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Medical Billing and Coding: The Fundamentals

Posted: April 14, 2021

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Medical billing and coding involves translating patient care and treatments into a code that can be submitted to insurance as part of a claim.

Every medical practice needs an organized, detail-oriented, committed back-office team that works to keep the whole practice running smoothly behind the scenes. That includes the medical billers and coders who ensure that patients receive the right financial and insurance coverage for medical visits, procedures, and treatments.  

So, what is medical billing and coding? Let’s go over some of the fundamentals. We’ll also let you know how you can get started in this growing and engaging career in as little as 8 months by completing the online medical billing and coding certification program at Career Quest Learning Centers.

Learn more about our Medical Billing and Coding Program

What Does a Medical Coder Do?

In short, medical coders are the translators. Here’s how it works:

  1. Providers document all aspects of a patient encounter in a report, including tests, diagnoses, medications, or any other services provided.
  2. The medical coder translates the details from the report into a numeric or alphanumeric code that’s included on the patient’s insurance claim.

Medical coders need to be accurate in how things are coded, because this is how insurance companies know which costs they’re being billed for. They also use these codes to determine how much they’re required to cover based on the patient’s policy. Properly coding services ensures that patients receive the financial coverage they expect from their insurance provider.

It’s good practice for medical coders to avoid coding any service that isn’t explicitly included in the provider’s report. This kind of diligence can help mitigate any conflicts that may arise with certain claims. It’s also a good way to help protect the practice or hospital you work for from any potential healthcare fraud or liability investigations.

The Different Coding Systems

There are several coding systems that medical coders need to learn when they’re transcribing a provider report. These codes correspond to the diagnosis, procedure, and charge for the visit, as well as facility fees and overhead:

  • ICD-10 Diagnosis Codes: Used to describe why a patient sought services and the severity of their condition.
  • CPT and HCPCS Procedure Codes: Explain what a provider did during the patient’s visit to the medical facility.
  • Charge Capture Codes: Indicate the price of services delivered by the provider.
  • Professional and Facility Codes: Used to cover the operational costs of running a medical practice or hospital.

All four codes are submitted to insurance providers as part of a claim. The insurance company uses this charge, as well as the procedure and diagnosis codes, to determine how much they’ll reimburse the practice on behalf of the patient.

Is it Difficult to Learn Medical Billing and Coding?

What Does a Medical Biller Do?

Medical billers collect payments owed to the medical facility for services. This can come in the form of co-pays paid by the patient upfront, or reimbursements from insurance companies or other payers. In short, medical billers help to keep the practice financially afloat by ensuring that all services are paid for.

The medical billing process often takes place in two parts: front-end and back-end.

Front-End Medical Billing

Front-end medical billing begins before the patient even visits the facility. When a new patient makes their first appointment, front-office staff will often collect their insurance information. Staff then communicates with insurance companies to determine whether the patient will owe a co-payment at the time of check-in.

At check-in, payments owed by the patient will often be collected by front-office staff, like an administrative assistant or receptionist. Sometimes medical billers will be responsible for clarifying and collecting this payment as well.

Back-End Medical Billing

Back-end medical billers are responsible for:

  • Submitting claim forms to insurance providers or other payers
  • Resolving and resubmitting rejected or denied claims
  • Creating and sending statements to patients
  • Following up on outstanding bills from patients

Back-end medical billing begins once the patient’s visit has been coded. At that point, the medical coder will deliver the report to the biller, who will put together an itemized bill. Providers will use this bill to create insurance claims. These bills often include information about the provider, patient, and visit (including all codes).

After checking to make sure that all codes are present and accurate based on provider notes, medical billers will submit this information to the insurance company or payer on a claim form. At this point, the payer will analyze the claim and decide whether to accept, deny, or reject it.

If a claim is denied or rejected, it’s up to the medical biller to resolve the issue and resubmit the claim form. If it’s accepted, billers will create a statement that they’ll send to patients for any outstanding costs not covered by insurance.

A final part of the role of a medical biller includes following up on outstanding statements from patients to ensure they’re paid in a timely manner.

Medical Billing and Coding Specialists at Work

As you can see, medical billers and coders are a vital part of any medical practice. The field is also very diverse. The day-to-day work you’ll do as a medical billing and coding specialist will vary based on the size of the practice itself.

Larger practices or hospitals may have designated medical billers and coders. However, many professionals in this career perform both roles simultaneously.

Smaller practices may have an office manager who is in charge of all aspects of the front- and back-office experience, including checking in patients and collecting front-end payments, as well as coding services and billing for them. 

Where Do Medical Billing and Coding Specialists Work?

The field of medical billing and coding is expected to grow faster than average, with an estimated growth of 8% by 2029, according to the U.S. Bureau of Labor Statistics.* This means that medical billers and coders are in-demand professionals who provide immense value to a variety of medical practices and facilities. Some of their most frequent employers include:

  • Hospitals
  • Physicians’ offices
  • Nursing homes
  • Long-term care facilities
  • Therapy practices
  • Chiropractic offices
  • Dental offices

In some cases, medical billers and coders may also have the opportunity to work from home!

Skills Medical Billers and Coders Should Have

If you’re planning on entering the workforce as a medical billing and coding specialist, there are several skills you’ll want to learn to ensure success on the job, including:

  • An understanding of basic medical terminology
  • Basic accounting and bookkeeping
  • An understanding of appropriate medical codes
  • The ability to create and process invoices
  • Basic computer and data-entry skills
  • An understanding of fair debt collection practices

These are all skills you’ll learn if you attend an online medical billing and coding program, like the one offered at Career Quest. You’ll also have the opportunity to complete an externship to gain on-the-job experience and practice soft skills, like your communication and problem-solving abilities.

Traits of Successful Medical Billers and Coders

While anyone can experience an engaging and fulfilling career as a medical billing and coding specialist, there are a few traits that stand out among the most successful employees in this role. The most successful medical billers and coders tend to be:

  • Detail-oriented
  • Interested in basic human anatomy and healthcare
  • Comfortable working independently
  • Discreet and respectful of patient privacy
  • Tech-savvy
  • Good at communicating
  • Patient and empathetic

If you have any of these traits, then you may enjoy a career in the office of a healthcare facility!

How to Start a Career in Medical Billing and Coding

There are four things that you’ll want to do to begin a career as a medical biller and coder:

  1. Enroll in a medical billing and coding school
  2. Receive any applicable certifications
  3. Complete an externship
  4. Apply to employment listings

These are all things that Career Quest can help with if you’re excited to start your new career in healthcare.

Enroll in a medical billing and coding school

Our career college has an online medical billing and coding program that offers plenty of flexibility while providing a high-quality education. In our program, you’ll take classes like:

  • Allied Healthcare Procedures
  • Administrative Compliance
  • Anatomy and Physiology
  • Billing and Coding Procedures

Receive any applicable certifications

Career Quest medical billing and coding programs are designed to prepare students to sit for applicable certifications. Depending on availability, some certifications you can take before graduating from our program include:

  • HIPAA/OSHA-BBP
  • Billing and Coding Specialist
  • Medical Administrative Assistant

Complete an externship

Before you graduate from our online program, you’ll complete an externship that provides you with hands-on experience and on-the-job training in medical billing and coding. This is an opportunity for you to practice the skills you learned in the classroom while also learning the nuances of the role.

Apply to employment listings

The Career Services Department offers lifetime job placement assistance to all our graduates. We’re here to help you keep your career on the right path by helping you with:

  • Resumé and cover letter writing
  • Interview preparation
  • Career search assistance

Is Medical Billing and Coding the Career for You?

Now that you know the fundamentals of what medical billing and coding is, does this sound like the right career for you? If you’re excited to jump in and start your new role as a medical biller and coder, then Career Quest can help you get the training you need to succeed.

Courses are filling up now, so contact our Admissions team and enroll today!

*https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm#tab-6