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Class # 11: "Advanced Medical Billing & Coding"


Medical billing and coding Terminology Review: 

Medical billing and coding is a complex vocation that requires extensive knowledge of the healthcare system, medical terminology, and accounting, not to mention a vast suite of medical code sets. Understanding these subjects and the role that a medical billing specialist plays in them will bring you one step closer to starting a career in the field.

Because of the complexity of the medical billing field, it can be easy to feel overwhelmed by the subject matter at first glance. Let this extensive glossary of key medical billing terms serve as a reference to help you get a better grasp on the language of this field.


Please read and study the common medical billing terminology definitions and explanations in the alphabetized list below (we also recommend printing the list for future reference):


Allowed Amount: The sum an insurance company will reimburse to cover a healthcare service or procedure. The patient typically pays the remaining balance if there is any amount left over after the allowed amount has been paid. This amount should not to be confused with co-pay or deductibles owed by a patient.

American Medical Association (AMA): The AMA is the largest organization of physicians in the U.S. dedicated to improving the quality of healthcare administered by providers across the country. The current procedural technology (CPT) code set is maintained and revised by the AMA in accordance with federal guidelines.

Aging: A formal medical billing term that refers to insurance claims that haven’t been paid or balances owed by patients overdue by more than 30 days. Aging claims may become denied if they aren’t filed in time with a health insurance company.

Ancillary Services: Any service administered in a hospital or other healthcare facility other than room and board, including biometrics tests, physical therapy, and physician consultations among other services.

Appeal: Appeal occurs when a patient or a provider tries to convince an insurance company to pay for healthcare after it has decided not to cover costs for someone on a claim. Medical billing specialists deal with appeals after a claim has been denied or rejected by an insurance company.

Applied to Deductible (ATD): This term refers to the amount of money a patient owes a provider that goes to paying their yearly deductible. A patient’s deductible is determined by their insurance plan and can range in price.

Assignment of Benefits (AOB): This term refers to insurance payments made directly to a healthcare provider for medical services received by the patient. Assignment of benefits occurs after a claim has been successfully processed with an insurance company.

Application Service Provider (ASP): ASP is a digital network that allows healthcare providers to access quality medical billing software and technologies without needing to purchase and maintain it themselves. Providers who use ASP typically pay a monthly fee to the company that maintains the billing software.

Authorization: This term refers to when a patient’s health insurance plan requires them to get permission from their insurance providers before receiving certain healthcare services. A patient may be denied coverage if they see a provider for a service that needed authorization without first consulting the insurance company.


Beneficiary: The beneficiary is the person who receives benefits and/or coverage under a healthcare plan. The beneficiary of an insurance plan may not be the person paying for the plan, as is the case for young children covered under their parents’ plans.

Blue Cross Blue Shield: Blue Cross Blue Shield is a federation of 38 health insurance companies in the U.S. (some of which are non-profit companies) that offer health insurance options to eligible persons in their area. Blue Cross Blue Shield offers healthcare plans to over 100 million people in the U.S.


Capitation: A fixed payment that a patient makes to a health insurance company or provider to recoup costs incurred from various healthcare services. A capitation is different from a deductible or co-pay.

Civilian Health and Medical Program of Uniform Services (CHAMPUS): CHAMPUS (now known as TRICARE) is the federal health insurance program for active and retired service members, their families, and the survivors of service members.

Charity Care: This type of care is administered at reduced or zero cost to patients who cannot afford healthcare. Providers may offer charity care at their discretion.

Clean Claim: This refers to a medical claim filed with a health insurance company that is free of errors and processed in a timely manner. Some providers may send claims to organizations that specialize in producing clean claims, like clearinghouses.

Clearinghouse: Clearinghouses are facilities that review and correct medical claims as necessary before sending them to insurance companies for final processing. This meticulous editing process for claims is known in the medical billing industry as “scrubbing.”

Centers for Medicare and Medicaid Services (CMS): The CMS is the federal entity that manages and administers healthcare coverage through Medicare and Medicaid. CMS coordinates with providers and enrollees to provide healthcare to over 100 million Americans.

CMS 1500: The CMS 1500 is a paper medical claim form used for transmitting claims based on coverage by Medicare and Medicaid plans. Commercial insurance providers often require that providers use CMS 1500 forms to process their own paper claims.

Coding: Coding is the process of translating a physician’s documentation about a patient’s medical condition and health services rendered into medical codes that are then plugged into a claim for processing with an insurance company. Medical billing specialists must be familiar with many code sets in order to perform their job duties.

COBRA Insurance: A federal program that allows a person terminated from their employer to retain health insurance they had with that employer for up to 18 months, or 36 months if the former employee is disabled.

Co-Insurance: The percentage of coverage that a patient is responsible for paying after an insurance company pays the portion agreed upon in a health plan. Co-insurance percentages vary depending on the health plan.

Collection Ratio: This refers to the ratio of payments received relative to the total amount owed to providers.

Contractual Adjustment: This refers to a binding agree between a provider, patient, and insurance company wherein the provider agrees to charges that it will write off on behalf of the patient. Contractual adjustments may occur when there is a discrepancy between what a provider charges for healthcare services and what an insurance company has decided to pay for that service.

Coordination of Benefits (COB): COB occurs when a patient is covered by more than one insurance plan. In this situation one insurance company will become the primary carrier and all other companies will be considered secondary and tertiary carriers that may cover costs left after the primary carrier has paid.

Co-Pay: A patient’s co-pay is the amount that must be paid to a provider before they receive any treatment or services. Co-pays are separate from a deductible, and will vary depending on a person’s insurance plan.

Current Procedural Technology (CPT) Code: CPT codes represent treatments and procedures performed by a physician in a 5-digit format. CPT codes are entered together with ICD-9 codes that explain a patient’s diagnosis. Medical billing specialists will enter CPT codes into claims so insurance companies understand the nature of healthcare a patient received with a provider.

Credentialing: The application process for a provider to coordinate with an insurance company. Once providers have become credentialed with an insurance company, they have the opportunity to work with that company in providing affordable healthcare to patients.

Credit Balance: Refers to the sum shown in the “balance” column of a billing statement that reflects the amount due for services rendered.

Crossover Claim: When claim information is sent from a primary insurance carrier to a secondary insurance carrier, or vice versa.


Date of Service (DOS): The date when a provider performed healthcare services and procedures.

Day Sheet: A document that summarizes the services, treatments, payments, and charges that a patient received on a given day.

Deductible: The amount a patient must pay before an insurance carrier starts their healthcare coverage. Deductibles range in price according to terms set in a person’s health plan.

Demographics: The patient’s information required for filing a claim, such as age, sex, address, and family information. An insurance company may deny a claim if it contains inaccurate demographics.

Durable Medical Equipment (DME): This refers to medical implements that can be reused such as stretchers, wheelchairs, canes, crutches, and bedpans.

Date of Birth (DOB): The exact date a patient was born.

Downcoding: Downcoding occurs when an insurance company finds there is insufficient evidence on a claim to prove that a provider performed coded medical services and so they reduce or remove those codes. Downcoding usually reduces the cost of a claim.

Duplicate Coverage Inquiry (DCI): A formal request typically submitted by an insurance carrier to determine if other health coverage exists for a patient.

Dx: The abbreviation for diagnosis codes, also known as ICD-9 codes.


Electronic Claim: A claim sent electronically to an insurance carrier from a provider’s billing software. The format of electronic claims must adhere to medical billing regulations set forth by the federal government.

Electronic Funds Transfer: A method of transferring money electronically from a patient’s bank account to a provider or an insurance carrier.

Evaluation and Management (E/M): E/M refers to the section of CPT codes most used by healthcare personnel to describe a patient’s medical needs.

Electronic Medical Records (EMR): EMR is a digitized medical record for a patient managed by a provider onsite. EMRs may also be referred to as electronic health records (EHRs).

Enrollee: A person covered by a health insurance plan.

Explanation of Benefits (EOB): A document attached to a processed medical claim wherein the insurance company explains the services they will cover for a patient’s healthcare treatments. EOBs may also explain what is wrong with a claim if it’s denied.

Electronic Remittance Advice (ERA): The digital version of EOB, which specifies the details of payments made on a claim either by an insurance company or required by the patient.

ERISA: Stands for the Employee Retirement Income Security Act of 1974. This act established guidelines and requirements for health and life insurance policies including appeals and disclosure of grievances.


Fee for Service: This refers to a type of health insurance wherein the provider is paid for every service they perform. People with fee-for-service plans typically can choose whatever hospitals and physicians they want to receive care in exchange for higher deductibles and co-pays.

Fee Schedule: A document that outlines the costs associated for each medical service designated by a CPT code.

Financial Responsibility: Whoever owes the healthcare provider money has financial responsibility for the services rendered. Insurance companies or patients themselves may be financially responsible for the costs associated with care, and these responsibilities are typically outlined in a healthcare plan contract.

Fiscal Intermediary (FI): The name for Medicare representatives who process Medicare claims.

Formulary: A table or list provided by an insurance carrier that explains what prescription drugs are covered under their health plans.

Fraud: Providers, patients, or insurance companies may be found fraudulent if they are deliberately achieving their ends through misrepresentation, dishonesty, and general illegal activity. Medical billing specialists who deliberately enter incorrect or misleading information on claims may be charged with fraud.


Group Health Plan (GPH): A plan provided by an employer to provide healthcare options to a large group of employees.

Group Name: The name of the group, insurance carrier, or insurance plan that covers a patient.

Group Number: A number given to a patient by their insurance carrier that identifies the group or plan under which they are covered.

Guarantor: The party paying for an insurance plan who is not the patient. Parents, for example, would be the guarantors for their children’s health insurance.


Healthcare Financing Administration: The former name for what is now the CMS.

Healthcare Financing Administration Common Procedure Coding System (HCPCS):HCPCS is a three-tier coding system used to explain services, devices, and diagnoses administered in the healthcare system. Medical billing specialists utilize codes in the HCPCS on a daily basis to file claims.

Healthcare Insurance: This is insurance offered to a group or an individual to cover costs associated with medical care and treatment. Those covered by healthcare insurance typically must pay a premium for their plans in addition to various co-pays and/or deductibles.

Healthcare Provider: These are the entities that offer healthcare services to patients, including hospitals, physicians, and private clinics, hospices, nursing homes, and other healthcare facilities.

Healthcare Reform Act: The major healthcare legislation passed in 2010 designed to make healthcare accessible and less expensive for more Americans.

Health Insurance Claim: The unique number ascribed to an individual to identify them as a beneficiary of Medicare.

Health Insurance Portability and Accountability Act (HIPAA): HIPAA was a law passed in 1996 with an aim to improve the scope of healthcare services and establish regulations for securing healthcare records from unwanted parties.

Health Maintenance Organization (HMO): HMOs are networks of healthcare providers that offer healthcare plans to people for medical services exclusively in their network.

Hospice: This refers to medical care and treatment for persons who are terminally ill.


ICD-9 Codes: ICD-9 codes are an international set of codes that represent diagnoses of patients’ medical conditions as determined by physicians. Medical billing specialists may translate a physician’s diagnoses into ICD-9 codes and then input those codes into a claim for processing.

ICD-10 Codes: ICD-10 codes are the updated international set of codes based on the preceding ICD-9 codes. ICD-10 codes are estimated to be mandatory in the American healthcare system by October 2014.

Incremental Nursing Charge: A fee for nursing services a patient is charged during the course of receiving healthcare.

Indemnity: A type of health insurance plan whereby a patient can receive care with any provider in exchange for higher deductibles and co-pays. Indemnity is also known as fee-for-service insurance.

In-Network: This term refers to a provider’s relationship with a health insurance company. A group of providers may contract with an insurance company to form a network of healthcare professionals that a person can choose from when enrolled in that insurance company’s health plan.

Inpatient: Inpatient care occurs when a person has a stay at a healthcare facility for more than 24 hours.

Independent Practice Association (IPA): The IPA is a professional organization of physicians who have a contract with an HMO.

Intensive Care: Intensive care is the unit of a hospital reserved for patients that need immediate treatment and close monitoring by healthcare professionals for serious illnesses, conditions, and injuries.


Medicare Administrative Contractor (MAC): MACs are contract with the federal government to process Medicare claims.

Managed Care Plan: A health insurance plan whereby patients can only receive coverage if they see providers who operate in the insurance company’s network.

Maximum Out of Pocket: The amount a patient is required to pay. After a patient reaches their maximum out of pocket, their healthcare costs should be covered by their plan.

Medical Assistant: An employee in the healthcare system such as a physian’s assistant or a nurse practitioner who perform duties in administration, nursing, and other ancillary care.

Medical Coder: A medical coder is responsible for assigning various medical codes to services and healthcare plans described by a physician on a patient’s superbill.

Medical Billing Specialist: A medical billing specialist is responsible for using information regarding services and treatments performed by a healthcare provider to complete a claim for filing with an insurance company so the provider can be paid.

Medical Necessity: This term refers to healthcare services or treatments that a patient requires to treat a serious medical condition or illness. This does not include cosmetic or investigative services.

Medical Record Number: A unique number ascribed to a person’s medical record so it can be differentiated from other medical records.

Medicare Secondary Payer: The insurance company that covers any remaining expenses after Medicare has paid for a patient’s coverage.

Medical Savings Account (MSA): An MSA is an optional health insurance payments plan whereby a person apportions part of their untaxed earnings to an account reserved for healthcare expenses. A person with an MSA can only contribute a certain amount of their earnings per year. Any unused funds in an MSA at the end of the year will roll over to the next.

Medical Transcription: The process of converting dictated or handwritten instructions, observations, and documentation into digital text formats.

Medicare: Medicare is a government insurance program started in 1965 to provide healthcare coverage for persons over 65 and eligible people with disabilities.

Medicare Coinsurance Days: Referring to 61st through 90th days of inpatient treatment, the law requires that patients pay for a portion of their healthcare during Medicare coinsurance days.

Medicare Donut Hole: This term refers to the discrepancy between the limits of healthcare insurance coverage and the Medicare Part D coverage limits for prescription drugs.  

Medicaid: Medicaid is a joint federal and state assistance program started in 1965 to provide health insurance to lower-income persons. Both state and federal governments fund Medicaid programs, but each state is responsible for running its own version of Medicaid within the minimum requirements established by federal law.

Medigap: Medigap is supplemental health insurance under Medicaid for eligible persons who need help covering co-pays, deductibles, and other large fees.

Modifier: Modifiers are additions to CPT codes that explain alterations and modifications to an otherwise routine treatment, exam, or service.


Non-Covered Charge (N/C): N/Cs are procedures and services not covered by a person’s health insurance plan.

Not Elsewhere Classifiable (NEC): A term used to describe a procedure or service that can’t be described within the available code set.

Network Provider: A provider within a health insurance company’s network that has contracted with the company to provide discounted services to a patient covered under the company’s plan.

Non-participation: This is when a provider refuses to accept Medicare payments as a sufficient amount for the services rendered to a patient.

Not Otherwise Specified (NOS): This term is used in ICD-9 codes to describe conditions with unspecified diagnoses.

National Provider Identifier (NPI) Number: A unique 10-digit number ascribed to every healthcare provider in the U.S. as mandated by HIPAA.


Office of Inspector General (OIG): The organization responsible for establishing guidelines and investigating fraud and misinformation within the healthcare industry. The OIG is part of the Department of Health and Human Services.

Out-of-Network: Out-of-network refers to providers outside of an established network of providers who contract with an insurance company to offer patients healthcare at a discounted rate. People who go to out-of-network providers typically have to pay more money to receive care.

Outpatient: This term refers to healthcare treatment that doesn’t require an overnight hospital stay, including a routine visit to a primary care doctor or a non-invasive surgery.


Palmetto GBA: A MAC based in Columbia, South Carolina that is also a subsidiary of Blue Cross Blue Shield.

Patient Responsibility: This refers to the amount a patient owes a provider after an insurance company pays for their portion of the medical expenses.

Primary Care Physician (PCP): The physician who provides the basic healthcare services for a patient and recommends additional care for more serious treatments as necessary.

Point of Service Plans: A plan whereby patients with HMO membership may receive care at non-HMO providers in exchange for a referral and paying a higher deductible.

Place of Service Code: A two-digit code used on claims to explain what type of provider performed healthcare services on a patient.

Preferred Provider Organization (PPO): A plan similar to an HMO whereby a patient can receive healthcare from providers within an established network set up by an insurance company.

Practice Management Software: Software used for scheduling, billing, and recordkeeping at a provider’s office.

Preauthorization: Some insurance plans require that a patient receive preauthorization from the insurance company prior to receiving certain medical services to make sure the company will cover expenses associated with those services.

Pre-Certification: A process similar to preauthorization whereby patients must check with insurance companies to see if a desired healthcare treatment or service is deemed medically necessary (and thus covered) by the company.

Pre-determination: A maximum sum as explained in a healthcare plan an insurance company will pay for certain services or treatments.

Pre-existing Condition (PEC): PEC is a medical condition a patient had before receiving coverage from an insurance company. A person might become ineligible for certain healthcare plans depending on the severity and length of their PEC.

Pre-exisiting Condition Exclusion: The existence of a PEC denies a person certain coverage in some health insurance plans.

Premium: The sum a person pays to an insurance company on a regular (usually monthly or yearly) basis to receive health insurance.

Privacy Rule: Standards for privacy regarding a patient’s medical history and all related events, treatments, and data as outlined by HIPAA.

Provider: A provider is the healthcare facility that administered healthcare to an individual. Physicians, clinics, and hospitals are all considered providers.

Provider Transaction Access Number (PTAN): This refers to a provider’s current legacy provider number with Medicare.


Referral: This is when a provider recommends another provider to a patient to receive specialized treatment.

Remittance Advice (R/A): The R/A is also known as the EOB, which is the document attached to a processed claim that explains the information regarding coverage and payments on a claim.

Responsible Party: The person who pays for a patient’s medical expenses, also known as the guarantor.

Revenue Code: A three-digit code used on medical bills that explains the kind of facility in which a patient received treatment.

Relative Value Amount (RVA): The median amount Medicare will repay a provider for certain services and treatments.


Scrubbing: A process by which insurance claims are checked for errors before being sent to an insurance company for final processing. Providers scrub claims in an attempt to reduce the number of denied or rejected claims.

Self-Referral: When a patient does their own research to find a provider and acts outside of their primary care physician’s referral.

Self-Pay: Payment made by the patient for healthcare at the time they receive it at a provider’s facilities.

Secondary Insurance Claim: The claim filed with the secondary insurance company after the primary insurance company pays for their portion of healthcare costs.

Secondary Procedure: This is when provider performs another procedure on a patient covered by a CPT code after first performing a different CPT procedure on them.

Security Standard: The security standard serves as the guidelines for policies and practices necessary to reduce security risks within the healthcare system. The security standard policies work in concert with the security guidelines set in place with the passage of HIPAA.

Skilled Nursing Facility: These are facilities for the severely ill or elderly that provide specialized long-term care for recovering patients. Skilled nursing facilities are alternative healthcare establishments to extended hospital stays and may be covered by eligible patients’ insurance policies.

Signature on File (SOF): A patient’s official signature on file for the purpose of billing and claims processing.

Software as a Service (SAAS): Medical billing software hosted off site by another company and only accessible with Internet access. SAAS is useful for providers who don’t want to maintain and update in-house medical billing software.

Specialist: A physician or medical assistant with expertise in a specific area of medicine. Oncologists, pediatricians, and neurologists are among the many specialists in the medical field.

Subscriber: The subscriber is the individual covered under a group policy. For instance, an employee of a company with a group health policy would be one of many subscribers on that policy.

Superbill: A document used by healthcare staff and physicians to write down information about a patient receiving care. The superbill can contain demographic information, insurance information, and especially any diagnoses or healthcare plans written by the physician. A medical billing specialist inputs the information on a patient’s superbill into a claim.

Supplemental Insurance: Supplemental insurance can be a secondary policy or another insurance company that covers a patient’s healthcare costs after receiving coverage from their primary insurance. Supplemental insurance policies typically help patients cover expensive deductibles and copays.


Treatment Authorization Request (TAR): A unique number the insurance company gives the provider for billing purposes. A provider must receive the insurance company’s TAR number before administering healthcare to a patient covered by the company.

Taxonomy Code: Medical billing specialists utilize this unique codeset for identifying a healthcare provider’s specialty field.

Term Date: The end date for an insurance policy contract, or the date after which a person no longer receives or is no longer eligible for health insurance with company. Term dates are typically determined on a case-by-case basis.

Tertiary Insurance Claim: A claim filed by a provider after they have filed claims for primary and secondary health insurance coverage on behalf of a patient. Tertiary insurance claims often cover the remaining healthcare costs such as deductibles and co-pays left over after the primary and secondary claims have been processed.

Third Party Administrator (TPA): The name for the organization or individual that manages healthcare group benefits, claims, and administrative duties on behalf of a group plan or a company with a group plan.

Tax Identification Number (TIN): A unique number a patient or a company may have to produce for billing purposes in order to receive healthcare from a provider. The TIN is also known as the employment identification number (EIN).

Triple Option Plan (TOP): Also referred to as the cafeteria plan, this plan gives an enrolled individual the options to choose between an HMO, a PPO, or a traditional point of service plan for their health insurance. Some companies offer triple option plans to their employees to accommodate the needs of a diverse staff.

Type of Service (TOS): A field on a claim for describing what kind of healthcare services or procedures a provider administered.

TRICARE: TRICARE is the federal health insurance plan for active service members, retired service members, and their families, in addition to survivors of service members. TRICARE was previously known as CHAMPUS.


UB04: A form used by providers for filing claims with insurance companies. The UB04 form has a format similar to that of the CMS 1500 form.

Unbundling: This term refers to the fraudulent practice of ascribing more than one code to a service or procedure on a superbill or claim form when only one is necessary.

Untimely Submission: Claims have a specific timeframe in which they can be sent off to an insurance company for processing. If a provider fails to file a claim with an insurance company in that timeframe, it is marked for untimely submission and will be denied by the company.

Upcoding: Upcoding is the fraudulent practice of ascribing a higher ICD-9 code to a healthcare procedure in an attempt to get more money than necessary from the insurance company or patient.

Unique Physician Identification Number (UPIN): A unique six-digit identification number given to physicians and other healthcare personnel, which has subsequently been replaced by a national provider identifier (NPI) number.

Usual Customary and Reasonable (UCR): The UCR is the amount of money stipulated in a contract that an insurance company agrees to pay for healthcare costs. After passing the UCR a patient is typically responsible for covering their healthcare costs.

Utilization Limit: The limit per year for coverage under certain available healthcare services for Medicare enrollees. Once a patient passes the utilization limit for a service, Medicare may no longer cover them.

Utilization Review (UR): An investigation or audit performed to optimize the number of inpatient and outpatient services a provider performs.


V-Codes: A codeset under ICD-9-CM used to organize healthcare services rendered for reasons other than illness or injury.


Worker’s Compensation: Worker’s compensation is paid by an employer when an employee becomes ill or injured while performing routine job duties. Most states have laws requiring that companies provide worker’s compensation.

Write-Off: This term refers to the discrepancy between a provider’s fee for healthcare services and the amount that an insurance company is willing to pay for those services that a patient is not responsible for. The write-off amount may be categorized as “not covered” amounts for billing purposes.

Please view the videos below: 

Medical Billing and Coding Specialists most often work in a medical office, hospital, clinic or other healthcare setting- and many are now choosing to run their own Medical Billing and Coding Service. Below is some information that will be very helpful if you decide to open and run you own business.

Running Your Own Medical Billing and Coding Service

In this course, you’ll learn about the day-to-day activities and responsibilities of the medical biller and medical coder. You’ll also explore some of the tools you’ll use as a professional biller and coder, the regulations you’ll have to follow, and tips on starting your own medical billing and coding service.

Explore a Day in the Life of a Medical Biller and Coder

Any time a medical service is provided, whether it’s a routine checkup or a major surgery, information about that service is recorded and given to the medical billing and coding specialist. A doctor gives the medical biller and coder procedure documentation of the services provided, which the biller and coder must then translate into the proper code. Medical billing and coding specialists are responsible for correctly coding the diagnoses and procedures performed by the healthcare provider. This requires a thorough knowledge of both ICD-9-CM codes and ICD-10-CM codes for diagnostics, and CPT codes for procedures.

A procedure document includes relevant information like the date of the procedure, the patient’s name, and his or her date of birth. More importantly, a procedure document includes the doctor’s diagnosis and the procedure performed. For example, a doctor may provide documentation of a mole removed from the torso of a patient via cryoablation (essentially, freezing the mole). The medical biller and coder would look at the procedure documentation and decide which codes correspond to the diagnosis and procedure listed. In the case of this example, a coder would select the CPT code 11710 (destruction of benign lesions or skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) for the procedure, and the ICD-9-CM code 216.5 (benign neoplasm of skin of trunk, except scrotum) for the diagnosis.

The bulk of the medical coding portion of the billing process involves turning procedure reports into correct medical code, then entering it into the system for the claims process. Medical coders spend their day taking procedure documentation, looking up the proper codes, and entering that information into their claims software. Most medical coding is relatively straightforward (for example, the CPT code 99213 corresponds to a routine visit to the doctor’s office), but even with common codes there are discrepancies or gray areas. Coders must consult their manual, professional associations, and periodicals to stay up-to-date on current professional best practices.

Learn about lag days

Like medical billing, medical coding is a time-sensitive operation. Any hiccup in the coding process can cause a ripple effect, which delays billing, the claims process, and ultimately the reimbursement of the healthcare provider from the insurance company. For this reason, most coders are asked to keep their operations within a number of “lag days.” Lag days refer to time between when a procedure note is given to the coder and when the claim for that procedure is filed. Most offices keep the number of lag days between two and five, so coders must stay on top of their work in order to ensure efficiency in the operation of the health-care provider.

Review crosswalking

In certain cases, a medical billing and coding professional has to perform a code “crosswalk” between these sets of codes. Crosswalking is covered in depth in courses 11 and 12. To briefly review, a crosswalk refers to an equivalency or translation between two code sets. A medical coder may have to use a crosswalk in order to track data between two different sets of code (as in the case of ICD-10-CM and ICD-9-CM) or translate between two sets to comply with certain form requirements (as with translating CPT codes into ICD-9-CM codes).

Avoid clerical errors to shorten reimbursement time

Coders should also make sure the procedural and diagnostic codes that they are entering on a claim make sense with one another. For example, you would not want to pair the procedure code for a tonsillectomy with the diagnosis code for a broken hand. Inaccurate, contradictory, or improperly crosswalked codes are just a few of the many reasons a claim may be denied, and it is up to the coding specialist to prevent as many of these clerical errors as possible.

Understand the role of medical billers

As stated earlier, the job of the medical biller aligns closely with that of the medical coder, but there are other integral tasks that are unique to the medical biller. As you read in Course 2, the initial part of the medical billing process is the collection of data from the patient. Medical billing specialists must ensure they have all the relevant information from the patient and that this information is correct in order to proceed with a claim to the insurance company.

Once medical billers have the correct information regarding a patient’s history, contact information, and insurance policy (or policies), they then input that information into their medical claims software and begin the claims process. Upon translating the procedure notes into diagnostic and procedural codes (or upon receiving these codes from a third-party coder), the medical biller creates an insurance claim and sends this to an insurance company. Medical billers should be familiar with claim formats for each of the major payers, including Blue Cross/Blue Shield (and other private payers), Medicare, Medicaid, TRICARE, CHAMPVA, and various worker’s compensation and disability organizations.

When the claim is returned and the healthcare provider is properly reimbursed for services, medical billers must then bill the patient. This process involves following up with patients about late payments or arranging for a collections service in the case of notably delinquent bills. Medical billers are also responsible for interpreting the Explanation of Benefits (EOB) and explaining the general billing process to patients. Medical billers must be familiar with co-pays, coinsurance, and deductibles in order to bill patients correctly.

If a claim is returned to the healthcare provider as denied or rejected, the medical billing expert must determine why and correct errors if possible. If the claim was denied because of inaccurate or inappropriate coding, the medical biller must input the correct codes and resubmit the claim (or pass it back to the third-party coder who initially coded the procedure).

Medical billers must also prepare appeals to denied claims on behalf of patients or the healthcare provider. A denied claim may be due to a clerical error (as with a missed code), or it may come down to a discrepancy in the provider’s contract with a payer. Medical billers also have to help patients prove the necessity of their medical procedure. They must be prepared to research all of the elements of the appeals process. As with coding, the appeals process is time-sensitive, so medical billers handling claim appeals must work quickly and efficiently to ensure their appeal is filed in a timely manner.

See What Tools You Will Use as a Biller and Coder

Many professionals in the field rely heavily on billing and coding software. This software is especially important if you are planning on working from home. Software like Medisoft or MediTouch allow coders to look up specific codes for accuracy and create claims quickly. There are dozens of billing and coding software programs at various price points, and you will have to assess what your individual needs and preferences are when it comes to the coding software you use.

While medical billing and coding software is becoming an industry standard, some smaller practices still use paper hard copies for their coding and billing services. Paper is less efficient than electronic records, and can create problems such as duplicate data (in the case of there accidentally being two separate files for one patient), not to mention the massive amount of physical space needed for storage of paper claims. Coding and billing via hard copy also makes it difficult for different parties (like other insurance companies or healthcare providers) to access important health records. Still, despite the clear advantages of electronic health records for the purposes of billing and coding, professional billers and coders should familiarize themselves with hard copy billing and coding forms. Medical billers also have to refer to hard copies of a patient’s medical records and EOBs throughout the day when creating a claim.

Find Out What Regulations You Have to Follow

While there are no laws that apply exclusively to medical billing and coding, billers and coders must operate within the laws and regulations that govern the whole of the healthcare industry. Because the information they handle includes confidential patient medical histories, they must follow guidelines laid out in the Health Insurance Portability and Accountability Act (HIPAA), and the Correct Coding Initiative, which is a project of the Centers for Medicare and Medicaid (CMS).

Title II of HIPAA, also known as the Administrative Simplification Statute, ensures that the confidentiality of patients will be secure when their information is transmitted electronically. This applies to all entities that handle health information electronically, including health plans, healthcare providers, and healthcare clearinghouses. These rules also apply to any off-site or third-party entity (such as a freelance biller or coder) that handles sensitive healthcare information. The HIPAA Administrative Simplification Statute states, effectively, that all parties capable of accessing or transmitting sensitive health information have a set of rules in place that a) protect patient health and b) identify which employees or persons will have access to a particular level of private information. Privacy rules may vary from one practice to another, and HIPAA mandates internal audits as a primary method of ensuring adherence to the law. Audits may mean a routine review of protocol and procedure for the medical coder and biller.

Note that this part of HIPAA applies only to electronic transactions, including claims and encounter information (such as ICD-10-CM codes) and inquiries into claim status. Healthcare providers, coders and billers, clearinghouses, and insurance companies are not required to submit this information electronically, but if they do, they must follow HIPAA guidelines.

The Correct Coding Initiative provides detailed guidelines for professional coders and billers. Updated annually by CMS, the initiative ensures that the codes used for various medical transactions are uniform around the country. You are already familiar with certain initiative regulations: The initiative mandates that Current Procedural Terminology (CPT) be used to code medical procedures, and that ICD-10 be adopted by October 1, 2014 for all diagnostic reports. The Correct Coding Initiative also regulates which codes will be used in pharmacy and dental transactions. The medical biller and coder should be aware of these regulations and be able to research them whenever the need arises.

Start Your Own Business

The medical billing and coding field is expected to grow steadily in the next few decades. As health informatics change and the healthcare industry continues to expand, coders and billers will be in demand to cope with the increased burden of processing information that changes hands during a medical procedure. Third parties sometimes perform billing and coding operations, and there are opportunities for entrepreneurs to build their own billing and coding business.

One of the interesting benefits of starting a billing and coding profession is the ability to work from home. Because the job requires mostly clerical work that can be done on a computer, a medical biller and/or coder does not need to work from a medical office or even interact with patients directly. However, starting your own coding and billing business will not be easy. Even if you are working from home, you’ll have to stay in frequent contact with your clients, health insurance companies, and clearinghouses. Explore the following tips to running your own successful billing and coding business:

1) Get training

In today's complex world of medical billing and coding formal training as a Medical Billing and Coding Specialist is a must

2) Get experience

Before you start your own billing and coding service, you’ll want to get some experience working at a healthcare provider’s office. While it might not make sense to start your own at-home business working for someone else, you’ll have a very hard time finding any clients willing to entrust the sensitive health information of their patients to an unknown third party. Working for an established provider grants you a reference, proof of your legitimacy, and possibly even future clients.

3) Know the law

As you pursue certification, you’ll undoubtedly learn the regulations and laws that govern the day-to-day tasks of a medical biller and coder. However, don’t forget about local, state, and federal laws, as well. If you’re going to run your own billing and coding service, you’ll need to apply for a business license. You may also need to apply for special licenses within your state. Some medical billing agencies, for example, must be registered as collections agencies. You may also need to get a federal tax ID number for your small business. It’s worth the time and money to consult a professional accountant or financial adviser when it comes to setting up these licenses.

4) Get the tools

Like any start-up business, a medical billing and coding business will require some initial investment. Fortunately, unlike the capital needed for a lot of other small business, this investment is relatively low. You’ll have to invest in coding, billing, and accounting software, such as Quickbooks. You should invest in high-quality software (which may cost as much as $1,500), and avoid any program that seems too good to be true. You’ll also have to budget for expenses such as a computer and monitor, a fax machine/copier/scanner, separate phone line, reference books, clearinghouse fees, and more. To save money, explore all your options when searching for reference books. For instance, reference books can cost around $450, but there are online reference services that are available for around $30 per month. Also, set aside a space in your home for an office, and furnish it accordingly. Lastly, add the cost of training and certification into your start-up budget. All in all, be prepared to spend between $4,000 and $6,000 to start your coding and billing business.

5) Actively pursue networking opportunities

Once you’ve got your certification and business license and your home office is set up, it’s time to reach out to clients. If you worked with a provider before starting your own business, that provider may have work for you, or may be able to suggest other offices in need of coding and billing services. Note that smaller practices may have less on-site administrative help and could be interested in outsourcing coding and billing tasks. You may also want to choose a medical specialty, like cardiology or radiology. If you become proficient in a certain area of coding and billing, it’s easy to reach out to different practices that focus on the same thing. Set up a website for your business and keep it updated regularly.

You should also network the old-fashioned way, by attending conferences and joining professional associations. Professional associations like the AAPC provide valuable resources and opportunities to learn from other individuals in your field.

6) Get paid

When you’re about to begin work with a client, you’ll have to work out how you’ll be paid. Third-party coders can be paid by the hour, by the claim, or by a percentage of that client’s monthly revenue. The payment arrangement will depend on a number of things, such as the size of the practice and the frequency of patient visits. A general practitioner, for example, can have more than 40 office visits a day and charge a small amount, while a radiologist may have only a few visits but charge a significantly higher amount. Whichever payment rate you decide on, be sure to get that rate in a written contract.

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