How Does Someone Become a Medical Biller and Coder?

Medical billing is unlike billing for most professions. A plumbing company’s billing clerk might prepare a bill based on a plumber’s record of time spent on a project and add charges for supplies used in the project. On-the-job training teaches employees how to prepare a bill of that nature.

Medical billing requires specialized knowledge that most clerical positions lack. Gaining that knowledge opens the door to a satisfying career as a medical biller and coder. The Bureau of Labor Statistics expects jobs for clerical support staff for healthcare providers to increase by 11% before 2030. That’s a sharp contrast to most other clerical positions, which are expected to decline because of changes in technology. The growth of the healthcare industry, prompted in part by the nation’s aging population, assures that medical billing and coding specialists will be a vital part of the economy for decades.

Unlike plumbers, doctors do not typically charge by the hour. Insurance companies and government agencies that pay for Medicare and Medicaid expect healthcare providers to charge by the service or procedure. They generally pay a set amount for each service or procedure performed.

Since different doctors might use different terminology to describe the same procedures, the medical industry has created standardized codes that identify specific services and procedures. Those codes are developed and maintained by the American Medical Association. More than 10,000 Current Procedural Terminology (CPT) codes identify services and procedures that range from brief office visits to heart bypass operations.

Medical coders identify each specific service or procedure that the patient received. They then match those services and procedures to specific CPT codes. That task is more complex than it might sound. For example, the coder must choose from six different codes that describe heart bypass surgery, depending on the number of coronary bypass grafts that were involved in the operation.

Coders must also keep in mind that the code may differ depending on whether multiple procedures were performed at the same time. Rather than billing each procedure separately (a mistake that is known as “unbundling”), the coder must apply a code that applies when those procedures are performed in the same operation or office visit.

Coders must also use a separate set of codes, known as diagnostic codes or International Classification of Diseases (ICD) codes, to identify each diagnosis that the physician made. Diagnostic codes are developed by the World Health Organization to describe tens of thousands of diseases, injuries, and other health conditions.

Medical billing and coding experts need to understand the terminology used in the medical profession. They need to interpret medical records so that they can made a precise determination of the services and procedures provided to a patient and of the patient’s specific diagnosis. 

Medical billers and coders take classes in medical terminology and learn the fundamentals of anatomy, physiology, and pathology. They take classes in diagnostic coding, CPT coding, and preparation of medical bills. They also take classes that will help them become proficient in specialized computer software used to prepare medical billings.

Medical billers and coders study the process of submitting billings to insurance companies and medical agencies and the requirements that those entities impose as a condition of paying medical bills. They take classes in insurance claims processing and learn about their obligations when billings are challenged. They learn about the various ways that medical records are prepared and stored, either on paper or in electronic databases.

Since some healthcare providers may pressure billing and coding specialists to help them defraud insurance companies or government agencies, students take classes in medical ethics to help them understand their legal obligation to prepare honest bills that are justified by the medical records. Students also study rules and laws governing patient confidentiality, records management, and security procedures to assure that medical records are not inadvertently disclosed without a patient’s consent.

A medical billing and coding specialist must pay close attention to detail. The work cannot be performed successfully by people who become easily distracted or have a short attention span. Medical billing requires intense concentration and a focus on each task that is part of the billing process. It also requires patience and a willingness to double-check work to make sure it is accurate.

Individuals with a nursing background are often attracted to the field of medical billing and coding because they are already familiar with medical terminology. The job is less physically demanding than nursing because it does not require long hours of standing or interaction with difficult patients.

The healthcare industry is a primary employer of medical billers and coders. Hospitals, clinics, and private medical offices that deliver medical services in a variety of specialties all employ medical billers and coders.

The insurance industry also employs individuals with a background in medical billing and coding to review medical bills in order to determine whether they should be paid. Government agencies that administer Medicare and Medicaid also employ specialists to determine whether billings satisfy standards that must be met as a condition of payment.

People who are particularly proficient in medical billing and coding may join private firms that provide expert services to lawyers, patients, and others who need to understand whether billings are accurate and reasonable. Medical billing experts help lawyers and their clients detect fraud and identify intentional or inadvertent overbilling.

To collect medical expenses as an element of damages in a trial, injury victims must prove that the bills were reasonable. Medical billing experts develop an understanding of how usual, customary, and reasonable (UCR) charges are determined. They also learn to use specialized databases that help them determine whether particular billings meet the UCR standard. Medical billing experts prepare reports to assist litigation and may testify in depositions or trials for either the plaintiff or defendant when the reasonableness of medical billings is contested.