Medical Coders and Billers Need to Know More Than Just the Codes

by  Find-A-Code™
Oct 12th, 2023

At first glance, it might seem like there is nothing to becoming a certified medical coder or biller. If you know how to look up codes online, you're all set, right? No, not really. There is a lot more to medical coding and billing than looking up numbers. You need to know a lot more than just the codes themselves.

In its simplest form, medical coding is the practice of translating a clinician's notes into a series of standardized codes. Medical billing is the process of transforming medical code data into compliant bills for submission to payers. Combined, medical coders and billers are the most important link in the healthcare payment chain.

There are four things that coders and billers need to know to succeed. Here they are:

1. Types of Code Sets

Before a medical coder or biller can look codes up online, they need to know which code set to work with. Yes, there is more than one. The three most utilized code sets are the CPT, ICD-10, and HCPCS code sets. But there are more. Each code set has its own unique purpose.

All the sets combined work out to tens of thousands of codes. Medical coders and billers must use the right set for each document they prepare. Sometimes, knowing which set to use can be tricky. Therefore, coders and billers need to understand the differences between the sets. They must know when to apply each one.

2. Medical Terminology

Despite not being clinicians themselves, medical coders and billers need to possess a good grasp of medical terminology. The terminology relates to human biology, diseases, injuries, and even medical procedures.

Coders and billers need to have a grasp of terminology relating to anatomy, physiology, and pharmacology. Even pathology is on the table. If coding and billing professionals are going to make sense of clinician notes so as to accurately create bills, they have to know what those clinicians are referencing. That is nearly impossible to do without a working knowledge of medical terminology.

3. Diagnoses and Procedures

ICD and CPT codes deal with medical diagnoses and procedures. Therefore, coders and billers need to be familiar with both. From a diagnosis standpoint, the medical coder needs to understand the difference between knee replacement surgery for osteoarthritis as opposed to surgery performed following a sports injury.

This simple illustration of knee surgery covers both diagnosis and procedure. Diagnosis is essentially the doctor's determination of a patient's medical condition and its root causes. The procedure is more or less the treatment prescribed to correct the problem.

4. Code Classifications

Most of the code sets medical coders and billers work with on a daily basis are subdivided into classifications for organizational purposes. Coders and billers need to have a working knowledge of these classifications for a number of reasons, beginning with the fact that a single procedure or service can be billed using any number of codes. The determining factor is often classification.

The four things described here barely scratch the surface. Medical coders and billers must learn and retain a ton of information to be proficient. The knowledge is not picked up overnight. And in fact, the most successful coders and billers never stop learning.

Looking medical codes up online is just one small facet of the medical coder's job. Ditto for medical billers. The medical coder or biller needs to work through a whole list of criteria before ever getting to the lookup stage. Doing so requires a tremendous amount of knowledge with plenty of experience thrown in.