Ever wondered how healthcare providers run a medical practice, take care of their finances, deal with payment providers, and offer the best possible patient care all by themselves?

The truth is,  that behind the financial success of almost every medical practice lies a certified coding and billing specialist. Medical coding specialists play a key role in supporting the medical practice’s financial dealings and ensuring that the practice is reimbursed for the services it provides.

The job of a Medical Coding specialist

A medical coding specialist is a professional who is responsible for managing the important administrative work associated with medical coding and billing so that the practice can maintain the income necessary to keep running. This allows clinical workers to focus on the most important element of running a medical practice, i.e., providing patient care and improving health outcomes.

The medical coding specialist either works remotely as a third-party service provider or works in-house, depending on the respective business model and needs.

The typical responsibilities of a Medical Coding and Billing Specialist include:

  • Maintenance of electronic health records.
  • Development of a robust coding system to select appropriate diagnosis and procedure codes.
  • Entry of the correct procedure and diagnosis codes of patients in their electronic health records.
  • Ensuring HIPAA compliance while maintaining all electronic health records and coding.
  • Use of medical billing software to create and submit claims to request payment from payment providers.
  • Reviewing all claims to ensure accurate coding of procedures.
  • Management of medical billing systems.
  • Following up with patients and insurance companies about any outstanding bills.
  • Tracking payments.
  • Ensure timely receipt of reimbursements.
  • Stay up to date with coding regulations and requirements.
  • Finding out why a claim was denied and follow up to ensure the claim is accepted.

Understanding the Medical Coding specialist’s scope of practice

Medical coding specialists play a vital role in the healthcare system. They help healthcare professionals save time and money, allowing them to receive timely payments from insurance companies.

This gives them the liberty to invest more time in their practice and enhance productivity within their operations. There is a greater demand for experienced and certified coding specialists because they help reduce errors in the coding and billing process while also ensuring that payments are promptly collected.

The need for certified coding specialists is only expected to grow with time as the healthcare industry experiences changes in insurance programs and the use of electronic health record management systems increases. The field of medical coding has a projected employment increase of 22% between 2016 and 2026, which will result in a predicted increase of 129,000 new jobs for certified coding specialists.

The need for a certified Medical Biller and Coder:

As two of the most essential components of any medical practice, medical billing and coding are critical to ensuring the best possible patient care, receiving rapid payments, and optimizing operations. Since medical billing and coding are vital processes that are paramount for the upkeep of medical practices and offices, most organizations depend upon certified professionals who can read, record, and interpret complex medical information quickly, efficiently, and with ease.

A certified medical biller and coder is an essential member of a medical staff’s team because they ensure that every claim filed by their organization is as accurate as possible. Medical coding, in particular, requires a basic understanding of medical terminologies, without which medical practice’s run the risk of submitting false claims to insurance companies that list the wrong medical diagnosis or condition. This could ultimately lead to doctors being underpaid due to insurance denials and other serious implications for the medical practice.

According to the False Claims Act, anyone who knowingly submits a false claim to the government is liable to pay the government’s damages in addition to an added penalty. In the fiscal year 2020, the Department of Justice obtained more than $2.2 billion in settlements and judgments from civil cases that involved the filing of false claims, including false medical claims, against the government. Employing a certified medical coding and billing specialist is paramount to avoiding such hefty penalties.

Additionally, having a certified medical biller and coder by your side is of the essence to ensure a constant flow of payment. A certified medical coder and biller has specialized knowledge of following up on claims and resolving claim denials and an in-depth understanding of different medical regulations and insurance plan policies. This not only helps you improve the revenue flow throughout your practice but also helps ensure the smooth operation of your revenue cycle.

Medical coding plays a critical role in the financial revenue cycle of practice because it directly relates to insurance reimbursements. As medical coding systems and regulations get stricter and more complex, physicians are being increasingly underpaid due to inaccurate coding and billing systems. Hiring a professional coding and billing specialist can not only help practices recover pending payments and reduce denial rates for medical claims but can also allow physicians and doctors to receive accurate reimbursement for the service they are providing.

Moreover, the biggest benefit of all is that having a certified medical biller and coder reduces the overhead costs associated with the recovery of denied claims. With the expertise and wide range of knowledge a certified coding and specialist has to offer, efficient management of claims, denial resolutions, payment posting, appeal submissions, and collections management is an absolute guarantee.

Medical Billing vs. Medical Coding

Although often used synonymously, medical billing and medical coding are two different job functions that have specific job descriptions and responsibilities. While most practices hire the same certified coding specialist for both tasks, other practices might divide the job between two different specialists. It’s important to know the difference between the two, so you can understand how they add value to your practice.  

Medical Coding

While the word coding is in the job title of a medical coding specialist, a certified coding specialist does not have to write code for computer programming. In simpler terms, medical coding involves using a healthcare professional’s notes about a patient’s diagnosis and procedures performed, then translating them into standard codes based on a set of rules that help payment providers identify the services that have been provided and billed.

Medical Billing

Once the certified coding specialist has recorded the appropriate codes for the service provided to the patient according to the procedure performed and the diagnosis concurred, a specialist is responsible for generating an invoice and sending a claim to the patient’s insurance company after verifying the accuracy of the codes entered. The insurance company will use the data provided and the codes entered to approve or deny the claim.

In case any insurance claim is denied, the billing specialist will have to identify the reason and adjust the payment request accordingly. Any remaining costs not covered by the patient’s insurance provider will then be invoiced to the patient for payment.

What it takes to be a Medical Coding specialist

While medical coding may seem like a difficult task, the requirements of becoming a medical coding specialist are very basic. You can become a certified coding specialist, after enrolling in a medical coding and billing program and completing a nine-month training.

Here are some of the skills and areas of knowledge one must be proficient in to become a medical billing and coding specialist.

Medical Codes

Needless to say, a certified coding specialist must be proficient in coding for health services. These include:

  • International Classification of Diseases (ICD-10) Codes – used for medical diagnoses.
  • Current Procedural Terminology (CPT) Codes – used for specific procedures and examinations performed by the physician.
  • Healthcare Common Procedure Coding System (HCPCS) – used for all services not covered in the above two categories.

Medical terminologies

While a certified coding specialist does not need to be a physician or have a degree in medical science, they must have a basic understanding of complex medical terminologies such as anatomical and procedural terminologies used regularly within the medical practice. This is so the coder has a better understanding of how to code for different medical services.

Computer skills

The medical billing and coding process requires coding specialists to be comfortable with using different sorts of IT infrastructures. Medical coding and billing involve the use of different coding and billing software and electronic health record systems and the specialist must have a working knowledge of these software and systems.

Good communication skills

The certified coding specialist’s job involves interacting with patients for insurance claims. They are also responsible for requesting payment from the patient for any costs that are not covered by insurance.

Rules and regulations

Part of a medical coding and billing specialist’s job is to be up to date with the latest medical rules and insurance regulations issued by agencies such as HIPAA. A medical coder also has to ensure that all contractual rules set out in the contract with the insurance company are being followed while practicing medical procedures.


Bottom line

A medical coding specialist not only acts as a liaison between a healthcare facility and a payment provider but also performs all the behind-the-scenes activities that allow patients to have a smooth experience with their healthcare provider. While physicians do most of the job on the frontline, certified coding specialists ensure that the healthcare practice continues to offer a stress-free experience for patients.

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