Medical billing and medical coding are two related disciplines. Professionals in each field use similar skills to achieve similar results, but the methods they use, and how they pursue their goals, are different.

Many medical billers are also medical coders, and vice versa. The two skill sets overlap because both professions involve the translation of medical documentation into standardized codes to communicate medically necessary information. Medical billers focus on providing accurate, timely reimbursement based on the codes used. Medical coders are less concentrated on reimbursement issues. Their role is to provide the most complete picture possible of a medical encounter, leaving the money-related aspects to the billers.

While both professions strive to the adhere to the guidelines, statutes, regulations, and to contractual obligations to provide accurate information, medical coders usually deal in a wider variety of codes, adhering more to the ideal of coding theory. Medical billers are more knowledgeable about commercial insurance requirements, what codes can be billed, claim submission rules, and how to assemble a clean claim.

Accurate Medical Coding

Medical code is the foundation of both professional activities. Standardized medical code is the industry-wide language used to describe medical services outside the patient’s written record. Medical code is an abstraction of the many details that make up the patient record, with set standards of what each code means to someone who understands the language.

Both medical billers and medical coders have a solid foundation in the variety of codes that make up the grammar of describing medical services. At its most basic, medical code is composed of procedure codes and diagnosis codes.

The Healthcare Common Procedure Coding System (HCPCS) is a two-tiered system that includes Common Procedure Terminology, at Level I, which is usually referred to as CPT codes. More specialized codes are used for reporting services to Medicare and other payers at Level II. Since these codes do not have an equivalent in any other manual but the Center for Medicare and Medicaid Services HCPCS manual, these codes are referred to as HCPCS in the field, to differentiate them from the more universal CPT codes.

The use of HCPCS for all medical transactions was mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPPA). While HIPPA established a number of regulations governing the transmission of Protected Health Information (PHI), its enactment also mandated the use of the same codes across the industry to describe medical procedures. For this reason, both medical billers and medical coders need a solid understanding of how these codes are meant to be used, the kind of understanding that can only be gained through a formal education program of study.

Diagnosis coding is governed by the rules established in the International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM). ICD-9 is the coding system currently used in the United States. ICD-10 was originally scheduled for implementation in October 2013, but the U.S. Department of Health and Human Services announced on February 16, 2012 that the deadline to adopt ICD-10 codes for diagnoses may be postponed. While ICD-10 will replace ICD-9 in the future, the timeline is uncertain. Professionals who are familiar with the structure of ICD-9-CM are expected to make a smooth transition to the new coding system, with the appropriate training.

ICD-9-CM is a list of possible diagnoses a patient may exhibit. Both medical billers and medical coders review documentation in the patient’s chart to assign the most accurate code to describe the patient’s condition. From a medical biller’s point-of-view, the codes are used to describe medical necessity for specific services for reimbursement purposes. From a medical coder’s standpoint, the codes are assigned to capture the entire picture of the medical encounter between healthcare provider and patient.

In a large healthcare delivery setting, such as a hospital, medical coders are responsible for reading the entire medical record to assign codes. Codes in the inpatient setting are assigned differently than they are in the outpatient setting. Codes in an emergency room setting are assigned differently than they are in a skilled nursing facility setting. A professional medical coder is usually a member of a department separate from the billing department in the hospital setting, though medical coders communicate actively with medical billers who are assembling medical claims, in order to ensure that the information being transmitted is accurate and properly documented.

Medical Coders as Medical Billers

In a large professional setting where the two professions are separate, medical coders are more concerned with compliance to universal meanings of codes. Medical billers spend their efforts making codes conform to specific payer requirements to describe medically necessary services for reimbursement purposes.

Smaller, rural hospitals, that may have as few as fifteen beds, often employ a small staff trained in both medical coding compliance and medical billing requirements. The same is true of skilled nursing facilities, smaller rehabilitation hospitals, and rural ambulatory surgery centers. Healthcare facilities that see a smaller number of patients may combine the two roles of medical biller and medical coder in order to streamline operations and reduce operating expenses. When a medical biller also fills a coding compliance role in these situations, they often earn more than their medical billing counterparts in physician offices.

Every healthcare practice depends on a medical biller to ensure its financial operations in order to be able to continue providing medically necessary services. While a medical biller in a physician practice is also responsible for ensuring that communicated codes are accurate, the responsibility for accuracy falls more on the doctor, the nurse practitioner, of the therapist providing services.

In this work environment, the medical biller is a professional who can assemble claims without clerical or coding errors so that timely payment is received for services rendered. Medical billers, unlike medical coders are much more conversant in the contracts healthcare providers sign with third party payers. Many of these requirements include adherence to medical policies and coding guidelines specific to the payer. This includes commercial insurers, as well as government programs such as Medicare, Medicaid, and Tricare. While these all of these specific requirements cannot be taught in a classroom, the basics of contract law and government statutes are covered so that a professional biller can feel secure that he or she is submitting clean claims without risk of coding audits or legal penalties for his or her employer. It is an important responsibility that takes a professional mindset and a thorough understanding of all the issues involved.

Knowing the Rules of Medical Billing and Coding

A basic foundation in the healthcare reimbursement system, it governing bodies, and its requirements, is key to the successful performance of a medical biller’s and a medical coder’s duties. Change is an ever-present factor in the healthcare administration industry as codes are defined and re-defined, as their use is clarified and specified, and as reporting requirements adapt to evolving technology and medical treatment protocols. Without a grounding in the basics, a layperson soon becomes lost in the thicket of codes, acronyms, and regulations. A professional navigates them all, and ensures that medical services are described accurately based on the medical record, and that covered services are paid appropriately.

There are a number of formal educational programs available, from local community colleges, to private vocational schools, to online certificate programs, and bachelor’s degrees in healthcare administration. Anyone interested in entering the medical billing and medical coding field in the 21st century is advised to learn the basics from a reliable source so that they will be able to adapt and succeed in this industry, no matter which professional path they choose to pursue.