Medical billing and coding certifications offer entry into several high-demand professions. Billing and coding often go hand in hand, and both deal with medical record-keeping, though there are several distinctions between the two specializations.
Medical coding tracks information about patient diagnostics and procedures using Current Procedural Terminology (CPT) standards. Billing professionals use this data to generate invoices that allow health insurance companies to process claims.
Learners can obtain the necessary qualifications to practice one or both specializations through accredited postsecondary programs. This guide explains the different credentials available and examines the skill sets needed to succeed in school and the workforce.
The Importance of Certification
It is possible to pursue careers in medical billing and coding without professional certifications, but certification demonstrates that an employee has the knowledge and skills to work as a medical coder or biller. Consider the following reasons to earn certification.
The American Academy of Professional Coders (AAPC) notes that professionals with multiple billing and coding credentials enjoy higher average earnings than those with "any AAPC credential." In 2020, those with "any AAPC credential" made an average salary of $55,960, compared to $62,665 for professionals with two credentials and $68,016 for those with three or more credentials.
The Bureau of Labor Statistics projects the medical coding and billing field to grow by 8% from 2019-2029. This is much faster than the national average projected growth rate for all occupations. Despite this growth, the billing and coding job market is competitive, so earning at least one certification can increase the likelihood of securing employment.
While becoming a member of certification-granting organizations is not always necessary to become certified, membership does open connections to other medical coding and billing professionals. Connecting with individuals and groups who value professional certifications and education can lead to new career opportunities.
The benefits that come with passing a certification exam are not just for potential employers. Certified individuals can feel confident in the accuracy of their work, and training for certifications can lead to new knowledge and growth as a professional.
Governing Bodies That Grant Certification
Two main bodies grant certifications in medical billing and coding: the American Academy of Professional Coders and the American Health Information Management Association (AHIMA). Both organizations offer credentials that showcase specific skill sets, so it is important for professionals to understand the certifications on offer when choosing certification exams.
Originally founded with the goal of raising outpatient medical coding standards, AAPC has since expanded its training and certification to cover all aspects of the healthcare industry. Certifications are offered in medical billing, medical coding, auditing, medical documentation, compliance, and practice management. An annual membership costs $180, but students with proof of active student status can get a membership for $100 per year.
Qualifying students are enrolled in at least one field-related course and have not yet received any AAPC certifications. Certification exam costs vary, but most tend to be around $300-$400 with one opportunity to retake each exam. AAPC also offers continuing education units, which are required to maintain certification and ensure professionals stay up to date in the field. Webinars, workshops, courses, conferences, and local chapters all provide continuing education to AAPC members.
Focused on certifications for those who work in health information and informatics, AHIMA-granted credentials focus less on business elements and more on effective, efficient management of healthcare records in various settings. A standard membership costs $135 per year, but AHIMA offers reduced fees for students ($49 per year), first-time members ($79 per year), and members 65 years or older ($49 per year). Members can take certification exams at discounted rates.
Exam fees range from $199-$299 for members and $299-399 for nonmembers. Along with two certifications specific to health information, AHIMA offers three coding and three specialty certifications. Continuing education quizzes, online education, virtual labs and in-person courses allow medical billing and coding professionals to maintain certification and stay current in the field.
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Skill Sets of a Certified Medical Biller
Medical billing specialists do not formally require professional certifications if they have the necessary knowledge, skills, and educational background. Specialized medical billing programs typically require 40-80 hours of coursework, which students usually complete in 6-8 weeks.
However, formal certifications often lead to more job options, higher pay, and access to more advanced careers. The following subsections detail the hard and soft skills students need to complete their training, earn certifications, and succeed in professional roles.
- Knowledge of Medical Terminology: Medical billers need current knowledge of the clinical, diagnostic, and procedural terms doctors use when providing care.
- Computer Literacy: Billers need intermediate-level computer and internet literacy to use specialized enterprise software for entering coded statements into digital systems.
- Bookkeeping: Medical billing professionals do not need advanced accounting skills, but a strong working knowledge of bookkeeping basics may assist them in matching statements with payments as insurers process claims.
- Accuracy: Data entry is a major component of medical billing, and invoices must be 100% accurate to prevent delays, claims denials, and other associated problems.
- Strong Communication Skills: Billers and coders routinely communicate with healthcare providers and insurance companies when processing patient information and claims.
- Compassion and Sensitivity: In some cases, billers and coders deal directly with patients navigating the claims process. These interactions require compassion, sensitivity, and patience.
- Teamwork: Medical billing professionals are key members of larger teams, with each team member performing integrated roles. A collaborative attitude supports success.
- Adaptability: The billing and coding industry constantly integrates new software platforms, technologies, and shifts in standard medical practices that impact billing standards. Professionals must have the ability to respond quickly to such changes.
Front-End and Back-End Medical Billing
In the healthcare industry, standard approaches to revenue cycle management (RCM) include front-end and back-end processes. The front end involves pre-treatment insurance eligibility clearances and up-front payment processing. Front-end billers are typically involved during the patient registration and appointment scheduling processes. The front end usually unfolds as follows:
- A patient makes a new appointment or visits a healthcare facility for immediate treatment.
- At the outset of the patient's first visit, an administrative assistant collects and verifies the patient's insurance information.
- If a patient's insurance does not cover any necessary diagnostic procedures or treatments, the patient may have to cover them (partially or fully) prior to service delivery.
- Patient-facing staff members may explain payment plan options if they apply.
- The patient then receives care.
Back-end medical billing covers processes that occur after healthcare service delivery. It includes reviews of applicable charges, generating and submitting insurance claims, processing payments that come due after care is complete, and following up on unpaid bills and unprocessed claims. The back end of the RCM process initiates post-care:
- Medical coders review service delivery files, identifying billable services in keeping with CPT standards.
- Billing specialists convert coded service summaries into bills, invoices, or insurance claims.
- The patient becomes responsible for any outstanding charges their insurance does not cover.
- Insurance companies process and pay out qualified claims.
- Patients arrange to cover any outstanding balances.
- Members of the clinic or care provider's staff, or an authorized third-party agency, manages follow-ups and collections if necessary.
Medical Billing Certifications
Certification in medical billing shows a professional's ability to effectively navigate all aspects of billing and revenue without compromising reimbursement. The primary certification for professional medical billers is the certified professional biller (CPB) credential.
Certified Professional Biller
The CPB credential signifies coders' proficiencies across the medical billing and reimbursement cycle, including preauthorization, submitting appeals in cases of denial, posting payments, and following up to collect outstanding fees. Through their broad skill set, certified individuals can contribute to the smooth running and financial well-being of medical practices and facilities.
The CPB examination covers insurance requirements and differences between private insurance and public health plans, including managed care and worker's compensation. CPB-holders know coding best practices, guidelines for local or national coverage, and government regulations affecting healthcare and debt collection.
AAPC requires current membership for CPB certification and recommends that candidates hold at least an associate degree. Those applying for CPB credentials should prepare for each component of the exam, paying specific attention to laws like the Health Insurance Portability and Accountability Act or the False Claims Act.
Candidates may refer to certain approved manuals during the CPB examination, such as the American Medical Association's editions of CPT procedural coding guidelines. Examinees can choose their preferred edition of guidelines for International Classification of Diseases (ICD) and Healthcare Common Procedure Coding System (HCPCS) level II codes. All manuals must be for the current calendar years.
The CPB exam is proctored. Examinees have five hours and 40 minutes to answer 200 multiple-choice questions. Topics cover varying health plans, billing regulations, claim forms, and insurance payment policies. The test explores the use of coding resources, compliance with privacy laws, and requirements for medical record retention. Other topics include reimbursement, collections, appeals, denials, accounts receivable, and electronic claim submission.
Skill Sets of a Certified Medical Coder
While medical billing programs usually feature compact completion timelines, coding certifications take longer to earn. Coding programs generally require students to complete the equivalent of 6-10 courses, which typically takes 1-2 academic years.
As with billing, professionals do not strictly require medical coding certifications to find work. However, coders with industry-standard coding certifications typically have an easier time finding jobs. They also tend to earn higher salaries.
Successful medical coders display a common set of hard and soft skills. Academic programs develop some of these skills, while others are intuitive and innate.
- Reading and Listening: Coders need to interpret patient records and medical files, and may also need to listen to doctors' oral transcriptions of care delivery.
- Attention to Detail: The professional duties of medical coders include interpreting charts and other sources of data, then accurately transcribing this data.
- Accurate Keyboarding: Entering codes in electronic management systems demands quick, accurate keyboarding skills, particularly with numeric data.
- Computer and Internet Literacy: Medical coders need solid digital literacy, as their work is almost entirely computerized.
- Flexibility and Lifelong Learning: Coding standards undergo regular updates. As such, coding professionals need to adapt to change and commit to career-long professional development.
- Independence: Many coders primarily work on their own, reviewing charts and patient records for pertinent details. Thus, they require high levels of independence and the ability to work with minimal real-time supervision.
- A Collaborative Mindset: While coders perform more independent duties than billers, they still function as parts of a larger team and must remain mindful of how their work impacts their colleagues.
- Strong Organization Skills: Successful coders implement reliable, efficient systems for tracking their work. This enables them to quickly find the source of any inaccuracies or discrepancies that may occur.
Medical Coding Certifications
Certifications verify an individual's knowledge of the codes that identify medical services, procedures and supplies for purposes of billing and reimbursement. Certified coders can apply coding guidelines correctly with resources like the CPT, ICD, and HCPCS. Code sets undergo regular updates, so continuing education and training programs can help professionals maintain their certified status as coding systems evolve.
The certified coding associatecredential is awarded to coding associates who can competently code in any setting, including physician practices and hospitals.
The certified coding specialistcredential verifies a coder's ability to classify inpatient and outpatient medical data in a hospital setting.
The certified coding specialist–physician-based credential is for professionals who specialize in coding in physician-based settings. Individuals with this certification show mastery-level coding skills used in physicians' offices, group practices, and specialty clinics.
The certified inpatient coder credential specifically addresses inpatient hospital and facility coding. This certification verifies a professional's ability to create accurate inpatient codes from medical records and verifies an understanding of outpatient reimbursement methodologies.
Thecertified outpatient coding credential targets the use of codes in hospitals and facilities, such as ambulatory surgery centers. This certification attests to a professional's skills in coding emergency department visits, same-day surgeries, diagnostic testing, and other services, such as physical or speech therapy.
The certified professional coder is the most recognized credential that demonstrates a medical coding professional's training and experience.
The certified professional coder–payer credential applies to coders who work for organizations that process medical claims for payment. This certification addresses skills for handling claims submitted to private or public health plans like Medicare or Medicaid. The CPC-P exam focuses on adjudicating claims from the payer's viewpoint, highlighting the differences between insurance company and healthcare provider processes.
The certified risk adjustment coder certification is awarded to those who demonstrate proficiency in reading medical charts and assigning appropriate diagnosis codes used in risk adjustment models. CRCs understand reimbursement, compliance, and audit processes.
Specialty Certifications in Medical Billing and Coding
Specialty credentials confirm the expertise of experienced coders in specific medical disciplines ranging from cardiology to anesthesia. These certifications focus on specialized procedures and regulations, including Medicare billing guidelines and the codes commonly used for a variety of disciplines.
Frequently Asked Questions
Medical billers and coders review healthcare service delivery records to generate bills and insurance claims for processing. They play integral roles in healthcare revenue cycle management, ensuring that providers receive due compensation and patients' insurance covers eligible expenses.
The American Academy of Professional Coders tracks earnings among credentialed professionals. In 2020, those with at least one formal medical billing and coding certificate credential earned an average of $55,960.
Medical coders draw on patient records and doctors' reports to determine which billable procedures were used in a care delivery cycle. Billers then use that information to generate bills, invoices, and insurance claims.
Medical billing programs usually take the equivalent of 6-8 weeks of full-time study to complete. Coding programs are longer, usually taking 1-2 academic years. In both cases, accredited programs provide the knowledge base needed to pass optional certification examinations, though many candidates supplement their schooling with professional experience before attempting to earn certifications.
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