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Job descriptions often combine billing and coding within a single position. However, they are technically two different job functions, each with its own responsibilities and tasks. Many medical offices will hire the same person to do both jobs, though larger facilities may divide the work into two separate positions—so it’s important to understand the difference between the two roles.
The Medical Coder
Medical coding is the act of taking a provider’s diagnostic and procedural notes and converting them into the correct codes for record-tracking and billing purposes. The codes are industry-standard alphanumeric combinations used to identify the services being provided and billed. This will require knowledge of the different codes used:
Current Procedural Terminology (CPT) – These codes are used to identify specific procedures and examinations performed.
International Classification of Diseases (ICD-10) – These classification codes are used for medical diagnoses.
Healthcare Common Procedure Coding System (HCPCS) – This system includes codes not covered in the previous two sets, such as codes for specific medical devices or supplies and non-physician services.
Each of these codes is used in insurance billing, and the coder must follow specific guidelines for proper use and placement in the billing software.
Codes may be entered as soon as the patient makes an appointment. There will be codes for the type of visit and the symptoms reported by the patient. Further codes will be applied for the symptoms observed by medical staff, tests and procedures performed, diagnoses, and treatments recommended.
Because the billing and coding processes are so intertwined, many medical offices hire coding and billing specialists with the training to perform both roles. While some larger facilities will hire separate teams to take care of the billing and coding, these individuals typically work very closely together to ensure the process is done correctly. The most important aspect is avoiding coding and billing errors so payments are collected in a timely manner.