top of all software updates. This is mostly for security purposes, but using each tool’s new features and improvements can make your specialists’ jobs that much easier.
Medical Billing and Coding Courses for the Knowledgeable Professional
As a practice manager, you want to know that your specialists are knowledgeable, and accreditation can be just the reassurance you need.
Here are a few courses that many top-notch medical billers and coders have taken to get certified:
The AAPC created the CPC and CPB accreditations. So, when your expert is learning from them, it’s like getting knowledge straight from the horse’s mouth. And the AAPC offers even more certifications than just the CPC and CPB.
Want to specialize in cardiology? Take the Certified Cardiology Coder (CCC) certification.
Want to work in family practice instead? The AAPC also offers a Certified Family Practice Coder (CFPC) certification.
Both in-person and online training are available for all AAPC courses, and anyone who buys a course receives employment support and career advancement. And the best part of all? The AAPC boasts pass rates of 80% or higher.
Price: Packages start at $3,000
The American Health Information Management Association (AHIMA) offers eight credentials, including the Certified Coding Associate (CCA) and the Certified Coding Specialist (CCS). The Medical Coding and Reimbursement Online Course Bundle of 13 foundational courses prepares coders and billers for the CCA and CCS exams.
Students get one year’s access to this collection of self-paced study-at-home online courses. To sweeten the deal, they also become a member for one year after they finish the course bundle. That opens the door to perks like networking, professional development, and career guidance.
Since, according to their website, 75% of AHIMA members earn $50,000 or more, that’s a pretty good deal indeed.
CAHIIM stands for the Commission on Accreditation for Health Informatics and Information Management Education. Established by the AHIMA, this commission aims to closely monitor the quality of “academic programs in health information management and health informatics.”
Most of the programs in this directory are academic in nature.
That’s because the AHIMA partners with several accredited schools for Registered Health Information Technician (RHIT) and Registered Health Information Administrator (RHIA) credentials. So, after completing their studies, students can take the RHIT or RHIA exam and gain a shiny new degree.
Use this directory to find an accredited school in your state.
CareerStep’s comprehensive online medical coding and billing program is AAPC- and AHIMA-approved, and it’s designed to sync with the CPC exam.
Students get a full year’s access, giving them the freedom to learn at their own pace. The program also comes with 1:1 support, along with certification prep materials and exam fees.
Billed as a local school alternative, the CCO offers a variety of medical billing and coding courses, including specializations. And yes, these courses are AAPC-approved.
All courses are online, meaning that students can set their own pace for learning. However, unlike the previous courses mentioned on this list, these courses only come with nine months’ access. While that may not be enough time for someone with a packed schedule, the shorter deadline might light a fire in determined students.
The CCO has built a thriving learning community around its courses, with student support forums, live group webinars, and certified instructor support. Students also get free access to exam preparation documents, such as mock exams.
Price: Individual courses start at $429, but specializations cost between $1,000 and $2,000.
Build the best medical billing and coding team for your practice
With a medical biller and coder on your side, you have the tools and skills you need to boost your practice’s success—in both its mission and its bottom line.
Embracing this strategic field means you’re not just securing your practice’s financial health—you’re making a huge impact on those you serve. You’re in a better position to heal, uplift, and create lasting change.
Check out The Medical Practice for more information on practice management.
Now go forth, heal, and prosper!