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.
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.
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.
CPB Exam Information
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.
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.
CCAThe certified coding associatecredential is awarded to coding associates who can competently code in any setting, including physician practices and hospitals.
CCSThe certified coding specialistcredential verifies a coder's ability to classify inpatient and outpatient medical data in a hospital setting.
CCS-PThe 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.
CICThe 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.
COCThe certified 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.
CPCThe certified professional coder is the most recognized credential that demonstrates a medical coding professional's training and experience.
CPC-PThe 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.
CRCThe 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.
CASCCThe certified ASC coder credential focuses on billing for ambulatory surgery centers (ASCs), including the interpretation of operative notes and an overview of surgeries performed at ASCs.
CANPCThe certified anesthesia and pain management coder credential pertains to coding for surgical cases, codes from the American Society of Anesthesiologists, and elements of anesthesia claims, such as units of time.
CCCThe certified cardiology coder credential verifies professional experience with coding for cardiologist surgical procedures, such as heart catheterization and coronary interventions.
CCVTCThe certified cardiovascular and thoracic surgery coder credential shows a professional's familiarity with codes for cardiovascular and thoracic surgeries, such as cardiopulmonary bypass operations.
CCPCThe certified chiropractic professional coder credential affirms an employee's ability to code radiologic, neurologic, and musculoskeletal diagnostic procedures.
CDIPThe certified documentation improvement practitioner credential is awarded to coders with competency in clinical documentation, maintaining this competency even as electronic health records change documentation processes.
CEDCThe certified emergency department coder credential verifies skills in coding for typical emergency services, such as laceration repair, fracture care, removal of foreign bodies, and moderate sedation.
CEMCA certified evaluation and management coder credential confirms professional experience with medical decision-making guidelines used in multiple specialties, including time-based coding and risk assessment.
CENTCThe certified ENT coder credential applies to coding for procedures ear, nose, and throat specialists and otolaryngologists perform, such as laryngoscopies and sinus surgeries.
CFPCThe certified family practice coder credential verifies expertise in determining codes for multiple procedures and services, such as giving injections, caring for broken bones, and taking medical histories.
CGICThe certified gastroenterology coder credential covers coding for common gastroenterological procedures and surgeries, such as colonoscopies and esophageal dilations.
CGSCA certified general surgery codercredential focuses on services typically offered in teaching situations, shared visits, consultations, and operations, including hernia repairs and transplants.
CHDAThe certified health data analyst credential demonstrates mastery of health data analysis, including the ability to take data and transform it into useful information accurately.
CHONCThe certified hematology and oncology coder credential shows a coder's knowledge of the medical practice of hematologists and oncologists, including cancer-related procedures like chemotherapy, bone marrow biopsies, and other services.
CHPSThe certified in healthcare privacy and security credential is for professionals who specialize in the privacy and security of healthcare information and demonstrate the ability to design, implement, and administer privacy and security protection programs.
CHTSThe certified healthcare technology specialist exams are for health IT professionals who want to validate their competency in various topics, including workflow assessment, problem diagnosis, and system tests and installations.
CIMCThe certified internal medicine coder credential concentrates on coding for procedures typical in an internal medicine practice, such as injections and skin tag removals.
CIRCCThe certified interventional radiology cardiovascular coder credential was created to reduce the field's high error rates. This certification validates individuals who display advanced knowledge of diagnostic angiography, non-vascular interventions, percutaneous vascular interventions, diagnostic cardiac catheterization, and basic coronary arterial interventions.
COBGCThe certified obstetrics gynecology coder credential certifies familiarity with coding for obstetric services and deliveries as well as OB/GYN surgical procedures, such as hysterectomies and biopsies.
COSCThe certified orthopedic surgery coder credential verifies a candidate's proficiency in coding for procedures that orthopedists typically perform, including arthroscopies and fracture repairs.
CPCDThe certified professional coder in dermatology credential specializes in coding of surgical procedures common for dermatologists, such as skin debridement or the removal of damaged tissue.
CPEDCThe certified pediatrics coder credential can show experience in coding services and procedures relating to healthcare for children, such as vaccinations, vision testing, and foreign body removal.
CPRCThe certified plastic and reconstructive surgery coder credential demonstrates expertise in coding for procedures and services plastic and reconstructive specialists offer, including scar revisions and cosmetic surgeries.
CRHCThe certified rheumatology coder credential focuses on coding surgical procedures, such as joint injections and rheumatic disease treatment. This credential also includes coding for conditions like carpal tunnel syndrome, fibromyalgia, and rheumatoid arthritis.
CSFACThe certified surgical foot and ankle codercredential can verify the experience of coders working with podiatrists, orthopedists and medical facilities that offer consultations, services, and surgeries specifically for feet and ankles.
CUCThe certified urology coder credential offers verification of experienced coding procedures and surgeries common to this specialty, such as urinalysis, cystoscopies, and biopsies.
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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