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What is Medical Billing and Coding?

Traditionally, doctors graduate from medical school with the expectation that they will practice medicine, not run a business and do administrative, accounting and bookkeeping tasks.

The formula is simple: no coding - no billing - no money for the doctor

A medical practice is a for profit business (unless it is run as a charity) and need to be run as such. Over 819,000 doctors and surgeons practice the art of medicine in the USA alone and they ALL want to get paid for services. To give you an idea, there are thousands of dental offices, pharmacies, nursing homes, medical care facilities, clinics, rehabilitation centers, hospitals, health maintenance organizations (HMOs), health data organizations, cancer research centers, medical and clinical laboratories and even insurance companies that depend on medical billing and coding services to keep their business profitable and running. Running a business is best left to business professionals, administrators, and clerks. This is where medical billers and medical coders come into play.

Are Medical Billers The Same As Medical Coders?

The medical biller is not a medical coder, and a medical coder is not a medical biller, nevertheless, the two disciplines are so closely related that medical billers and coders must work hand in hand.

  • Medical coding turns diagnoses and services into number codes.
  • Medical billing takes the codes and turns them into $$$ for the doctor.

A medical biller's and a medical coder's work revolve around medical and healthcare provided, doctors, medical services to patients and all about receiving money. Both disciplines focus on statements, payments, collections, creating invoices and submitting the proper documentation to health insurance companies and federal agencies for reimbursement so that the healthcare provider gets paid.

A typical case scenario:
A medical biller might receive a chart regarding a patient that came in for a mass in the right breast; the diagnosis is mastitis. It was documented that the site was red and firm, weeping fluid on its own at the patients home early that morning before the appointment. It was then determined that the patient had an abscess and was charged for the visit and several injections. While reviewing the charges, the medical biller notices that one of the injections was a form of local mac sedation, which leads to a more closer review of the note to see if a procedure was performed but charges were not carried over. The medical biller reviews the note, and notices that the provider states under the procedure outline: "Skin abscess some fluctuation noted, drained through opening a small amount of yellow tinged fluid". The medical biller must now call that provider to verify whether an I&D was in fact performed or whether the site was opened by the patient before arriving for the visit and drained via the "patient formed opening" as stated in the note.

Typical medical billing duties include:

  • Reviewing medical notes, patient's charts and Superbills
  • Office bookkeeping and other administrative duties
  • Accurately completing HCFA and other claim forms
  • Reviewing EOB and explaining insurance benefits to patients
  • Sending claims to clearing houses
  • Prompt billing of medical claims
  • Collection of accounts receivables
  • Logging of co-payments
  • Filing Claim denial appeals
  • and reminders for past due accounts

The health insurance company reviews and processes a submitted claim. Their experts evaluate and verify their validity for payment. Important criteria are patient eligibility, provider credentials and medical necessity. Approved claims are reimbursed for a certain percentage of the billed services according to their contract with the provider. Invalid claims are rejected and a notice that explains the reason for denial is sent to the provider. A medical biller reviews this information and determines whether corrections need to be made and an appeal sent. It can get complicated, but once the lights go out in the office and they return home at the end of the day they know that they have helped many, many people and businesses to succeed.

Why So Many Choose this Career

Medical billers and coders choose this career because...

  • they enjoy the healthcare field but don't like the hands-on clinical aspects
  • understand finances, medical language and number codes
  • are detail oriented and meticulous when it comes to their work
  • know the principles of computer data entry and office administration
  • excel at doing research and find answers to complex problems
  • like helping people but prefer to work away from the public's eye
  • want to work toward becoming their own boss in a medical billing business

Ancillary tasks handled by medical billing professionals include responding to patient, or insurance company attorney requests for coding and billing information, protecting patient privacy and the patient-provider relationship, responding to and investigating patient complaints, providing client with requested coding and billing reports, complying with applicable state and federal Insurance Laws, performing provider audits to ensure compliance with current coding and billing guidelines, just to name a few. 

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