Inside the complicated realm of the healthcare industry, billing and coding medical practices are the key considerations. These systems determine the efficiency of practice and the reimbursement flow from insurance providers. Though the processes work interchangeably in healthcare, there are notable differences in their purpose, functions, and operation. Hence, professionals in practice must keep focus on the entire functionalities and accuracy as a single error or negligence can cause abruption. For instance, the reports suggest that 80% of medical bills are unacceptable due to coding errors in claims. Plus, such faulty claims are denied up to 35% due to coding issues. Therefore, efficient coding leading to flawless billing calls for special scrutiny across the healthcare business.
Follow the guide to learn the key difference between medical biller and coder responsibilities. One has to perform in healthcare administration while the other contributes to the handling of patient records with accuracy through systems like electronic health records (EHR). Overall, the purpose of both medical billing and coding is to ensure healthcare practices are working smoothly to get an uninterrupted reimbursement from insurance providers. Plus, the job of the medical biller and coder is to ensure healthcare revenue cycle management is in line by following the current billing and coding regulations.
Hence, for professional aspirants to work in healthcare administration, understanding the systemic differences in healthcare billing and coding is inevitable. Moreover, medical practices must also keep up with the differences in both of the processes to help streamline the medical reimbursement process and stay ahead!
Understanding Medical Billing in Healthcare: An Overview of the Process
Medical billing in healthcare is the systemic process of the practice’s revenue generation from the insurance and patients through the services provided. These may include patient balances and claims from insurance providers such as Medicaid and Medicare. Mainly, the billing is conducted inside the practice of two types. The one is “front-end billing” which ensures patients’ eligibility verification tasks. The task also includes requesting pre-authorization from insurance providers for patient services before the treatment. Whereas “back-end billing” is another type and process that begins after the doctor has seen the patient and generated the claim in the language of coding. Based on the services and treatment that the patient receives, billing teams generate the claim for insurance companies for reimbursement on services provided. Below are the keynotes in the process:
After the insurance claim submission to the supposed bodies, these are the steps that the practice follows:
- Medical billers track unpaid insurance claims and invoices until payment is received.
- The goal is to ensure providers get paid accurately for their services.
- Billers help optimize revenue for medical practices and healthcare organizations.
- Some insurance companies have strict filing deadlines.
- Missing deadlines can lead to claim denials and revenue loss.
- A proper billing cycle in healthcare management prevents financial setbacks.
- Efficient medical insurance billing ensures steady cash flow for healthcare providers.
What is Medical Coding? The Roles and Responsibilities in Healthcare!
Medical coding in healthcare is a structured language of numeric and alphanumeric codes used to indicate procedures and diagnoses. Coding is the universal system used across healthcare to inform all the entities involved in the system about the specific procedure. However, the purpose of using this system is to translate patient records and medical documents to get reimbursement from the insurance companies.
In the U.S., there are major coding systems used across all the private and federal healthcare institutions to serve care and get reimbursement. The two main code sets are the “American Medical Association’s Current Procedural Terminology (CPT) and the “International Classification of Diseases, Tenth Revision (ICD-10) monitored by the World Health Organization (WHO). Moreover, there are two subsets in the ICD-10 coding system, such as the Procedural Coding System (PCS). Professionals use this system in inpatient and hospital settings of providing care. Whereas the Clinically Modified (ICD-10-CM) is used for clinical and outpatient settings. Below are the key highlights of what the medical coding and billing roles include:
- Medical history is essential for providing the best treatment to new patients.
- Clinicians must quickly understand medical records despite thousands of diagnoses and procedures.
- Medical codes help healthcare professionals efficiently share patient information.
- These codes act as a common language, simplifying complex medical details.
- Instead of reviewing lengthy documents, practitioners rely on shorthand codes.
- Healthcare coding helps finance teams understand the reasons for treatments.
- Billing is based on medical codes, ensuring accurate reimbursement.
- Up-to-date coding optimizes revenue for healthcare organizations.
- Proper coding ensures practitioners are paid for every service provided.
What do the “Medical Coder Responsibilities” include?
The medical coding job description involves a greater role in terms of critically analyzing the documents after each patient visit. They review the documents, such as lab results, prescriptions, and transcription of physician notes. Since their responsibility is to ensure the completeness of the data recorded, they involve the clinicians to offer the missing data and complete the patient records. The certified coding professionals translate the records into billable alphanumeric codes using their coding knowledge and efficiency by ensuring the alignment of medical records with medical coding standards. The medical coder combines the codes on treatment and diagnosis in a claim and sends it to the biller for review. Moreover, these professionals may also perform additional research for the consolidation of the process so that the reimbursement gets the flow. The medical billing vs. coding career also includes adherence to medical coding industry guidelines through regular medical coding audits along with confirmation on accuracy practices.
Medical Billing V.s Medical Coding: The Key Differences and Roles
Medical billing and coding in healthcare are crucial since both of these processes help healthcare providers and practices reduce claim denials, stay compliant for overall efficiency, and ensure smooth revenue flow. One is the leading cause of the other’s efficiency and success. Yet, there are significant differences in the operations of both of these processes. Many factors, as mentioned below, cause the distinction:
| Aspects | Medical Billing | Medical Coding |
| Primary roles | Ensures providers get paid by the insurance companies and patients | Ensures accuracy in medical records and claims through proper coding |
| Key tasks | Claim submission, insurance verification, payment posting, denial management, patient invoices | Assigning ICD-10, CPT, and HCPCS codes to medical services based on documentation. |
| Required skills | Knowledge of insurance policies, claim processing, and revenue cycle management. | Understanding of medical terminology, anatomy, coding guidelines, and compliance. |
| Impact on revenue cycle | Affects cash flow and timely reimbursements. | Affects claim approval and minimizes errors leading to denials. |
| Errors and challenges | Up to 35% of claims are denied due to billing errors. | 80% of medical bills contain coding errors that delay payments. |
| Who performs it? | Medical billers, revenue cycle specialists, and billing coordinators. | Medical coders, compliance officers, and coding specialists. |
| Technology used | Billing software (e.g., eClinicalWorks, Kareo, Athenahealth). | Coding systems in healthcare (e.g., ICD-10, CPT, HCPCS) and EHRs. |
| Outcome | Payment collection and revenue management. | Accurate documentation and compliance with coding standards. |
Are there Medical Billing and Coding Jobs available in Pakistan?
With the advent of more medical billing and coding practices, several jobs are available in Pakistan for the medical billing process and coding. However, aspirants must understand and get prepared for the key requirements and training to perform successfully in medical billing and coding companies and in healthcare practice. Medical billing and coding regulations also require practitioners to have a certain degree of education and certifications that focus on medical terminology, coding systems, and healthcare reimbursement models. Moreover, these aspirants need to stay informed on insurance policies, patient billing software, and claims processing in healthcare.
MedsNexus is a leading medical billing and coding company ensuring safe and compliant practice for healthcare practices across the country. Join our practice if you are interested in the field or outsource your medical billing and coding needs with us for a more efficient and tech-based practice to ensure no error or inadequacy will disrupt your practice billing workflow.
Frequently Asked Questions (FAQs):
Which is easier? Medical Billing or Coding!
Each field plays a distinct but vital role in healthcare for practices to get completely reimbursed by the insurance companies. Practitioners must have specialized knowledge to make the process easy, yet billing is considered easier than claim processing. Medical coding, on the other hand, requires a thorough scrutiny of ICD-10, CPT, and HCPCS codes and an understanding of medical terminology and compliance knowledge.
What pays more: Medical Billing or Coding?
Since medical coding is considered a critical job compared to medical billing, medical coder salaries are also higher than billers. According to industry data, certified medical coders earn $55,000–$65,000 annually, while medical billers earn $40,000–$50,000 on average. Certifications like CPC (Certified Professional Coder) can further increase a coder’s salary.
What are some key regulations in medical billing and coding?
Medical billing and coding must comply with several regulations, including:
✔ Health Insurance Portability and Accountability Act (HIPAA Compliance in billing and coding) – Ensures patient data privacy.
✔ ICD-10 & CPT Codes – ICD codes ensure uniform coding for insurance claims.
✔ The No Surprises Act – Prevents unexpected medical bills for patients.
✔ CMS & Medicare/Medicaid Guidelines – Regulate federal insurance claims processing.
What do medical billing and coding examples include?
- Example of Medical Coding: A patient with diabetes (ICD-10: E11.9) has a foot examination (CPT: 11719). These codes are assigned by the coder to submit claims.
- Example of Medical Billing: For a physical therapy session, a provider files a claim. After making sure it has the appropriate modifiers, the biller sends it to the insurance company for payment.
