Most professional coders and billers work in the outpatient physician office setting. This is because every doctor needs to send out his or her own bills to insurance companies, government healthcare agencies, or to patients. The number of private physician practices outnumbers all other healthcare facilities combined. When a physician provides services to his or her patient in the inpatient hospital setting, in an outpatient facility, or in an acute care clinic, radiology clinic, or sleep study lab, the physician bill for professional services is separate from the bill generated by the technical service provided by the institution.

Professional Medical Service Coding

Many Common Procedural Terminology (CPT) codes and Level II Health Care Procedure Codes (HCPCS) consist of a technical component and a professional component. The technical component is billed by facilities that provide the supplies, the support staff, and the physical space to perform a medically necessary service. The professional component of a code is used to describe and bill a licensed healthcare provider’s expertise in interpreting results and managing a patient’s treatment plan.

Surgeons, radiologists, and pathologists, among other specialists, often utilize codes that contain both a technical and professional component. When services are provided outside of these physicians’ offices, only the professional component is coded and billed by appending the modifier -25 to the procedural code. The outside facility bills the same code, provided by the physician, with the modifier -TC. When the service is provided in the physician’s office, it is billed universally; both components are billed and coded without an appended modifier.

Some medical services consist only of a professional component. Physician medical billers and coders are familiar with these Evaluation and Management (E/M) codes. They are the codes used to describe and bill office visits, hospice and skilled nursing facility (SNF) visits, home visits, and consultations.

Physician Office Medical Coding and Billing

Because most physician-setting medical billers and coders are employed by smaller medical practices, they often fulfill both roles. In the small office setting, physicians cannot employ a large support staff to ensure accurate code assignment that complies with government and commercial payer contractual requirements and guidelines. A well-informed physician medical biller is aware of all the nuances of medical coding. A certified medical coder who works in a physician office codes procedures and submits bills, posts reimbursements, and discusses financial obligations with patients. A professional physician medical biller, or a certified medical coder with physician office experience, is a small medical practice’s first line of defense against legal charges of fraud and abuse of the healthcare reimbursement system.

Credentials Versus Experience

Physicians are focused on treating patients, not on understanding the complicated web of regulations, guidance, and contractual restrictions on providing and billing their services. They rely on their administrative staff to keep them abreast of current issues. Experience is important, but more important is their staff’s baseline education that allows professional medical billers and certified medical coders to understand the relevant issues and provide valuable, informed advice to their employers. New coders who have training from an accredited school, or certification from an industry body such as the American Association of Professional Coders (AAPC) or the American Health Information Management Institute (AHIMA), have proven, by passing tests and mastering a body of information, that they possess the latest information on industry trends and standards.

Many physician practices employ medical billers and coders for decades. An experienced medical biller offers a wealth of practiced experience that has served the business well over the years. When established billers are entrenched in their routines, however, they may not be able to keep up with industry changes. The best are aware of them, but they may not have the time to attend meetings and seminars, or to read all the available literature. Newly graduated medical billers and newly certified medical coders bring a fresh perspective to improve a physician office’s billing accuracy and legal compliance.

The Bottom Line

Physicians carry insurance to protect themselves from charges of malpractice. They do not carry insurance to protect from breaking healthcare billing laws or contracts. The penalties that can be imposed by government healthcare programs for evidence of fraudulent or abusive billing practices can bankrupt a medical practice and put it out of business. Physicians value the protection that well-trained medical billers and medical coders provide to their business’s ongoing financial health.