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Role of Medical Billers and Coders in Healthcare :Everyone Must Know

Coders and billers are amongst the top-most career choices and highly valuable service areas in the healthcare industry. To complete the patient’s care cycle, there aren’t just the doctors and nurses in the scene. Of course, theirs is a huge role but they aren’t the only ones who are on the go! People working at the backend too have a vital part to play in the institution’s successful functioning. If the coding and billing job isn’t carried out efficiently, the healthcare institutions won’t get paid. The efficacy of the skilled personnel is what literally compounds or alleviates the patient’s stressors. Moreover, retaining high levels of proficiency makes the reimbursement process as ethical and optimal as possible. So, if you are a certified professional, you are wanted. There’s a nationwide requirement for medical coders and billers.

Role of Medical Billers and Coders in Healthcare.


Medical Coding

From the point of examination to the tests and the treatments, a medical coder assigns standardized codes to all of the procedures that are used during the billing process. Based on these specific records, the collection process is initiated. Essentially, there are three different code sets that a medical coder deals with regularly. These include:

ICD Code – International Classification of Diseases

CPT Code – Current Procedure Terminology

HCPCS Code – Healthcare Common Procedure Coding System

Now that you have a hint of what’s medical coding about, let us get into the details of the code sets. Since these are what you’ll be working with, it is important to have a know-how of the three major types of medical code sets.

DIAGNOSIS CODES – Demonstrate the medical necessity

ICD Code – International Classification of Disease

Established by the World Health Organization (WHO), this set of codes came into use from the 1940s. Several updations have been made since its inception and the numbers that follow ICD— inform that exactly which revised version is currently in use. The ICD codes are diagnostic codes that describe the cause of an illness or the patient’s death. So for instance, in the United States, ICD-10-CM refers to the International Classification of Diseases, Tenth Revision, Clinical Modification (technical name). Talking of the ICD-10 code set, it contains around 10,000 code. However, on the other hand, the ICD-10-CM (Clinical Modification) code consists of more than 68,000 codes. All in all, the ICD codes tell us about the correct diagnosis of a doctor along with the patient’s condition. This is how billing makes sense – the procedure matches the diagnosis and the claim is accepted.

Plus, to give you a bigger picture, as a medical coder, you will have to deal with more than 60,000 Diagnostic Codes and somewhat 70,000+ Procedure Codes.

PROCEDURE CODES – Alerts the payer of what procedures have been performed

CPT Code – Current Procedure Terminology

Published, maintained as well as updated (yearly) by the American Medical Association, the CPT code set documents those procedures that are majorly performed at the physician’s office. The codes are even copyrighted and consist of three categories that are all based on five-digit numeric codes. To elaborate on these, the categories are as follows:

Category I corresponds to Medicine, Anesthesia, Surgery, Evaluation, and Management, Pathology, and Laboratory along with Radiology.

Category II includes an alphanumeric code which is usually added alongside the category 1 code. These, however, are optional code sets but AMA anticipates these to lower the administrative burden. The codes are more accurate, specific and informative on the performance of the facilities as well as the healthcare professionals.

Category III codes relate to the technological emergence in the medical field.

As a medical coder, you are supposed to be dealing more commonly with the Category I and II CPT code sets. Addendums used with these CPT codes add more accuracy. Various procedures need supremacy when it comes to detailing. So, this is when the CPT Modifiers come into play. These are again developed by AMA having two-digit alphanumeric codes. CPT modifiers offer you additional information, for instance, on which side of the body a procedure is performed or has it been discontinued, etc.

HCPCS Code – Healthcare Common Procedure Coding System

Shortened to just Hick Picks, these codes are developed by the Center for Medicare and Medicaid Studies (CMS) and are maintained by the AMA. So, things that aren’t covered by CPT codes including any medical equipment, procedures, and services come under HCPCS. Besides, it also is relevant for services such as outpatient hospital care, Medicaid, and Medicare, and chemotherapy drugs, etc. Hick Picks consists of two different levels:

Level I – This one’s very much like the CPT code sets

Level II – This one’s divided into 17 diverse sections each of which concerns just the specificity such as Rehabilitative Services.

Hick Picks must align with the diagnostic code to justify a procedure. All of this is again the medical coder’s responsibility and to also ensure that the doctor’s reports are accurate in terms of the diagnosis listed along with the procedure that’s mentioned.

Medical billing

Under this section, we will introduce you to the basics (not in-depth) of medical billing so you can understand the day to day activities of a professional medical biller. Now that you are aware of what are the duties of a medical coder plus the practice of specialized code sets, here comes the role of the medical biller. He/ she is responsible for using the ICD-10 medical codes which are provided by the coder itself and accordingly produce the bill. So first, the biller will create a claim for the insurance provider. Next, the company evaluates whether the claim is genuine and makes the returns. Lastly, the medical biller determines the patient how much they owe out of their pockets. It is the medical biller’s hard work that makes the after-processes much simpler. All of this is done on the patient’s behalf and therefore the billing process is easy to understand. It is a comprehensive process but an integral job in the modern-day health care industry.

Although the diagnosis and procedure codes track the effectiveness of a procedure or the spreading of disease, in the United States, their major use is during the reimbursement process. So, the codes help you bill accurately. Going to the doctor isn’t a one on one interaction process. It’s a part of the larger system – a system of information exchange as well as the payment. This is a three-party system that includes the patient, healthcare provider along with the insurance company. Healthcare providers may include physicians, hospitals, therapists, emergency rooms outpatient facilities, etc. It is the duty to negotiate as well as arrange the payment that makes the institution survive (essentially). If you are wanting to enter this sector, understand that you will always have to make sure that the healthcare providers are accurately compensated for whatever services they perform or the facility they provide. Information regarding the patient as well as their procedures is compiled into a bill for the reference of the insurance company also called the claim. This may contain details such as insurance coverage, patient’s medical history, demographic info, procedural reports and so on. So, precisely interpret the insurance plan and produce a particular patient’s claim documents.

As a biller, you will add essential information concerning What, Why Who, When along with How Much. The documents are to be both formally as well as factually accurate. Once the claim is compliant, it is sent to the payer. After the approval, it comes back to you with the amount they will segregate. You will then ask the patient to cover up the balance.

Everyday Activities

1.Working with the patients

After the completion of any medical services for a patient by the health providers, the patient is presented with a bill. This bill lists the cost of the procedure, balance, amount covered by insurance company along with factoring the deductible. You are also responsible for dealing with the medical records of the patients.

So, where the coders are there to translate the patient’s medical records from the reports into the desirable codes, a professional biller extracts those records as well as the insurance plans to precisely produce the medical bills.

2.Working with computers

The healthcare industry, or for that matter any line of business today makes use of one or the other personalized software. In hospitals or clinics, these are particularly employed to keep track of the patients, schedule the visits, store the essential medical data and therefore, help the business run smoothly.

3.Creating claims

A major part of the biller’s day is spent in creating as well as processing the medical claims. You must be familiar with the type of claims that will be accepted by the patient’s insurance firm. Consequently, adjust the claims and make sure it’s compliant. Usually, the claims are clean and processed much easily which effectively accelerates the reimbursement process.


This is a vital activity of a professional medical biller. You are constantly conversing with all the people involved during this process. You are the ultimate waypoint in the process along with being responsible and accountable for notification, clarification, and follow-up.

To sum it up in simple words, Procedure Codes deal with the WHATs of the patient’s visit and the Diagnosis Codes determine the WHYs. However, it is the biller’s effort to create an appropriate medical bill that will, in turn, let the services going.

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