The importance of the healthcare system has increased since the outbreak of the COVID-19 pandemic, and it has put a significant strain on healthcare providers. Medical documentation, billing, and coding help ensure that healthcare providers can give timely payments for their medical and clinical services. Medical billers and coders act as the middlemen between healthcare providers (such as Sutter Health, Kaiser Permanente, and Sharp Health) and health insurance companies (like UnitedHealthcare, Anthem, and Blue Cross Blue Shield). They generate accurate and efficient billing for patients. Because of this purpose, both medical billers and coders must act in tandem, ensuring that they bill patients the correct amount.
What is Medical Coding and Billing, and How Does It Impact Medical Documentation?
Medical coding and medical billing are two different positions that require some degree of training (such as a certification or an associate degree) due to their specialization. Both professions are amazing opportunities for individuals looking for both remote and in-person positions. There are employment opportunities with healthcare providers, insurance agencies, or medical documentation agencies. Another option is for a medical coder/biller to work freelance. They can work off of contracts with medical facilities or agencies. AI, of course, benefits both coders and billers as it can help automate certain aspects of the job that are either too tedious or that undercut the potential of the employee in question. While there has been a recent scare about the threat of people losing jobs in the face of the rise of AI, we assure you that there is no need to fear. Human judgment will always be favored over that of a machine.
What Are the Essential Skills?
As mentioned before, medical coding and medical billing have different job requirements, but both require a specialist to possess certain qualities. Here are a few of them:
1. Knowledge of HMO/PPO Plans
While both HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) are plans determining a patient’s ability to see providers and the coverage for out-of-network services, they differ in costs, as well as the services they can provide. For those unfamiliar, HMO plans form a network for health insurance based on contracts. Generally, patients that have an HMO plan can only receive care from doctors who are either contracted out by or work for the HMO.
This becomes unfortunate for those who become sick or need medical attention from those outside of the plan, as it usually will not be covered unless there is an extreme emergency. Additionally, HMOs may require anybody with their coverage to work or live within a certain area to be eligible to use their services. PPO plans contract with medical providers such as doctors and hospitals to create a network of medical care.
Oftentimes, PPO plans cover everything medical, but still, have preferred doctors and hospitals. If you choose to see them, medical care and treatment will cost less, and while you will still be covered going to a doctor outside of the network, it just means it will cost more. This also means that a PPO allows you to have coverage all across the nation, while HMOs constrict your movement. Both plans at a distance can look similar, as they both have services like dental, vision, and hearing, but any medical biller or coder worth anything need to know both of these plans inside and out.
2. Knowledge of Medical Practices
Just as you need to know which policies are available, there must be a sufficient knowledge base of medical practices and procedures. Since not every practice might be covered under an HMO or PPO plan, the ability to understand what procedure took place is crucial to dolling out the correct code or billing statement.
Obviously, this does not mean that medical billers and coders need to know how to perform a cardiac biopsy. This does mean, though, that if a patient does get a cardiac biopsy, that you must understand that they were probably referred to a cardiologist rather than an optometrist. I know that example feels self-explanatory, but the fact that biopsy can be performed by a myriad of doctors from different disciplines means that the best medical billers and coders must understand the difference.
3. Proficiency in Mathematics and Computer Skills
Since medical billers and coders deal in money and numbers, it is a must that they have some proficiency in mathematics and computers. Database software, such as Electronic Health Record (EHR) systems and medical coding and classification programs (ex. Healthcare Common Procedure Coding System [HCPCS]), will typically be used. This will help keep tabs on patients shared between both health professionals and insurance companies. They make sure everything is in order for easy access. Other examples of technology used include word-processing software and data-entry software.
4. Good Communication and Interpersonal Skills
This comes into play in a number of different ways, whether it be in contacting medical offices for patient information or in particularly high-stress situations involving rejected insurance claims and billing discrepancies. These are problems you just cannot afford to get wrong while on the job. Both the insurance company and the provider need accurate information to make sure that nothing goes amiss. The ability to talk and communicate with anyone across both fields is crucial to avoid any clerical errors while on the job.
5. Decision-Making Skills
While sometimes daunting it is important for any medical coder to be able to make on-the-spot decisions. As a coder, your main job is to translate patients’ needs into a universal code that can be read by all physicians and insurance reviewers. It is vital that you are able to analyze medical records and medical documentation to determine the best way to code them for the patient’s medical records, which should be much easier with time.
6. Attention to Detail
Of course, a good attention to detail is pertinent to accurately record and code patient data. MedDRA, the standard medical dictionary resource used by pharmaceutical medical coders, contains more than 70,000 terms, so it may be near impossible to recognize which is appropriate to use in a given situation. That is why it is important to have a keen eye for detail.
What is the Difference Between Medical Billing and Medical Coding?
Medical coders are typically the first people to view a patient’s medical record, which commonly starts as soon as the patient encounters their healthcare practitioner (ex. A doctor, podiatrist, dentist, optometrist, clinical psychologist, or nurse practitioner). This healthcare provider specifies the services, procedures, and items used during the patient’s stay in the healthcare facility.
By law, providers require clinical documentation use for provided treatment. This is evidence if an investigation ensues due to a conflict in the claim. Once the provider discharges the patient, their medical record goes to the medical coders. The provider then reviews and analyzes it to formulate connections to billing codes related to a diagnosis or procedure.
Once a medical coder finishes determining the billing code, the medical biller takes over. The medical biller records insurance claims and transforms the billing code into a formal bill. This ensures that the medical information is accurate. Healthcare insurance companies then receive this bill. They settle the details, plan denials/rejections, and then send out the statements to the patients.
AI in Medical Billing, Coding, and Documentation
As with many professions, implemented Artificial Intelligence goes into medical billing and medical coding. This profession helps identify and extract data from medical records/medical documentation. It also applies the appropriate code(s). But this software is not intended to steal jobs away from medical coders and medical billers, especially since the U.S. Bureau of Labor Statistics believes that the number of medical coding jobs will increase by eight percent between 2019 and 2029. The software intends to prevent costly mistakes such as inaccurate billing due to inaccurate coding. The software can also keep up with the new codes and the necessity to process as many charts as possible. As it stands, medical coders/billers can’t accomplish this alone.
The healthcare revenue cycle also reveals the need for this AI. Audits typically occur too late in the revenue cycle, limiting their usefulness. For example, the patient may already be paying off their bill by the time the audit has occurred and revealed the coding inaccuracy. The fact is that audits must occur frequently and quickly.
The AI software also alleviates the workload medical coders have, allowing them to focus on more meaningful work – or work that AI has not been able to assist with – such as spotting trends based on the diagnoses being reported.
Medical billing and coding is a burgeoning industry and in quite high demand, even in the face of AI. Both medical providers and insurance companies view these positions as essential, and with an ever growing population, there is no shortage of people who need healthcare.
How EDC Can Help
Whether you need a single technical writer for a brief project or a team of consultants to produce a complete line of documentation, the quality of our work is guaranteed for you. Our clients work closely with an Engagement Manager from one of our 30 local offices for the entire length of your project at no additional cost. Contact us at (800) 221-0093 or firstname.lastname@example.org to get started.
Written by Alexa Do