Knowing the difference between billing and coding is vital to maximizing your revenue. Many people assume they refer to the same concept when in reality these two areas require quite different skills and knowledge. Hiring someone to do both that is limited to an education or certification in one area can cost you thousands of dollars in lost revenue.
Today I am going to break down the difference between medical billing and medical coding and why you need a certified specialist for both departments.
Now don't get me wrong, one person CAN complete both of your billing and coding successfully, however that person should be certified as a professional billing expert and coding professional. Just because someone knows how to code medical records doesn't mean they understand billing rules, and what good is coding a claim if you don't know how to properly submit it to a payer.
Medical Coding
A medical coding specialist is a professional that has been certified through either AAPC (American Academy of Professional Coders) or AHIMA ( American Health Information Management Association). A certified coder should be a member of their certifying association and is required to pay annual dues and maintain their certification by submitting continuing education credits that pertain to medical coding.
Medical coders abstract data from a providers written documentation and assign the correct CPT, ICD-10 & HCPCs codes that reflect the services provided. A medical coder will communicate with physicians, nurses and other health care professionals to categorize services the patient received. A medical coder can audit a chart when the claim is denied for medical necessity or any coding related denial. These professionals can also get certified in specialty areas; for example Sloanmed.com specializes in Cardiology, Vascular and General Surgery. This means they have taken additional steps to focus their skills set to these specific specialties in order to have a better understanding of the code set, anatomy and terminology and billing requirements beyond what the basic coding certification requires.
Medical Billing
Just like a professional coder, medical billing specialists should be certified with a reputable organization. AAPC offers a Certified Professional Biller (CPB) course and certification that requires continued education submission and annual dues to be paid to remain a member.
A medical billing specialist will take the codes selected by the professional coder and create the claim that is submitted to the payer. The billing specialist will compile all necessary insurance information, filing procedures for the payer, billing modifiers and patient demographics to submit the claim to the clearing house or payer. The biller will follow this claim until it is completed/paid and closed. They follow up on unpaid claims, denials and outstanding patient balances. Your medical billers are also the contact for patients when they have questions related to charges, co-pays and deductibles. It is vital that your biller have proper customer service etiquette and represent your office in a professional manner.
You're just throwing money away...
Together these two unique professionals directly impact the money that hits your bank account. If you don't have certified, experienced and reliable employees you can kiss your cash goodbye.
Have you ever walked by your billing/coding specialist to see them on the phone with the insurance company for 45 minutes trying to figure out why a claim wasn't paid or simply trying to get to a human to talk to? Is this really the best use of your payroll? A billing specialist that understands the regulations and guidelines of the industry and the different insurance companies is less likely to need to call in for clarification on denials because they understand the denial reason codes. An experienced biller that is trained properly is also going to know how to access payer specific requirements online when they do have questions.
Coders that aren't trained to your specialty are like broken records............ they work in circles and don't get far because they don't understand the anatomy and terminology of your specialty. Are your coders constantly billing out the same bundled codes causing denials to be worked over and over? Are they spending more time researching what you did than actually coding it because they don't understand the anatomy? Wouldn't you rather be able to speak to your coders using medical jargon and trust they understand what you're saying? You spent years refining your skills to your specialty practice, don't down grade your reimbursement by hiring and trusting a billing and coding specialist that hasn't done the same.