Medical Coding vs. Medical Billing: What’s the Difference?
Should I do coding or billing? It’s a common question we receive.
Well how about this? I’m gonna run you through both jobs and that way you can decide what’s BEST for you.
There’s nothing more reassuring than you all coming to your own conclusions.
The Differences
Okay, well first off, depending on which one you decide, please make sure you are reading or, better put, analyzing the actual DESCRIPTIONS of the posted positions.
In other words, don’t just shut one down because the position is posted as “Medical Biller or Medical Coder.” Employers are infamous for listing jobs as Medical Biller, but if you take a close look at the job description, lot of these jobs are “coding skills” heavy and the same work the other way around too.
Something to know right of the bat is while The words “billing and coding” are used interchangeably, these are actually 2 completely different jobs.
It’s funny because I hear it all the time… coders get all UPTIGHT because it just never fails: someone in their family will ask them, “hey, can you please take a look at my medical bill?”
And when they clarify to them that they don’t do billing, the family member gets a deer in headlights and says, “but you’re a coder?”
So, you see, it’s two different jobs.
The Similarities
But while the have their differences, both positions work to get claims paid at the highest allowable amount.
- Both positions feed into the revenue cycle.
- Both positions provide opportunities to work from home.
- Both positions are challenging yet highly rewarding.
- Both positions are very “behind the scenes.”
- Both positions require you to sit on your tail all day long!
Additionally, coders and billers can work for:
- Small private practices
- Larger multi-specialty clinics
- Urgent care centers
- Billing companies
- Hospitals
- Health insurance companies
Or even clearinghouses, which are basically entities that handle the entire process of the revenue cycle. Clearinghouses are are actually loaded with coders and billers because of that.
How Medical Coders Do Their Jobs
The first thing to know about the coders is that they work very closely with the physicians. The reason the coders work so closely with the physicians is because they are responsible for querying or requesting the physicians to document with greater levels of specificity.
Anytime a coder comes to a screeching halt in coding something due to lack of specificity, the coders query the physicians. They work together to foster the strong documentation possible.
The coders don’t just do this to better code but also to protect the licenses of the physicians. The coders go to any and all means necessary in order protect their providers. They know all to well that if they don’t get their physicians documentation on point, the future of the entire entity can take a downward spiral due to audit penalties and fees.
For this reason, you bet the relationship between the coders and physicians are 100 percent built on TRUST. The physicians recognize their coders are constantly doing everything it takes to ensure the businesses are protect and that the physician or physicians of that entity receive the maximum allowable dollar amounts for every service he/she provides.
It’s truly something to be admired because the respect and gratitude the physicians have for the coders is ABSOLUTE!
Now in order to carry all or this out, medical coders are primarily responsible for analyzing medical records. These are the professionals who abstract all of the diagnosis and procedure “words” from the medical report and turn them into codes.
Medical coders report the most accurate codes by coding to the highest level of specificity and also by coding to the fullest completion of what was performed. It is through this acute level of accuracy and completion, that the coders essentially prove medical necessity. In other words, medical necessity is where the diagnosis codes warrant the procedure codes.
And to put it plain, the diagnoses warrant the need for the procedures. Okay so after after selecting all of the appropriate codes next the coder has to apply the medical coding guidelines. Doing this allows the coder to sequence the codes according to the guidelines dictated by the Coding Clinic and CPT Assistant.
As a final step in the coding process, coders run any necessary codes through the NCCI edits. The edits will prevent the coders from accidently bundling codes and at the same time prompt the coders to use special modifiers to bypass an edit, if and when possible.
It is by performing every one of these key steps that a medical coder ULTIMATELY ensures maximum reimbursement. In other words, taking these very valuable measures drive the “end result” of the providers getting paid at maximum allowable reimbursements for all the services and procedures, they render.
Coders are cherished by the entire staff because it doesn’t take long for the entire team to recognize that without the coders, not one employee would get paid.
Now in most cases, coders work directly out of a queue.
What I mean is, on a daily basis, medical records that need to coded will typically show up in their queues from within the billing software that they work out of. So yes so, the coders do their thing and then hand their codes for each encounter off to the BILLERS for entry of the codes on the billing software and claim submission.
The Truth!
Just because a coder codes a record and a biller sends it out for adjudication, that doesn’t always mean they won’t ever see it again. I say this because a claim can come back rejected for the smallest and darndest of things.
Thankfully lots of times rejections are often easily fixed then smoothly resubmitted and paid. In cases like this, the biller can often rectify the issue him or herself. Other times they’ll need to work with the coders or additional members of the revenue cycle, also known as revenue integrity teams, in order to reconcile the issue.
Again, so while the CODERS work closely with the providers, the medical billers work closely with the INSURANCE COMPANIES and REVENUE CYCLE TEAMS. I also want to point out that while the coders have to understand the medical CODING guidelines, the medical BILLERS need to understand the payer guidelines from not just once insurance company but multiple insurance companies.
Knowing the payer guidelines enable the billers to advocate for the patients and take as much of the financial BURDEN off the patient as possible by making sure the patients aren’t overcharged or undercharged.
How Medical Billers Do Their Jobs
The BILLERS ability to protect the patients produces some very happy patients. Very happy patients endorse their physicians by referring others to them and or writing wonderful reviews for them.
Having a strong reputation means acquiring more patients. A bigger patient panel grows the practice and with growth comes increased revenue for everyone.
It cannot be overstated enough, billers know that the #1 cause of bankruptcy in America is medical bills. And because of this, billers do everything possible to prevent patients from being tagged with harmful, life-altering debt that should be paid by the insurance companies and not them.
To explain further, billers take all the billable codes from the coders and enter them into the billing software. Their goal is to get the claims filed and timely submitted so that the payers can review them for prompt payment.
Billers also carry the task of analyzing EOBs (explanations of benefits) and the RAs (remittance advices). In other words, these are the professionals who get all the reports of payments and denials.
I point this out because it’s no secret that insurance companies like very much to “get out of” paying claims.
We joke about this, because this is the NATURE of this industry. But, in reality, it’s not a joke at all because the billers take their jobs very seriously. The billers know all the different nuances with all the different payer guidelines, the billing guidelines and even some federal guidelines.
Billers know all the different tricks as to what codes, which modifiers pay with which payer and at the same time which don’t.
The billers will know how long they have to submit an insurance claim because. Boy oh boy, does “timely filing” COMPLETELY depend on the payer. Some payers require claims be filed within 30 days of the service, some 60 some give a whole year. The billers are also going to be very familiar with the contractual amounts that were agreed upon by the providers and payers.
The billers know WHAT the appropriate reimbursement dollar amounts are. This knowledge is vital because if for whatever reason they don’t receive back the dollar amounts they were expecting, the billers then prepare to go to battle.
If after applying basic resolutions like fixing truncated codes, fixing inaccurate codes or justifying medical necessity, the claim still fails to pay, make no mistake about it, the billers plan their attacks! They do this in various ways, with one of the main approaches being an appeal.
‘Champion Billers’
As a matter of fact, some billers nicknamed “champion billers” for their “private investigator” types of natures and keen ability to act as “pitbull negotiators” are so good at this, that they are strictly asked to work denials and compose appeals.
You’ll see these professionals bulldoze their way in to the records department, they pull whatever op reports, Xray and lab reports like their life depended on it.
A champion biller will also know how to get the physicians to write letters of medical necessity like no other.
So, in the end, billers basically know all the facets to the revenue cycle.
What About Dual Roles?
Okay so now for the other side of all this. Medical coding and billing isn’t always so cut and dry. Sometimes, depending on where you work, the coder and biller can actually be the SAME person.
This is especially the case when you work for a small provider office out in, let’s say the rural parts of the country, believe me when I say you’ll not only be the coder, but you’ll also be the biller, the HIPPA compliance officer, the AR Manager, the credentialing specialist and more.
Often times mostly with bigger settings, the coders will be on one floor and billers will be on another floor.
But just as quick as I say this, in those very same BIGGER settings, I’ve also seen where all the coders and billers in the AR department handles the entire claims process from start to finish!
So you see not always so cut and dry… It really all depends on the job.
Interview Tip
Okay so time for me to clarify something huge You see, After some time in the industry, lots of coders inevitably learn billing just from working in the industry but having billing knowledge has NEVER been a requirement for getting a CERTIFIED CODING JOB.
EVER.
In many jobs I worked as a coder wouldn’t you know it, I had to do the appeals, research medical policies for some of the denials..so I mean it when I say It all depends on how the company has structured each department and the duties within it.
So when they ask you over at the interview, “Do you have any questions for me?” Absolutely one of those questions should be, “Will I be the coder, the biller or both?”
By the way, if you’re a certified coder, please don’t worry yourself about practicode or an internship. Watch this video right here:
Once you watch that video, you’ll learn that the only thing you need to be spending your time doing is learning how to get hired on the spot with no experience and none of it requires practicode or an internship.
I’ve been in the industry a really long time.
There a reason my guidance is ever so revered.
But getting back, ON THE FLIPSIDE, I’ve also worked at a NUMBER of entities where the coders have NEVER known a SINGLE thing about billing… and nor were they expected to.
Some Final Thoughts
Now then, I’ve also been around the industry long enough to see the physicians learn some very hard lessons.
One of the biggest points I wanted to clarify with the industry is that billing is trained or learned on the job! Not everyone is in a position where they can afford formal coding training so lots of people will apply for billing positions in order to land jobs in healthcare.
Billers are hired every single day with absolutely no experience and with no certifications whatsoever!
The reason this is the case is because every hiring manager recognizes that the AR team will train them on everything billing. They also know that lots of times the payers help guide the new hire billers to better understand the process and inevitably teach them how to proceed.
Now keep in mind they won’t ever tell you what codes the coders need to use, but they will tell the billers if a denial was due to something as trivial as an incorrect date of service, incorrect sex of the patient, lack of preauthorization, usage of incorrect modifiers, etc.
The fact is, billers don’t have to be certified coders.
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thanx for sharing this blog
you’re welcome..stay tuned there’s always more!
This is an interesting article that gives a brief insight into medical billing.