What is a Medical Coding and Billing Specialist?By Aimee Wilcox, MA, CST, CCS-P
Every hospital, doctor’s office and healthcare facility needs at least one specialist. Unless this specialist is around, a lot can go wrong. Patients will never get credit for the medical bills they pay, insurance companies will not receive a claim and medical professionals will not get paid. Who exactly is the person that can stop this from happening and bring order to a medical practice? You got it! It is the professional medical coding and billing specialist.
There are several ways to become a medical coding professional. Some medical coders started out working for a physician’s office as the front office receptionist and gradually learned on the job, over many years, the terminology, anatomy and diseases associated with the specialty practice they have worked in. They advance through the ranks as they gain additional knowledge and training and eventually find themselves billing insurance companies and following up on the claims submitted to them. They send statements to patients and follow-up on collection calls. They have, over years, gained the experience they need to perform these specific tasks in this specific office.
But, what happens when the pediatrics practice they worked at for the past six years closes or due to unforeseen circumstances they are now looking for work at another office? Do all the years of dedicated service and learning go out the window?
Although this is one way to gain experience to become a coder and biller there is a better way.
To become a professional certified medical coder, you need to pass a national certification test that is difficult to pass without specific training.
You may feel like you have seen, heard, and been witness to every disease possible to man in the orthopedic practice you are currently working in; however, when you sit to take the examination and they ask you questions about pregnancy-related issues, and heart surgery, you may have a panic attack.
The right education and training will prepare you to sit for national certification with confidence. Also, upon receipt of your certification you will be prepared to apply for and work in almost any medical specialty with confidence.
What Training Do Medical Coders Require?
Medical coders receive training in the basics including:
- Medical terminology
- Disease processes
- HIPAA (Health Insurance Portability and Accountability Act), which governs the privacy, confidentiality, and reporting laws of our nation with regard to medical information.
- ICD-9-CM diagnostic coding set
- CPT procedural coding set
- HCPCS medications, durable equipment, etc., code set
Software and other tools available to medical coders to aid in code selection and reporting.
It is imperative that coders have training on how to use the following code sets:
- 1. ICD-9-CM (International Classification of Diseases): Diagnoses or medical conditions are represented by three to five digit numeric or alpha-numeric codes.
- 2. CPT (Current Procedural Terminology): Medical services or procedures are represented by five-digit numeric codes.
- 3. HCPCS (Healthcare Common Procedural Coding System): Five-digit alphanumeric codes used to describe medical supplies and drugs (as well as some services not included in the other codebooks). These are referred to as hick-picks codes.
Each of these code sets are updated annually and are expected to be implemented by the first of each year. Once a medical coder has been trained on the process of code selection they can continue to train themselves on any new updates as they come.
This formal training can be obtained through local colleges or it can be obtained through online courses you can do in the comfort of your own home.
Testing and Certification Maintenance
Once you have passed the training you can apply for apprentice certification. Depending upon the certifying body you apply for testing with, you can either:
- Take an apprentice exam and then go work as a coder gaining experience for a couple of years , at which time you can apply for full status as a certified medical coder.
- Gain some experience first and then test to become a full status medical coder.
If you have been working in the medical field in coding/billing for a few years, you can take and pass the courseware and immediately apply for full status testing.
Certification testing, depending upon the certification you are testing for, can take anywhere from 4-6 hours to complete. You are allowed a very limited amount of materials to use during the exam and may or may not be allowed a break. You will have a variety of question types including multiple choice and specific coding scenarios you will have to think through and then code.
Once you have passed certification testing, you will receive an official certificate showing your status. Your employer may require a copy of this to be kept in your employee file. Additionally, with certification comes the responsibility to keep your credentials up to date. You do this through the accumulation of continued education units (CEUs) in the field you are trained in.
There are many conferences, teleconferences, and other activities you can participate in to keep your credentials current and yourself up to date on changes in the field of medical coding. At the designated period of time, determined by the certifying body who maintains your certification, you will turn in any CEUs and pay a renewal fee to keep your credentials in active status.
General Responsibilities of the Medical Coder and Billing Specialist
Responsibilities of Medical Coders:
- Review the medical report
- Locate the services rendered to the patient and select the proper CPT code for reporting those services to the insurance company.
- Locate the associated diagnoses for which services were rendered and select the proper ICD-9-CM/ICD-10-CM diagnosis code for reporting to the insurance company.
- Using special computer software enter the codes into the billing software program and submit the claim to the insurance company. (If your responsibilities are different from the billing specialist, you may simply code the reports and a billing specialist may enter them into the software program).
- Keep up to date on any changes to the code sets used to report services and diagnoses.
- Keep up to date on any new advances in medical procedures or newly discovered diagnoses that have come to pass and if associated with the practice or facility you work with, research to find the correct codes to use for reporting.
- Attend conferences, read, or listen to teleconferences to attain the CEUs needed for credential maintenance.
Responsibilities of Medical Billing Specialists:
- Collect copies of insurance cards from the patient and proper patient information for claims submission, etc.
- Verify insurance coverage and benefits and if the provider is contracted with the patient’s insurance for maximum benefit.
- Collect or determine the amount of money patient’s need to pay at the time they check in for their visit (co-payments, deductibles, and co-insurances).
- Enter patient information into the medical billing software program including insurance information and patient billing information.
- Enter codes provided by the medical coder into the program and submit a claim to the insurance company.
- Follow-up on the claim to ensure it is paid. If not, contact the insurance company to find out why and meet the expectations of the insurance company with supporting documentation to get the claim paid.
- Know the contract parameters for each of the insurance companies you are contracted with. Some have very stringent requirements to be met on a specific time-line or payment will not be made by them and you will be unable to seek payment from the patient. Unplanned free services will not make your employer happy so know your contracts well.
- Follow up promptly on any insurance requests for additional information to avoid claim denial and having to start the process all over again.
- When payment arrives from the insurance company, post the payment into the software program along with any contractual adjustments and determine if the patient owes a balance.
- Submit a statement to the patient for any balance owing they are responsible for.
- Run aged reports and verify past due accounts are being worked on properly until payment is made in full.
- Process any notices, payments, bankruptcies, financial aid requests.
- Verify insurance companies are paying according to contracts.
- And then perform all the little duties such as answering phones, collections accounts, refunds, etc.
With so much to do, a medical coder and billing specialist has a job that is forever evolving.
Tools used by Medical Coders and Billers
Traditionally medical coders and billers have used books with thousands of pages containing a list of all the medical codes. Book publishers also tried to includes as much additional code information as they could squeeze in. On their desk, coders and billers would have a book for each code set and often multiple year's worth of books as the books are updated annually.
Over the years more and more information has been produced regarding how and when to use the medical codes. Many additional and companion books appeared containing this additional coding information and the number of books on the coders and billers shelves has grown and grown. We have now reached the point where a professional coder needs the assistance of technology to maintain effectiveness and accuracy.
FindACode.com is a website that has been specifically designed to meet this need for enhanced medical coding and billing technology. FindACode.com has digitized the information from 100s of coding books and has put it all into a searchable system available through their website, http://www.findacode.com. The FindACode.com information is extensively cross-linked, indexed, and sourced.
Since the coding information now changes quarterly, monthly, weekly and even daily, a website is an ideal way to distribute the updated information and provides an always up-to-date copy of the coding data. FindACode offers a subscription service that provides this information to professional coders and billers.
Here Comes ICD-10
Not only is the speed at which the coding and billing information increasing, but there are also two new code sets on the horizon that will necessitate the need for technological assistance when coding.
Since 1977 coders and billers have had 3 main code sets to work with: ICD-9-CM, based on the World Health Organization (WHO) ICD-9 code set; CPT, a code set for medical procedures created and maintained by the American Medical Association (AMA); and HCPCS a code set of injections, medical supplies and medical devices maintained by Medicare.
In an inpatient or hospital setting ICD-9-CM volumes 1 and 2 are used for diagnosis codes, and volume 3 is used for procedure codes. Outpatient centers, like your doctor's office, use the ICD-9-CM diagnosis codes but use CPT and HCPCS codes for procedures and supplies instead of the volume 3 of the ICD-9-CM.
Starting in October of 2014, the two new code sets, ICD-10-CM (diagnosis) and ICD-10-PCS (procedures) will be required for use in inpatient facilities. Outpatient offices will also be required to use ICD-10-CM codes, but may choose to use either the existing CPT/HCPCS code sets or report their procedures using the new ICD-10-PCS code set.
Medicare will accept both CPT/HCPCS or ICD-10-PCS codes from outpatient facilities, but inpatient must use ICD-10-PCS for procedures. Private insurance companies will set their own rules, but generally the follow the practices of Medicare. Physicians and coders who work in both types of facilities may prefer to switch to the ICD-10-PCS code set for procedures as they would only need to keep up on the two ICD-10 code sets vs. all 4 code sets (ICD-10-CM, ICD-10-PCS, CPT, HCPCS).
There is a great increase in the number of medical codes in ICD-10 vs. ICD-9; 150,000 codes in ICD-10-CM/PCS vs. 17,000 codes in ICD-9-CM v1/3, CPT and HCPCS. With all the additional codes as well as the accompanying code information, usage notes and coding and billing instructions technological tools become an essential part of the professional coder's resources.
Computers, pads and tablets are ideal tools for assisting medical coders and billers in their tasks of code lookup, comparison, determination and researching the codes necessary for completing medical records and insurance claims.
The FindACode.com service assists medical billers and coders in keeping up on all the changes and helps them maintain their productivity as they merge the two new ICD-10 code sets into their work-flow. Because coding, billing and reimbursement is such an important aspect of the medical industry, coders and billers will always play a critical part. Keeping coders and billers effective, efficient and always up to date will be a major concern with the change in code sets from ICD-9 to ICD-10, and a tool like FindACode.com will be of great help.
Besides having all this wonderful reference material and the code sets at your very fingertips, medical coding and billing specialists can enjoy the great assistance FindACode.com gives them in claims tracking and insurance appeals for claims that are left unpaid. The ability to look up reference information, verify proper modifier use, special notes and articles on specific codes, and even fee schedules is a great benefit to the medical coding and billing specialist trying to keep up on insurance aging and unpaid or denied insurance claims.
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.
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