Medical Biller and Coder Certification

Medical Biller and Coder Certification

A Medical Biller and Coder is a crucial professional in the healthcare industry who plays an essential role in maintaining the financial and administrative aspects of medical practices. They are responsible for translating healthcare services provided to patients into standardized codes, which are then used for billing and insurance purposes. By accurately interpreting and applying these codes, they ensure that medical claims are correctly processed and that healthcare providers receive timely reimbursement. Additionally, Medical Biller and Coders work closely with physicians, insurance companies, and patients to address discrepancies, resolve disputes, and maintain the smooth flow of revenue. Their meticulous attention to detail and strong knowledge of medical terminology, coding systems, and regulations contribute significantly to the efficiency and financial stability of healthcare organizations.

What You will Learn

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Course Content

The career of a health insurance specialist (or reimbursement specialist) is challenging, with opportunities for professional advancement. Individuals who understand claims processing and billing regulations possess accurate coding skills, can successfully appeal underpaid or denied insurance claims, and demonstrate workplace professionalism are in demand. A review of medical office personnel help-wanted
advertisements indicates the need for individuals with all of these skills.

According to the American Heritage Concise Dictionary, insurance is a contract that protects the insured from loss. An insurance company guarantees payment to the insured for an unforeseen event (e.g., death, accident, and illness) in return for the payment of premiums. In addition to health insurance, types of insurance include automobile, disability, liability, malpractice, property, and life (discussed in Chapter 12). (This textbook covers health insurance in detail.) This chapter includes information about terms and concepts as an introduction to health insurance processing. These terms and concepts are explained in greater detail in later chapters of this text.

Managed health care (managed care) is a health care delivery system organized to manage cost, utilization, and quality. The delivery of health benefits and additional services is provided through contracted arrangements between individuals or health care programs (e.g., Medicaid) and managed care organizations
(MCOs), which accept a predetermined per member per month (capitation) payment for services. Currently,
more than 70 million Americans are enrolled in some type of managed care program in response to
regulatory initiatives affecting health care cost and quality.

This chapter provides an overview of the revenue cycle, which results in accurate, optimum, and timely reimbursement for health care services provided to patients. Electronic Data Interchange (EDI) content is also located in this chapter.

The health insurance specialist must be knowledgeable about laws and regulations for maintaining patient records and processing health insurance claims. This chapter defines legal and regulatory terminology and summarizes laws and regulations that affect health insurance processing. Internet links are also included as a resource for remaining up-to-date and obtaining clarification of legal and regulatory issues.

ICD-10-CM codes are reported for all diagnoses, regardless of the health care setting. These settings include physician offices and clinics, outpatient care, stand-alone clinics, home health care, hospice, hospitals, long-term care facilities, and skilled nursing facilities. The health insurance specialist employed in a provider’s office assigns ICD-10-CM codes to diagnoses, conditions, signs, and symptoms documented by the health care provider. Reporting ICD-10-CM codes on insurance claims results in uniform reporting of medical reasons for health care services provided.

This chapter introduces the assignment of Current Procedural Terminology (CPT) service and procedure codes reported on insurance claims. CPT is published by the American Medical Association and
includes codes for procedures performed and services provided to patients. It is level I of the Healthcare Common Procedure Coding System (HCPCS), which also contains level II (national) codes that are covered
in Chapter 8 of this textbook.

This chapter presents the procedure/service coding reference developed by CMS, the Healthcare Common Procedure Coding System (HCPCS, pronounced “hick-picks”). Two levels of codes are associated with HCPCS, commonly referred to as HCPCS level I and II codes

Since the Medicare program was implemented in 1966, expenditures have increased at an unanticipated rate, and the news media frequently report that the program will be bankrupt in a few years. In 1983, the Health Care Financing Administration (HCFA, now called CMS) implemented the first prospective payment system (PPS) to control the cost of hospital inpatient care. In subsequent years, similar reimbursement systems were implemented for alternate care (e.g., physician offices, long-term care). This chapter details CMS’s reimbursement methodologies and related issues, including the data analytics and related quality reporting programs, case-mix management, CMS Fee Schedules, and CMS Payment Systems.

The next step in learning to code properly is to determine that coding compliance is met, apply clinical documentation improvement (CDI) processes, select diagnoses and procedures/services from case studies and patient reports, and link each procedure/service with the diagnosis code that justifies the medical necessity for performing it. (Coding compliance, clinical documentation improvement, and coding
for medical necessity are required by payers for reimbursement consideration.) Coding compliance, clinical
documentation improvement, and coding for medical necessity require a background in patient record documentation practices and the ability to interpret provider documentation.

This chapter covers the general completion and submission requirements of CMS-1500 and UB-04 (CMS-1450) claims, including their electronic versions.

This chapter contains instructions for completing fee-for-service claims that are generally accepted nationwide by most commercial health insurance companies, including Aetna, United Healthcare, Prudential, Cigna, and others. (Instructions for filing BlueCross BlueShield, Medicare, Medicaid, TRICARE, CHAMPVA, and workers’ compensation claims are found in later chapters.)

BlueCross BlueShield health plans are perhaps the best-known medical insurance programs in the United States. They began as two separate prepaid health plans selling contracts to individuals or groups for coverage of specified medical expenses as long as the premiums were paid. BlueCross plans originally covered only hospital bills, and BlueShield plans covered fees for physician services. Over the years, the programs merged and increased coverage to include almost all health care services.

Medicare, the largest single health care program in the United States, is a federal program authorized by Congress and administered by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA). CMS is responsible for the operation of the Medicare program and for selecting Medicare administrative contractors (MACs) to process Medicare fee-for-service Part A, Part B, and durable medical equipment (DME) claims. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created Medicare administrative contractors (MACs), which replaced carriers and fiscal intermediaries and process both Medicare Part A and Part B claims. Medicare is a two-part program:

1. Medicare Part A reimburses institutional providers for inpatient, hospice, and some home health services.

2. Medicare Part B reimburses institutional providers for outpatient services and physicians for
inpatient and office services.

In 1965, Congress passed Title 19 of the Social Security Act, establishing a federally mandated, state-administered medical assistance program for individuals with incomes below the federal poverty level. The federal name for this program is Medicaid; several states assign local designations (e.g., California uses Medi-Cal; Massachusetts uses MassHealth; Tennessee uses TennCare). Unlike Medicare, which is a
nationwide entitlement program, the federal government mandated national requirements for Medicaid and gave states the flexibility to develop eligibility rules and additional benefits if they assumed responsibility
for the program’s support.

TRICARE is a health care program for uniformed service members and their families, National Guard/Reserve members and their families, survivors, former spouses, Medal of Honor recipients and their families, and others registered in the Defense Enrollment Eligibility Reporting System (DEERS). CHAMPUS (now called TRICARE Select) was an abbreviation for the Civilian Health and Medical Program of the Uniformed Services, a federal program implemented in 1967 as a benefit for dependents of personnel serving in the uniformed services. TRICARE was created to expand health care access, ensure the quality of care, control health care costs, and improve medical readiness.

Federal and state laws require employers to maintain workers’ compensation coverage to meet minimum standards, covering a majority of employees for work-related illnesses and injuries (as long as the employee was not negligent in performing the assigned duties). Employees receive health care and monetary awards (if applicable), and dependents of workers killed on the job receive benefits. Workers’ compensation laws also protect employers and fellow workers by limiting the award an injured employee can recover from
an employer and by eliminating the liability of coworkers in most accidents. Federal workers’ compensation statutes (laws) apply to federal employees or workers employed in a significant aspect of interstate
commerce. Individual state workers’ compensation laws establish comprehensive programs and apply to most employers.

Taking responsibility for meeting your objectives, including deadlines and work targets, demonstrates your attitude of professionalism. While it can be difficult at times, being accountable for delivering on your
objectives shows that you are reliable, organized, and dedicated to your work. This course introduces the
importance of personal accountability and outlines strategies for developing a personal accountability
framework. This helps empower you to set your standards and carry yourself with professionalism and confidence.

Career & Certification

(MCBC) Medical Coder & Biller Certification

The American Medical Certification Association is a provider of national certification exams in the allied healthcare industry.

(CBCS) Certified Billing & Coding Specialist

The National Healthcareer Association prepares the next generation of healthcare workers through validated, nationally recognized certifications.

  • Medical Billing Specialist
  • Medical Coding Specialist
  • Health Information Technician
  • Medical Office Manager
  • Insurance Claims Analyst
  • Medical Billing and Coding Educator

The U.S. Bureau of Labor Statistics (BLS) projected a growth of 8% for Medical Records and Health Information Technicians, including medical billers and coders, between 2019 and 2029. This growth rate is faster than the average for all occupations, indicating a promising job outlook for certified billing and coding graduates.

According to the BLS, the median annual wage for Medical Records and Health Information Technicians was $44,090 in May 2020. The lowest 10% earned less than $29,130, while the highest 10% earned more than $73,370.

What to Expect from a Career Academy Course

On-Demand Lectures

Online On-Demand lectures by top instructors who are industry subject matter experts. Learn from your computer, tablet as well as mobile devices.

Academic Coaching

You will be assigned an academic coach to guide you through the coursework when you enroll. Your academic coach is available via Zoom live, Text and Emails during both weekdays and weekends.

Instructor Support

Meeting with our instructors and subject matter experts one on one during both weekdays and weekends via flex schedules of live Zoom mentoring sessions.

Total Flexibility

Flexible online coaching and live mentoring combined with on-demand training gives you ultimate control of your learning experience.

Simulation Software

Our simulation software is used by students to develop practical skills and knowledge relative to program they are taking.

Certification Preparation

Our award-winning test prep engine provides you with the most relevant test questions to fully prepare you for the cert exam

Total Flexibility

Flexible online coaching and live mentoring combined with on-demand training gives you ultimate control of your learning experience.

Hands-on Labs

Reinforce your knowledge by accessing REAL equipment online with no restrictions and full administrator privileges, live in real time.

Certification Preparation

Our award-winning test prep engine provides you with the most relevant test questions to fully prepare you for the cert exam

Total Flexibility

Flexible online coaching and live mentoring combined with on-demand training gives you ultimate control of your learning experience.

Earn Contact Hours/PDUs

With our Programs and Courses you have the ability to earn Contact Hours or PDU’s that are applicable to your industry.

Certification Preparation

Our award-winning test prep engine provides you with the most relevant test questions to fully prepare you for the cert exam

Total Flexibility

Flexible online coaching and live mentoring combined with on-demand training gives you ultimate control of your learning experience.

12 Month Access

You will have up to 12 month access to your course to help you further prepare for your certification after completion.

Certification Preparation

Our award-winning test prep engine provides you with the most relevant test questions to fully prepare you for the cert exam

Accelerate Your Career With Online Managed Learning

From the moment you reach out to Career Academy, our education consultants will work with you to find scholarship opportunities and the best funding options available.

Live Virtual Classroom

Enjoy a learning environment that allows for live interaction as you are progressing through your training and hands-on labs.

Total Flexibility

Flexible live online class schedule combined with on-demand training gives you ultimate control of your learning experience.

Elite Online Instructors

Our live instructors guide you through the training and assist you with your hands-on labs during the virtual classroom sessions.

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