Why are medical billing and coding specialist important in healthcare? Healthcare facilities need money to keep the lights on, but how they’re funded is unlike any other business. Multi-payer revenue cycles must be carefully managed to ensure that medical facilities get paid. That’s what you’ll do as a medical billing and coding specialist.
What Does a Medical Billing and Coding Specialist Do?
Medical billing and coding specialists handle insurance claims and invoicing for doctor’s offices and other healthcare institutions. Their work includes:
Medical coding reduces the volume of data required on insurance forms. Lengthy descriptions of symptoms, diagnoses and treatments are replaced with short, alphanumeric sequences. Medical billing and coding specialists translate health information into medical codes for billing purposes, streamlining the reimbursement process.
Managing Insurance Claims
Medical billing and coding specialists manage health insurance claims from start to finish. They research charts, code the forms, and review them for accuracy before submitting them for final approval.
If they’re rejected, they file appeals, working with insurers and providers to fix errors or troubleshoot coverage issues. Quick turnarounds are a must to ensure a steady cash flow.
Multiple payers share responsibility for the majority of US medical bills. The patients and their insurers each pay a portion of the balance. If more than one insurer is involved, each pays their fair share in order of liability.
Negotiated rates, early payment discounts, interest on overdue balances and other adjustments, however, further complicate billing. As a medical billing and coding specialist, you’ll keep track of the debits and credits on patient accounts to identify each party’s responsibility.
No two insurance policies pay for the same treatments. If patients receive non-covered care, they’re left holding the bag for the bill. To avoid surprises, you’ll call insurers to verify coverage before services are rendered.
Medical billing and coding specialists have a broad range of other financial responsibilities, including accepting payments, reconciling credit card receipts, making cash deposits, and compiling financial reports. You’ll work with accountants, office managers and administrators to manage the fiscal health of the facility or practice.
Medical billing and coding specialists help patients navigate the billing process. You’ll explain how services are covered, what discounts are available and how to find financial assistance. When balances are overdue, you’ll establish payment plans. The goal is to maximize reimbursement without resorting to collections.
Why is Medical Billing and Coding Important in Healthcare?
Medical facilities are paid as part of the healthcare revenue cycle, a series of steps from patient registration and insurance pre-authorization through claim submission, approval, and reimbursement. While most healthcare bills are covered by insurers, doctors and facilities aren’t paid until claims are approved. Medical billing and coding specialists manage the process from authorization through payment.
How Do You Become a Medical Billing and Coding Specialist?
Unlike other careers in healthcare and finance that require a college degree, you can become a medical billing and coding specialist with a vocational school diploma. Programs are short but comprehensive, preparing you for success in an entry-level position.
What Do You Learn During a Medical Billing and Coding Program?
A vocational school program will prepare you for your first job as a medical billing and coding specialist. The curriculum is designed for beginners, so you’ll succeed even if you’ve never stepped foot in a medical office. The curriculum includes classes, such as:
Medical billing and coding specialists have no clinical responsibilities, but they need a healthcare background to code insurance forms. Medical terminology courses familiarize you with the terms, acronyms ,and abbreviations you’ll see in doctor’s notes and surgical reports.
It’s a basic class that teaches you how to decipher terms based on their parts. Instead of memorizing words, you’ll learn how prefixes, suffixes and root words are combined to make complex but easily understood terminology.
Anatomy and Physiology
Anatomy and physiology courses cover body structure and function. Students learn just enough about the major body systems to feel confident reviewing Electronic Health Records (EHR).
You don’t need a background in chemistry or biology to understand what you’ll learn. The focus is on anatomy and physiology as a coding resource. You’ll learn, for example, that the word respiratory and the prefix pneumo- mean lung, cueing you to search for medical codes in the respiratory code set.
Electronic health records are a digital version of your health record but better. Stored in a database, they’re overarching compilations of medical and financial information that make sharing data simpler. Medical billing and coding specialists access, enter, store and secure information in EHRs.
This course offers a background in EHR theory, why it’s important and the general rules governing the care of medical information. This is followed by hands-on training using the same type of software you’ll use on the job. Through simulations and case studies, you’ll learn how to manage EHRs for billing purposes.
Multiple coding systems are used throughout the healthcare industry for purposes ranging from billing to benchmarking. Which you’ll use the most depends on where you work. Courses cover the three most common:
ICD-10 – stands for the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Developed in the early 1800s, it’s still used today to classify symptoms, disorders, injuries, and procedures.
Medical billing and coding students learn how the manual is indexed. Divided into three volumes, the first is a tabular index with cause of death codes, inclusions, and exclusions. Volume 2 covers coding guidelines and rules. Volume 3 is an alphabetical index of diseases and injuries with reference tables for drugs and chemicals.
CPT – Common Procedural Terminology (CPT) codes are assigned to medical, surgical, and diagnostic procedures. Developed and maintained by the AMA, the CPT index gives doctors a uniform language for coding medical services and procedures.
Medical billing and coding courses cover each of its four parts. Category I codes categorize services by type or anatomy. Category II codes are supplemental. Used to measure outcomes, they’re a part of benchmarking programs.
Category III codes are temporary. They’re used for evolving technology and new procedures not yet approved for Category I. Finally, PLA, or Proprietary Laboratory Analyses codes, provide a way to reimburse independent laboratories for one-of-a-kind testing.
HCPCS – The Healthcare Common Procedure Coding System (HCPCS) was developed exclusively for Medicare. You’ll learn about its two parts , Level I, which is essentially the CPT index, and Level II, a distinct coding system that covers medical products and ancillary services.
Principles of Health Insurance
There are hundreds of commercial insurance policies and dozens of government-sponsored programs that pay medical bills for enrollees. The billing processes are similar, but each has its quirks.
In this course, you’ll learn the difference between conventional insurers and health maintenance organizations (HMOs), how private and public policies differ, how the differences impact providers and how to request and receive reimbursements.
Other topics include negotiated rates, larger pools of insured customers give some insurers better rates based on their contracts. While patients get early pay discounts, direct-to-patient savings for paying their projected balance early. You’ll also learn how to handle charge reversals and interest fees on overdue accounts.
Students use financial case studies to track charges and payments to a simulated account, juggling reimbursement from multiple providers in order of liability to determine the final balance.
Understanding Insurance Claims
Claim forms are similar but not standardized. In general, they’re completed online and submitted electronically, but each company has unique requirements that make the process challenging.
This course covers how forms are structured and the basic information insurers need to review claims. With experience, you’ll learn the nuances. You’ll also take a deep dive into what happens after claims are submitted and how insurers validate data. Working on simulated cases, you’ll troubleshoot rejected claims, figuring out what went wrong so that forms can be corrected and resubmitted promptly.
Managing the revenue cycle efficiently is the key to financial survival for healthcare providers. Billing and coding specialists support their patients and communities by making that happen.
Want to Learn More?
The Medical Billing and Coding training program at Peloton College provides students vital knowledge in Medical Terminology and Understanding Health Insurance Claims and prepares students to be able to work with and maintain electronic health record systems in the health care industry. Graduates of this Medical Billing and Coding training program will also be eligible to sit for the Certified Electronic Health Records Specialist (CEHRS) Certification or the Certified Billing and Coding Specialist (CBCS) Certification.
The mission of Peloton College is to be the premier provider of hands-on training and education by providing students and graduates with the necessary skills to secure occupational careers. Contact us today to learn more.