When you leave an appointment with your physician, you might not think too much about what happens next. You know they’ll charge your insurance and you’ll get a bill in the mail, but that’s usually it.

Behind the scenes, there’s a medical coder and biller hard at work. These experts are responsible for performing the administrative work that the claims submission process requires.

What is a medical coder and biller? If you’re interested in learning more about this exciting profession, read on. Today, we’re sharing the basics of these two roles and explaining why they’re so important.

A Quick Look at Medical Billing and Coding

Medical Billing Service

Before we dive into the differences between a medical coder and a medical biller, let’s start with a high-level overview of how this industry works.

Coding and billing are distinct from one another, but they are both necessary in the medical realm. Without them, healthcare providers wouldn’t receive payment for the services that they provide.

Medical coders start by scanning each patient’s record and clinical data. They are looking for billable details that they can send to that patient’s health insurance company. Each service has its own medical code, and they’re the ones who will translate it.

Once they’ve listed all of the codes that apply to the visit, they’ll send that information to a medical biller. Then, the biller will enter those codes on the patient’s insurance claim. They will also use them to create bills for any outstanding payments due.

Thus, the claims development process requires both coders and billers to function successfully. Now that we’ve covered that quick medical billing guide, let’s break these roles down a little more.

What Does a Medical Coder Do?

Every time you visit a physician, hospital, or any other type of medical facility, your provider has access to your medical record. Within that record, they enter details about your visit.

Key details include:

  • The services they provided
  • The prescriptions they wrote
  • The medical devices or items they used
  • The procedures they performed

If this documentation seems extensive, it’s for a reason. Physicians have to make sure they’re getting appropriately compensated for the work they’re providing. If they miss even one detail, that could be a costly error.

Once you leave the facility, the physician shares that record with the on-site medical coder. The coder then matches those services and details with specific industry billing codes. These codes could signify a specific:

  • Diagnosis
  • Procedure
  • Charge
  • Professional service
  • Facility

Let’s take a look at two of the most common ones.

Diagnostic Codes

Medical coders use diagnostic codes to describe a patient’s medical condition or injury. There are also codes to mark their overall health level, as well as other relevant characteristics.

The regulatory standard that coders reference to find and manage these codes is the International Statistical Classification of Diseases and Related Health Problems, Eleventh Revision, or ICD-11. While these codes will begin with ICD-11, they have additional markers that are even more granular.

For example, ICD-11-CM denotes a clinical modification. Coders will use this to classify a diagnosis if it occurs in a general healthcare setting. However, if a provider delivers inpatient services at a hospital, they will use ICD-11-PCS, which stands for procedure coding system.

Procedure Codes

Next, they’ll need to see what services the provider actually delivered. Instead of ICD, they’ll reference two other standards:

Electronic Medical Billing Services

  • Current Procedural Terminology (CPT)
  • Healthcare Common Procedure Coding System (HCPCS)

CPT falls under the jurisdiction of the American Medical Association (AMA). They publish new CPT guidelines every year, including updates to code modifiers. Coders add modifiers to CPT codes to describe services in greater detail.

While most private payers prefer to use CPT codes, other third-party payers prefer HCPCS codes instead. One example is the Health Information Portability and Accountability Act (HIPAA).

What Does a Medical Biller Do?

A medical biller submits claims to payers, such as insurance companies. They also bill patients for their portion of the financial responsibility.

The billing process occurs even before the appointment begins. It’s enacted right when the patient schedules a visit. At that time, the biller will start conducting their pre-visit duties, including:

  • Making sure patients have completed all required forms
  • Confirming patient contact information
  • Confirming patient insurance coverage
  • Confirming patient financial responsibility
  • Submitting prior insurance authorizations

If a patient does not have insurance, or if their coverage isn’t sufficient to cover the services provided, then the biller will inform them of their outstanding costs. When the patient arrives at the appointment, they will usually collect a copayment.

Then, once that patient completes the appointment and checks out, the biller will obtain the medical records from the coder, who has turned the data into billable codes.

Completing the Billing Process

Working together, the medical biller and coder will use all codes and patient data to create what’s known as a superbill.

This is a detailed, itemized form that medical providers need to set up a new claim. Each superbill will include the following information:

  • Medical provider data (e.g. name and location, official signature)
  • Patient data (e.g. name and contact information, birthdate, symptoms, and treatment details)
  • Appointment data (e.g. diagnostic codes, procedure codes, authorization details)

Once they scrub each claim to make sure all of the information is accurate, the biller will submit it to the associated payer. They will use one of two main forms to do so. These include:

  • CMS-1500 Form: Physician practices and non-institutional healthcare facilities
  • CMS-1450 (UB-04): Institutional healthcare facilities or hospitals

Outsourcing The Medical Billing Services

Even smaller hospitals will need to use CMS-1450. Often, they’ll outsource their hospital medical billing services to an authorized third party.

What Is a Medical Coder and Biller? Essential Healthcare Administration

Medical coding and billing are two essential parts of the healthcare cycle. While these are two distinct roles, they can be combined into one. This is especially common in smaller medical offices, where teams are more limited in size and scope.

What is a medical coder and biller? Without the support of this professional, physicians would not receive compensation for their work, and services would cease. They’re responsible for keeping the entire billing process flowing smoothly and successfully.

Interested in more medical-related news? Check out the guides in our Health and Fitness section!

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