Tag Archives: Training

Medical Billing and Coding Professions, Which one is best for you?

By: Karen Mooney, MBA, BS, CPC, CPC-I, CMSCS, CHI

There is a large misconception from those that are just entering into the medical administration field.  Many people believe that billers and coders are one in the same.  In reality, there is a big difference on the focus between these two categories.  A medical biller is focused on data entry of claims, claims processing, claims follow up, accounts receivable, patient billing, and collections.  Billers also make very strong registration specialists and front desk staff.  A medical biller is a strong strength when it comes to collecting funds due by the patient at the time of appointments as they know what to look for.  Billers are also great enforcers of referrals and authorizations that may be necessary for payment of services.  One other avenue that could work for a biller would be working in the health information department as billers are trained on HIPAA requirements and the need for completed medical records.

When a person is considering a coding profession, there is much more challenge in this aspect due to the level of knowledge that is necessary to perform the duties of a coder.  A coder must understand the working knowledge of the ICD-9-CM as well as the CPT coding reference. Coders are responsible for making sure that when coding services and procedures that the diagnosis that has been provided supports the medical necessity for the service before these are forwarded for processing.  Medical Coders hold a very large responsibility in their hands when performing their daily duties and are completely responsible for what they code.  Coders can find work in physician offices, clinics, hospitals with the right background of training.  From there, coders become quality reviewers, advanced educators, auditors, and consultants.

When individuals are researching new careers, the medical profession is a great choice as there is a long line of stability in the medical profession.  With that said, locating the best focused training is very important to a person’s success.  History has proven that the most direct route into medical administration is through the billing side of the profession.  This provides a great passageway into the field and allows many opportunities to a new comer to the medical field. Practices and physicians are more likely to hire individuals that are right out of school for a billing position versus a coding position.  The reason for this is that the coders hold a large responsibility of a physician’s revenue in their day to day process. Physicians are completely aware of this fact and are less apt to hire a person, right out of school without any live experience in the coding realm.

When researching your career path, and you are looking to learn to become a Medical Biller, then you want to focus on a program that will be sure to provide you with the background knowledge of the types of insurances, patient’s responsibilities, what can and cannot be processed from a billing side of the process and still covering an introduction of ICD-9 and CPT coding.  An introduction to ICD-9 and CPT does not make a biller qualified to work as a coder.  If you are looking to become a coder, be sure that the program offers you an entire review of the CPT coding reference. This process should be a minimum of 3 months to accomplish the course you are looking at.  If you decide that a medical biller and coder is the program that you are interested in, the program should be a minimum of 9 months to ensure that you have learned the skills necessary for both specialties. The most direct process is to become a biller and introduce yourself to the profession in the billing community, build experience, continue to code, then work your way into a coding position within the profession.  Ultimately the final decision is yours.  You need to make the best decision for reaching your final goal. Just remember that anything worthwhile is worth working towards.

Electronic Encoders: Friend or Foe?

In today’s day and age, everything seems to be about technology, instant gratification, quicker turn around as well as more for less.  I can say that I have seen and worked within the concept of “more for less” for many years and it just seems to be the nature of our society today, or so it would seem.  So as we look at the transition of health care and the migration of medical records to electronic health records, this has actually managed to create a new vein of career paths in the health care field within our environment, which is great.  Along these same lines now emerges electronic encoders.  It is the opinion of this blog writer that encoders are positive and negative in a few different ways in the coding world for the profession coder and I am going to share why.

Encoders are great tools to help increase production standards because you can save time searching for your codes by having the system do the work for you.  They have built in references that are wonderful to have at your fingertips and not have to leave your work station to locate or search the all mighty web.  Not all working environments give their employees access to the internet so the fact that the encoder programs could possibly provide medical dictionaries, CPT Assistants, drug listings, Coding Clinics, anatomy diagrams, ICD-9 guidelines, and GEM guidelines would be invaluable to the work flow for a coder.  Not to mention the space it would safe from having all of these references in the work space.  Some encoders also come with other administrative functions that assist us to conduct research on specific procedures as well as individual payer information.  So there are some real great benefits that come with an encoder software package, depending on what is purchased and implemented in the working environment.

So you probably are wondering then, why would I even be asking why an encoding product would be a Foe in the world of a coder?  Here is my reason why.  Coding is a skill that we work extremely hard to learn and perfect.  Hours, months and years of time go into learning what we know and how we do what we do in our line of work.  Encoders are a great tool but can also spoil and ruin us as coders, if we allow them to.  If a coder becomes too reliant on an encoder, this is a bad thing.  If a coder becomes to “comfortable” coding with an encoder, this is a bad thing.  A coder needs to use their skills that they have built or they lose these skills over time.  They may not lose them completely but they can become very rusty for sure.  It is good practice to still manually code from time to time.  It is good for the brain to keep your fingers in your coding references so you remember how your books work, where to find everything, keeping your skills fresh on crosswalks and modifiers.

Things to keep in mind is that even if your working environment is using an encoding product, not everything in the coding world is and remember that to maintain your coding certification, you have tom complete continuing education credits.  Many of these continuing education credits are manual coding exercises.  If you look to gain any additional certifications above the certifications you already carry, these will be manual coding exams.  Not to mention, it is really difficult to put your personal coding notes in an encoder program but you have the luxury to place them anywhere you would like in your personal coding reference.

Medical Billing and Coding…..Is it Billing? Is it Coding? How do I choose?

Almost everywhere you turn today you see the combination of Medical Billing and Coding or Medical Coding and Billing tied together in some way shape or form so many people, if they are not familiar with the medical profession may believe that they are one in the same process.  In reality, they are really quite different.  This is a good thing because there are often times that people come into this specialty thinking “I want to be a coder” until they start seeing what exactly the job entails and they quickly realize that this responsibility is not for them so they automatically begin to think “Great, I chose the wrong profession”.  That is not the case.  Not everyone is meant to be a coder and that is perfectly fine to discover.  It takes a special mind set to be able to wrap your brain around all of the concepts and processes that need to take placed to be an effective coder and not everyone fits that bill.

So, if not a coder, what then is there for me to do?  There is the billing aspect of this profession to consider.  Here the responsibilities are just as important as on the coding side of the process because it is the billers that ensure that the claims are properly filled out, correctly submitted to the insurance companies for processing, follow up on outstanding claims that have not been processed by the insurance company, The Medical Biller is responsible for knowing and understanding the parts of the different insurances  in their geographical area, may handle the accounts receivable in a working environment,  work on submission of secondary insurance claims, responsible for correcting and reprocessing rejected claims and the list goes on and on.

There is a whole other world that exists in the medical profession outside of being a coder and that is the Medical Biller.  Now often times, Billers and Coders work closely together to help ensure that claim information is correct to expedite the processing of the claim for proper reimbursement which is a great way for the system to work but to be honest, the system needs both of these parts for the whole process to work as one.  Without one side or the other, you will find that there will be delays, errors, hold ups, mistakes, and all around major problems.

So, have you wondered what Medical billing and coding really is?  Have you ever asked yourself if it was one or two positions?  As you can see from above, there are many more than just two positions that exist in this realm which is great because it provides many different pathways for those that are looking for something different.  If you do not want to be a coder, do not think that this will prevent you from working on this side of the administrative process of the medical profession.  There is more to this profession than just coding.  Research this
and see what the pathways may be.  Billing can provide many different veins for you to take advantage of and the choices are yours to make.

If you are considering a change in career, Billing and Coding may be a great pathway based on the opportunities outlined above.  Now all you have to do is decide where and how you are going to obtain that education you are going to need to move forward on this career decision.  Hopefully you will find that this will help with making your decision in moving forward. What do you have to lose? Not sure coding is for you? Then take that billing course first as it should introduce you to the use of the coding references used in the profession and once through your introduction of the coding material if you find you really liked the coding aspect then look to expand your education  pathway to pick up some coding classes after your billing course is completed. After all, some of the best coders today were billers before they became coders.  Feel free to leave your thought. May you have a Happy New Year and may you make this a New Year’s resolution that you follow through on.

Medical Scribe-The Job Description!

Medical Scribes are individuals trained in medical documentation who assist a physician throughout their shift. The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on what is most important, the patient.

A summary of a Medical Scribes duties include performing all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. You also must be able anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care.  Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe.  You must be adaptable and versatile since you will be responsible for many tasks. Good attendance is also an important element of this job since you will be hard to replace.

Some of the more detailed job duties and responsibilities of a Medical Scribe are:

1.         Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:

  • Patient medical history and physical exam,
  • Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
  • Patient education and explanations of risks and benefits.
  • Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
  • Prepare referral letters as directed by the physician

2.         Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribe also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.  You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.

3.         Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.  All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record.  Alert physician when chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

4.         Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance.

5.         Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

Qualifications:  To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.         Language Skills – The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production. Handwriting must be clear and legible.

2.         Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.

3.         Mathematical Skills – Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.

4.         Reasoning Ability – Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.

5.         Computer Skills – To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software. Must accurately enter data into a database, search for information, send and receive email and attachments. Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents. Must use Microsoft Excel to prepare flowcharts and organize data. Must use the internet to access schedules, research information, etc.

6.         Other Skills and Abilities – Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information.

7.         Physical Demands – While performing the duties of this Job, a Medical Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The Medical Scribe must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

As you can see, Medical Scribes are an invaluable asset to physicians in busy emergency departments, hospitals, or clinics. With more time to focus on interacting with their patients, doctors see more patients while the Medical Scribe is documenting the patients visit and care plan – alleviating that burden from the doctor. As you can see, Medical Scribes are becoming more and more important to a doctor and a profession that is in high demand.

Do you have what it takes to become a Medical Scribe? Find out more!