Medical Billing and Coding Certification

As the healthcare and insurance industries require accuracy and compliance with complex regulations, medical billers and coders are held to these same standards. Certification is a way of showing your dedication and expertise. While you may not necessarily need a medical coding certification to get an entry-level job, you will find that your opportunities for career advancement multiply once you’ve achieved such a distinction. You’ll be more likely to demand a higher salary, earn a position of leadership, and perform different kinds of work.

Certifications are available for various professionals that work in the medical records and health information field. They’re also offered by a number of different organizations. As you plan your career goals, do your research to get the basic facts about certification and opportunities for specialization. Then consider a timeline for gathering the education, training, and experience that will help you pass the certification exam that’s right for you.

Explore Certification and Continuing Education

Important information about the types of certification available for medical billers and coders is explained in the following section.

AAPC certification

The most well-known agency that administers and oversees certifications for medical billers is The American Association of Professional Coders (AAPC). It also tracks required continuing education units through a system that records the knowledge you’ve gained from classes, conferences, seminars, and other educational opportunities on a variety of topics. The AAPC offers general certifications, as well as 21 specialty certifications.

General certifications: The main certifications are the Certified Professional Coder (CPC), Certified Professional Coder – Hospital Outpatient (CPC-H), and Certified Professional Coder – Payer (CPC-P).

Specialty-specific coding certifications: You can choose to focus on a particular area in the healthcare industry and pursue certification to demonstrate expertise in that area. These specialty certifications emphasize coding problems related to those fields, as well as professional requirements to work in these areas. You don’t necessarily need to acquire a general coding certification to obtain one of these specialty certifications (see the AAPC website for accurate and up-to-date information about specific requirements), but you will find that a variety of certifications make you more versatile and marketable to employers.

Use the following list to discover the wide variety of medical billing and coding jobs that are available across all sectors of the healthcare industry.

• Ambulatory Surgical Center (CASCC™): Also known as outpatient surgery, ambulatory surgical centers (or same-day surgery) perform medical procedures that do not require overnight stay. This specialization requires knowledge of surgical procedures. You’ll interpret notes provided by medical professionals and convert them into medical codes that accurately represent highly specific information. There are no prerequisites for this certification exam (other than AAPC membership,) which is designed to simulate the transcription of case notes.
• Anesthesia and Pain Management (CANPC™): Anesthesiologists administer drugs to patients for their symptoms or as part of their surgical procedures. You’ll be expected to know how to choose the right CPT codes for different procedures, as well as how to use modifiers for anesthesia cases. You’ll also be tested on determining time units and total units for cases that require anesthesia.
• Cardiology (CCC™): Heart health is a growing sector of the healthcare industry. Passing the examination for this certification demonstrates that you have a knowledge of cardiological surgical practices and equipment, such as stents and pacemakers. Because heart health is often related to other vascular procedures and has associated insurance regulations, this coding specialization presents unique challenges. You’ll be expected to know how to code for surgical procedures such as catheterization, placement of pacemakers, and peripheral vascular procedures.
• Cardiovascular and Thoracic Surgery (CCVTC™): This certification demonstrates that you possess knowledge of the treatment, equipment, and testing procedures associated with cardiovascular and thoracic surgery (surgeries performed on the heart, lungs, and greater vessels in the chest). You’ll need to possess both technical knowledge of Medicare billing rules and medical knowledge of the heart and circulatory system.
• Chiropractic (CCPC™): Chiropractic services involve manually adjusting a patient’s spinal system, which is considered complementary or alternative medicine. Medical billers and coders working alongside chiropractic professionals need to be able to navigate the specific ways that insurance companies reimburse these practitioners. You’ll also need to be aware of its diagnostic procedures in this field.
• Dermatology (CPCD™): Dermatologists diagnose and treat diseases related to the skin. Billers and coders working with dermatologists need to have knowledge of these skin conditions and related treatments. This means you’ll have to familiarize yourself with the anatomy of human skin and the classification of its disorders. You should also be knowledgeable of procedures such as debridement, lesion excisions, and flaps.
• Emergency Department (CEDC™): Billers and coders who have this specialized certification have obtained proof of their expertise in accident and trauma codes, as well as some knowledge of pain management and sedative treatments. Because this dynamic subfield requires you to work quickly on your feet, you’ll need to be very familiar with associated codes.
• Evaluation and Management (CEMC™): The healthcare industry relies upon a system of classifying codes not only to bill insurance companies, but also to track health information for planning purposes. Coding professionals in this specialization work to manage the costs incurred by medical offices and hospitals and help ensure quality treatment. As you’ll be tested on both billing regulations and your coding proficiency, you’ll do best after earning broad professional experience in the field.
• Family Practice (CFPC™): There’s a variety of health information that billers and coders must manage in family practice settings. You’ll need to understand general insurance reimbursement regulations and know how to accurately sequence codes when several procedures are performed together (as in an annual checkup.) You should also have general knowledge of pediatric medicine.
• Gastroenterology (CGIC™): Gastroenterology is the field that treats gastric disorders. You’ll need to be knowledgeable about each abdominal organ in order to code very specific conditions and procedures. You can expect to learn codes used for procedures such as ERCPs, colonoscopies, and esophageal dilations.
• General Surgery (CGSC™): This certification demonstrates your expertise in the field of billing and coding surgical procedures. With a variety of surgeries performed each day, you’ll be tasked with quickly and accurately transcribing operating room notes into codes. You’ll need to also understand the set of rules regarding private and public insurance reimbursement. The AAPC recommends that you complete this certification after having plenty of work experience as this exam is based on simulated coding scenarios.
• Hematology and Oncology (CHONC™): This certification signifies that you have an expertise in coding issues related to the treatment of cancers and blood disorders. These can include bone marrow treatments, chemotherapy and hydration, and blood tests. These procedures are particularly complex, requiring that billers sequence on-going care that requires a number of treatments. Insurance providers also have stipulations about compensation for surgeries and drug-based forms of disease treatment and management.
• Internal Medicine (CIMC™): Internal medicine is the treatment and prevention of adult diseases. You’ll have to be comfortable using codes to classify vaccinations, blood draws, and other minor procedures and surgeries. This specialty requires high attention to detail and accuracy, and your best preparation for the exam is real-world experience.
• Obstetrics Gynecology (COBGC™): This medical coding specialty requires training and experience working in women’s health. To manage the health records and information in an OB/GYN office, you’ll need to be familiar with the procedures used in prepartum, postpartum, and childbirth care. You’ll have to stay up-to-date on gynecological concerns and complex sets of regulations maintained by insurance providers.
• Orthopaedic Surgery (COSC™): Coding orthopaedic surgeries requires a basic familiarity of the anatomy of the human skeletal system and its functions, as well as its related surgeries. These include fracture repairs, spinal surgeries, and other types of procedures for a variety of disorders. You’ll also need to demonstrate knowledge of insurance and billing regulations, including Medicare rules regarding shared visits, teaching situations, and consultations.
• Otolaryngology (CENTC™): Billters who work in the ENT specialty (ear, nose, and throat) have to learn the diagnostic procedures and treatments used by ENT specialists, including nasopharyngoscopies, laryngoscopies, and sinus surgeries, The AAPC recommends having work experience in this field because it requires a familiarity with insurance regulations, Medicare, and billing procedures for common surgeries and procedures.
• Pediatrics (CPEDC™): Achieving this professional certification demonstrates that you have training and experience managing the health information of children. You will need to possess general knowledge of pediatric medicine, as well as common procedures (like immunizations.) Pediatric care also requires knowledge of a wide range of treatments, many including multiple procedures or visits. The examination for this certification is based on sample doctor’s notes, so it’s a great advantage to have professional experience.
• Plastics and Reconstructive Surgery (CPRC™): Coding procedures for this field of medicine can be complex because of the highly specific kinds of procedures and surgeries performed. Because this field is also the site of elective and cosmetic procedures, you’ll need to organize data accurately for patients who are undergoing restorative surgeries so their insurers can cover their expenses. Medical coders who have experience working with plastic surgeons are more likely to succeed on this certification examination.
• Rheumatology (CRHC™): Rheumatology is the study of the treatment of joint disorders, such as arthritis. Medical billers and coders who earn this certification demonstrate general knowledge of the procedures, treatments, and medical devices and equipment used in patient care. You will also need to have an understanding of Medicare and other forms of public and private insurance billing procedures. Rheumatologists work with patients over multiple visits, and treatment can be extensive, which requires rheumatology coders to keep track of repeat treatments.
• Surgical Foot and Ankle (CSFAC™): To earn this certification, you’ll have to develop knowledge of common foot and ankle problems, as well as their associated medical treatment options and equipment. You’ll have to turn doctor’s notes into codes that accurately convey the forms of treatment provided, and know the ins and outs of Medicare and insurance billing. The AAPC recommends that you have significant clinical experience as a coder in this subfield before taking the certification examination.
• Urology (CUC™): Medical coders working with urologists must develop an understanding of urinary tract issues for patients of both genders, as well as knowledge of male reproductive health issues. If you choose to specialize in this subfield of medicine, you’ll need to accurately code ancillary procedures performed in a urologists’ offices, such as injections and urinalysis. You’ll also have to be familiar with codes for procedures performed in hospitals, such as biopsies, cystoscopies, and prostatectomies.

AMBA certification

The American Medical Billing Association (AMBA) confers the title of Certified Medical Reimbursement Specialist to qualified individuals who pass its certification exam. AMBA also offers a certificate program that teaches medical terminology and ICD-9, ICD-10, CPT, and HCPCS standards for coding medical procedures. You’ll also learn about state and federal regulations, as well as insurance company policies and practices.

AMBA doesn’t recommend taking the exam unless you have on-the-job medical experience, or some other education in medical billing and coding. Continuing education and membership to the organization are also requirements of this certification.

AHIMA certification

The American Health Information Management Association (AHIMA) offers several general medical coding certifications, which demonstrate the proficiency and accuracy required to work in hospitals, clinics, nursing homes, care centers, and private coding businesses.

Certified Coding Assistant (CCA): This is the general-purpose certification for professional coders. The exam requires a high school diploma, but the association encourages medical coding experience or training. AHIMA also requires 20 continuing education units biannually, as well as a fee to remain certified.

Certified Coding Specialist (CCS): This certification is for coders who use their coding skills in a clinical environment, like large hospitals and research institutions. This designation requiresspecialized training and/or experience, and you’ll need to brush up on your accuracy and proficiency with code systems in order to pass the exam. You’ll also need 20 units of continuing education and a fee to remain certified.

Certified Coding Specialist – Physician-Based (CCS-P): This certification program emphasizes the coding used in physicians’ offices and private practice work environments. AHIMA recommends that you’ve had some combination of work experience or education in coding or managing health records and health information. Like the other AHIMA certifications, this also requires 20 continuing education units every other year (which can be earned from a variety of sources, so check the website for details.)

Pass the AAPC Certified Professional Coder Examination

The AAPC offers twenty-one specialty examinations in medical specialties, such as cardiology and pediatrics, which you can take without earning a CPC or other certification. These exams are conducted in the same way as the CPC exams, but the content can vary slightly. Take a look at the AAPC’s list of specialty credentials to see what coding and other topics you will need to study.

Planning for the Exam

As noted above, the AAPC offers three main medical coding certifications and a number of specialized additional certifications, all of which are earned by examination. All of these examinations are multiple-choice based in medical coding, with some access to a medical coding manual allowed. In addition, the CPC-P exam includes questions on health insurance reimbursement.

All of AAPC’s exams are structured in a similar way: 150 multiple-choice questions, with the exam proctored at a specific location. The subjects of those questions vary; a CPC exam covers most topics in a general sense, while the other exams get increasingly focused on specific skills. All their exams provide you with five hours and forty minutes to finish, as well as providing you with an opportunity to retake the exam once at no additional cost.

AAPC charges a set fee for each of their examinations, which includes membership in the group – $300, or $260 if you have joined AAPC as a student. There is no formal educational requirement, although AAPC recommends that you earn an associate’s degree. You will also need to have two years of experience as a medical biller and coder to be fully certified. However, if you complete the exam without this work experience, you will still receive certification as a coding apprentice (CPC-A, CPC-P-A, etc.) and will earn your full credential as long as you work in the field and complete continuing education.

When you arrive at the exam site, you will be permitted to bring coding manuals with you. Here’s what you can bring:

• A CPT book (AMA standard or professional edition); no other publisher’s work is allowed.
• An ICD-9-CM codebook of your choice.
• An HCPCS Level II codebook of your choice.
• Officially published corrections to any errors in the above books.
• For specialty exams only, relevant anatomical charts and sample worksheets for the specific field you are testing on; check the AAPC site for full details.

The questions in the exam are structured so that these books, as well as reasoning and understanding of medical terminology, anatomy and physiology, will permit you to succeed.

You will also need to continue studying in order to keep your certification, along with remaining a dues-paying member of AAPC. You will be expected to complete 36 Continuing Education Units (CEUs) every two years. This is less demanding than it may seem; you can earn a CEU each month by completing an small test in AAPC’s journal, and workshops, online webinars and conferences give you plenty of opportunities to make up the difference.

Preparing for the Exam

AAPC offers a range of exam preparation products, and there is a great deal of material on medical billing and coding available at bookstores. What’s more, you may already be studying medical billing and coding as well as related topics in formal courses at a school or other institution. Here are some tips that may help you prepare more effectively, as well as deal with other problems leading up to your certification exam.

• If you’re stressed by the prospect of an expensive exam, remember that your payment comes with one free retest. AAPC will provide you with a full report of how you performed, including exact scores and notation of areas where you need to focus your studies. It may be helpful to think of your first try as practice.
• Remember that you are permitted to bring in codebooks; you will not need to memorize the entire coding system you are being tested on, but instead you will need to know how to quickly and efficiently find out the codes you need. Focus your practice on learning to look up codes quickly and accurately, as well as on medical terminology.
• A powerful way to study uses flash cards. Write down the information you are studying on a series of them, and go through the entire stack. If you get one right, place it in the “once weekly” stack; if you get it wrong, place it in the “once daily” stack. Review the “once daily” stack daily, moving correct answers into the “once weekly” stack, and do the same for the “once weekly” stack. This combines regular review with a focus on what you truly need to cover.

Study Guides

These resources can help you prepare yourself for medical billing and coding certification. Some of these are unofficial and others are produced by the AAPC or other professional groups.

• Quizlet: Medical Billing and Coding – This resource provides you with free, student-made online “quizlets”. There is no cost for them, and you can be certain they were made to address genuine student needs.
• ICD9.chrisendres.com – A free and searchable guide to ICD-9’s code standards, which are the primary topic of your certification exams.
• Step-by-Step Medical Coding (2013 edition) – A guide to understanding medical coding by a veteran in the field. The latest update to a long series of yearly issues; earlier editions are still largely valid, although you should look up, and keep in mind, what changes have taken place in coding practice.
• Official CPC Certification Study Guide – Published by the AAPC and written by the same panel that writes the CPC exam, you can be certain this guide will tell you what you need to know. It includes sample questions of all sorts, a specially prepared study guide, and a series of practical examples.

Sample Tests

Taking practice examinations can help you find your own weak spots for further study, as well as having benefits as a learning practice in its own right. These are some sources for sample medical coding and billing tests, which will let you test your learning without pressure and at little or no cost.

• Ritecode.com: Medical Coding Consultants – These training specialists provide a wealth of resources on the AAPC certification exam and other medical coding topics. Look for the light blue entries to find the free resources.
• Career Coders: Test your Knowledge – These sample questions, provided by a medical billing and coding instructional company, let you test your knowledge in specific fields, such as ICD-9, Medicare/Medicaid, and medical terminology.
• AAPC – Online Practice Exams – AAPC offers a series of online practice exams in all of their certification, providing you with quick feedback, detailed explanations of the reasoning behind various questions’ answers, and as many retakes as you like. They are only available for a fee, although you will get a substantial discount with AAPC membership.

Convert CPT CODES to ICD-9 Codes for Medical Billing and Coding

Understanding Current Procedural Technology (CPT) Codes

Current Procedural Terminology (CPT) is a code set developed and maintained by the American Medical Association (AMA) that describes medical, surgical, and diagnostic procedures. CPT codes allow for uniform communication, research, and data analysis across local, regional, state, and national bodies. CPT Codes are updated annually on January 1.

Unlike ICD codes, CPT codes are trademarked by the AMA, making it impossible to find a comprehensive list of CPT codes online. But you should still know how to use them to look up procedures and understand their role in the medical billing and coding industry. These five-digit numeric codes identify medical procedures and services in a standardized manner, and are used by physicians, coders, health insurance companies, accreditation agencies, and patients. CPT codes can be used for financial, analytical, and administrative purposes, and are divided into three categories.

CPT Category I Codes

CPT is organized into three distinct categories. The first category, which is by far the largest of the three, contains codes for six subtypes of procedures. Much like ICD-9 and ICD-10, these procedural codes are organized into clusters, which are then subdivided into more specific ranges. For instance, codes for radiology fall in the number range of 70010 to 79999, and codes for a diagnostic ultrasound procedure fall into the range of 76506 to 76999. Within that number range, procedures have a designated code, ensuring healthcare payers record exactly which procedure a patient has undergone. For example, the codes 99213 and 99214, which you may have seen on your medical bill following a checkup, correspond to routine doctor’s visits (of simple and medium complexity, respectively).

As is the case with ICD-9 or ICD-10, the goal of CPT codes is to condense as much information as possible into a uniform language. CPT codes are designed to cover all kinds of procedures and are therefore very specific. For example, the code for a 45-minute session of psychotherapy with a patient and/or family member is 90834, while the code for a 60-minute session with a patient and/or family member is 90837.

CPT Category II Codes

The second section of CPT (Category II, or CPT II) consists of optional supplemental tracking codes. These codes are formatted with a letter as their fifth character, and are coded after the initial CPT code. These Category II codes include information on test results, patient status, and additional medical services performed within the larger Category I procedure. Like Category I codes, they are divided into clusters. CPT II codes for Patient Management, for example, fall into the 0500F-0575F range. While optional, these codes reduce the need for record abstraction and chart review, and lower the administrative burden on healthcare professionals. In addition to increasing efficiency, Category II CPT codes facilitate research and the collection of data related to the quality of patient care. Some codes also relate to state or federal law, as in the case of the codes 3044F-3046F, which document the blood alcohol level of a patient.

These codes are a supplement, not a substitute, for the codes in Category I, and therefore must always be attached to an existing Category I code. An example of a CPT code with a Category II code attached is 80061-3048F, which describes a test of low-density lipoprotein cholesterol (CPT I code 80061), with a result of less than 100 mg of cholesterol per deciliter (CPT II code 3048F).

CPT Category III Codes

The third section of the CPT code is devoted to new and emerging technologies or practices. Note that this code does not indicate that the service performed is ineffectual or purely experimental. A Category III code simply means the technology or service is new and data on it is being tracked. Like Category II codes, Category III CPT codes are numeric-alpha, meaning the last digit is a letter. After a predetermined period of time (typically five years of data tracking), a procedure or technology described by a Category III code may move into Category I, unless it is demonstrated that a Category III code is still needed.

Understand How CPT and ICD-9-CM Codes Interact

CPT codes work in tandem with ICD-9-CM codes to create a comprehensive picture of medical services rendered. ICD-9-CM codes, discussed in detail in Course 10, are numeric (and in certain cases alphanumeric) diagnostic codes that describe the symptoms, area, and type of injury or disease in a patient. When listed together, ICD-9-CM and CPT codes present a picture of both the diagnosis of an injury or disease and the type of service provided to the patient by the healthcare provider.

In some cases, it may be necessary to convert CPT codes to ICD-9-CM codes. ICD-9-CM’s alphanumeric codes describe the services, tests, consultations, and any other way that that a healthcare provider has interacted with a patient. There is often significant overlap between this set of codes and CPT. For instance, the CPT code for two doses of Hepatitis A vaccine, of pediatric or adolescent dosage, for intramuscular use is 90633. The ICD-9-CM code for that same vaccine is V05.3. In general, CPT codes provide more specificity than their ICD-9-CM counterparts. For instance, three doses of the above vaccine is coded in CPT as 90634, while in ICD-9-CM it is still coded as V05.3. Medical coders should familiarize themselves with the equivalencies between these two code systems, and be able to freely translate one into the other.

In addition to converting between these two codes, medical coders must ensure that the code they enter for a medical procedure (the CPT code) makes sense with the diagnosis code (ICD-9-CM). The two codes work in tandem to show which procedure was done for what reason. By confirming that the codes correspond correctly, coders ensure that a claim will not be denied and returned by a health insurance company. For instance, if you submitted a claim for a Human Papilloma Virus vaccine (CPT code 90650), but list the diagnosis as acute appendicitis with generalized peritonitis (ICD-9-CM code 540.0), a health insurance company would catch this error, deny the claim, and return it to you for correction. Lastly, the upcoming switch to ICD-10-CM on October 1, 2014, means that coders should also be able to convert CPT codes into ICD-10-CM codes.

Use CPT Codes to Determine Doctor Fees

CPT codes can be used to assess the actual costs of a procedure in terms of the doctor’s fees. While medical billers and coders have access to this information already, the AMA allows non-professionals and students the ability to use a free CPT lookup for one procedure at a time. This is done through theCodeManager system on the AMA website, which allows patients to enter an existing CPT code to determine the procedure or treatment or look up a CPT code by entering the procedure, which will allow you to assess the cost paid by Medicare for this procedure in your area. In addition, you can also determine the average cost of this service throughout the U.S.

Step-by-Step process for looking up CPT codes

The steps for looking up the cost of a treatment or procedure using the CodeManager system are simple.

1. Get Started. First, click the above link to enter the AMA CodeManager website.
2. Agree to play by the rules. You will have to read and click an agreement that stipulates that you do not sell the information you receive from the website, and that the number of times you can use this service are limited. To continue, hit the “Agree” button.
3. Specify your location. Next, the screen asks you to select the state and nearest city in which the procedure was performed,
4. Specify your procedure. Enter either the CPT code or keywords that describe the medical treatment or procedure you wish to look up.

Your query may not return anything right away, so use these tips to search successfully:

• Try a few different search terms. For example, if you were trying to determine the cost of surgery to remove a ruptured appendix, you could enter the keywords “appendectomy” or even just “appendix”, which would lead you to several possible procedures and their costs, including code 44960 for a simple appendectomy, as well as other codes describing unlisted procedures involving the appendix, examinations of that organ, and related surgical procedures.
• Use medical terminology. In most cases, procedures and body parts are described by their medical terms, so while a search for “hip replacement” will give you no hits, a search for “hip arthroplasty” will give you several options of possible procedures. Of course, if you have the CPT code you can enter it outright and it will take you straight to the relevant procedure.

Note that in the costs column, the medical payment listed can either be “non facility” or “facility”, depending on where the procedure was conducted. Facilities include hospitals, including emergency rooms, ambulatory surgical centers (ASCs), and skilled nursing facilities (SNFs), while non facility means any other setting, such as clinics or private practice offices. You may also notice that some procedures can only be conducted in a facility or non-facility setting, which means that the other column will have an “NA” or non-applicable label and no price.

Using RVUs to determine average costs

The medical payments listed are an average of the Medicare cost throughout the U.S. multiplied by the relative value amount (RVU) of a region, which may be higher or lower than 1.0. For example, the same procedure, such as an appendectomy (44950), is priced at $722.57 in Manhattan but only $642.29 throughout Arizona. This is due to the relative costs of goods and services in a region, and is reflected in CPU pricing.

It is also very important to note that the prices listed on the CodeManager website reflect the cost of a procedure paid by Medicare based on the Medicare Physician Fee Schedule (MPFS), which is very close to its actual cost, though the prices patients or insurance providers are typically charged more to account for the costs of the facility and its staff; This is particularly true of private medical institutions.

Medical Billing Errors

As a medical billing specialist, it’s critically important that you minimize any coding and processing errors as you file claims. Healthcare providers receive the majority of their revenue through the processing of successful claims, so any mistake you make could cost your employer. This course is designed to help you avoid the most common errors and keep denied and rejected claims at a minimum.

Understanding the Difference Between a Denied and a Rejected Claim

First, you need to know the difference between a denied claim and a rejected claim. A denied claim is one that has been determined by an insurance company to be unpayable. Typically, insurance companies explain the reasons in the Explanation of Benefits (EOBs) attached to the claim. Claims are often denied because of common billing errors or missing information, but can also be denied based on patient coverage. Denied claims can be appealed and reprocessed in some cases.

A rejected claim has been rejected because of errors. An insurance company might reject a claim because a medical billing specialist incorrectly input patient or insurance information. Once a medical billing specialist amends the errors on a rejected claim they can resubmit it for processing with an insurance company.

Common Errors Made When Filing a Claim

It is easy to overlook parts of a claim when you’re processing many in a given day. But if you can identify some of the more common mistakes medical billing specialists make, you can try to avoid them. Here are some of the most common mistakes made when filing a claim:

• Entering incorrect information for the provider (name, address, contact information, etc.)
• Entering incorrect information for the patient (name, sex, date of birth, insurance ID information, etc.)
• Entering incorrect information for the insurance provider (policy numbers, address, contact information, etc.)
• Inputting the wrong codes or confusing codes such as CPT codes, point of service codes, or ICD-9-CM codes
• Entering too few or too many digits for ICD-9-CM codes
• Inputting mismatched treatment and diagnostic codes
• Forgetting to input codes at all for services performed by a physician or another healthcare official

Again, every piece of information on a claim has to be accurate in order for it to be processed correctly. It is particularly important to make sure the correct codes are used. Be sure to familiarize yourself with all the relevant codes as well as patient, provider, and insurance information prior to filing a claim.

Other common billing errors include the following:

• Not having access to EOBs on denied claims: Sometimes an insurance company may forget to attach the EOB to a denied claim. In these cases, you won’t know the reason the claim was denied because the insurance company didn’t provide it at all or it was mistakenly sent to another provider. You can minimize problems with the EOB by keeping track of denied claims as soon as you receive them from insurance companies.
• Not verifying a patient’s insurance coverage: A patient’s health insurance can change at any time, sometimes without the patient knowing it. As a medical billing specialist, part of your job is to verify insurance coverage.
• Duplicate billing: Duplicate billing is an issue that occurs when you bill for the same service more than once. This might happen if more than one person at a provider’s office reports that a patient received services without checking whether or not those services had been paid for. The best way to avoid duplicate billing is for you to be extra vigilant about suspicious entries on a patient’s superbill and to communicate your concerns to a physician about them.

Some billing errors are simply beyond your control including the following:

• Upcoding: Upcoding occurs when physicians or medical coders enter codes into a patient’s superbill for services not received. Typically this is done to inflate the total amount a patient owes for receiving care at a healthcare provider. Upcoding is illegal and can lead to fines and criminal prosecution.
• Undercoding: Undercoding occurs when a physician or a medical coder leaves out codes from a patient’s superbill or codes them for less treatment than they actually received. Healthcare providers might undercode for healthcare services in an attempt to avoid audits or to minimize a patient’s cost. Undercoding is also illegal and can have legal repercussions.
• Sloppy documentation: Medical billing errors can also arise when physicians or other healthcare providers turn in sloppy documentation to medical billing specialists. A physician might have illegible handwriting, for example, making it hard to assign codes and bill for a patient’s healthcare. A physician’s documentation may also cause you to inadvertently undercode a patient’s bill.

How to Catch and Correct Errors Early

To avoid common medical billing: stay vigilant about simple mistakes on your end, be thorough when reviewing a patient’s superbill, and consult with your physician whenever you have questions about what should or shouldn’t be billed for. Most medical billing errors can be avoided well before claims are sent for processing with an insurance company, and it’s up to you to keep the claims moving through the system quickly and accurately. Here are a few tips to help you stay on track:

• Coordinate with everyone at the provider’s office: You aren’t the only person responsible for the information you in a claim. The physician who administered the actual healthcare and the personnel who collected a patient’s co-pay and insurance information also contributed to the superbill. So if you have any concerns about a claim, you can check with them to work out any issues before submitting the claim.
• Double-check patient and insurance information before filing a claim: Entering patient and insurance information incorrectly is one of the easier mistakes to avoid, but they still happen. The strategy for avoiding this mistake is simple: double-check your work.
• Study billing and coding trends: You can guard against coding mistakes by staying up to date on the latest medical billing codes. Medical billing codes change over time to accommodate modifications in healthcare regulations, newfound illnesses, and new treatments for illnesses and conditions. Be sure to study new codes and billing procedures as they become available.
• Follow up on claims: You can avoid and anticipate errors by following up on claims filed with insurance companies. A representative working on the claim for the insurance company might be able to tell you of any errors they find on their end, and thereby provide you with an opportunity to resubmit a claim before it gets denied.

Health Insurance Providers

Government Insurance Providers

The federal and state governments fund and operate several government insurance providers. Many of the government-operated insurance programs are specifically designed to cover a certain part of the population, such as veterans, the elderly, or low-income persons. Below are some of the government insurance providers that you will encounter when filing claims:

• Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA): This government program covers certain healthcare costs for dependents of veterans who are permanently disabled due to injuries or conditions suffered during service, as well as dependents of veterans who died during service.
• Consolidated Omnibus Recollection Act (COBRA): COBRA was a law passed by the federal government to serve as a safety net for individuals recently terminated by a company that provided health insurance. Under COBRA, terminated employees and their dependents can still receive health insurance from their previous company’s healthcare plan for up 18 months, and up to 36 months if they are disabled.
• Medicare: Medicare is a program started by the federal government to provide healthcare coverage options for persons over 65 years old, as well as younger people with disabilities. The Medicare program itself is broken up into several parts, each of which provides insurance that covers certain aspects of healthcare (such as prescription drug coverage) to eligible individuals.
• Medicaid: Medicaid is a program started by the federal government to offer healthcare coverage to low-income individuals. The costs of the Medicaid program are divided between the state and federal governments, a complication you will need to be aware of as you file claims. Note that all states have their own version of a Medicaid program, though they all must meet minimum requirements of care as established by the federal government.
• Children’s Health Insurance Program (CHIP): This program provides health insurance to children of families who can’t afford private coverage and whose incomes are too high to receive Medicaid coverage. CHIP is jointly funded by state and federal governments just like Medicaid, and each state has a different interpretation of its program.
• TRICARE: This healthcare program provides insurance to active-service members and their families, retired military personnel and their families, and the survivors of deceased service members. TRICARE (formerly known as Civilian Health and Medical Program of the Uniformed Services, or CHAMPUS) is funded and run by the federal government.
• Worker’s Compensation Insurance: This type of health insurance is available for employees who suffer injuries or illnesses while performing their regular work duties. Worker’s compensation insurance is required by law in most states.

There are other federal and state insurance programs available to those who are eligible, but those mentioned above make up the majority that you will encounter as a medical billing specialist. Check out the federal government’s resource for more information about government insurance providers.

Commercial Insurance Providers

Commercial insurance providers are private insurance companies that contract with businesses or individuals to help cover healthcare costs according to criteria set forth in a formal health plan. Private health insurance plans typically require that the company or the individual receiving coverage pay a predetermined deductible or a monthly premium before benefits take effect.

Commercial health insurance providers offer plans that can be sold individually or collectively as a group plan. Plans offered by commercial insurance providers range in price and in the scope of services covered. Coverage from commercial providers depends on a number of factors, including a patient’s personal medical history, family medical history, and the amount of money the patient (or the sponsoring employer) is willing to spend on premiums, co-pays, and deductibles.

Most Americans who have health insurance have plans with private insurers. According to a recent survey by the Center for Disease Control, nearly 64.2% of insured Americans have private health insurance. Commercial insurance providers include companies like Aetna, United Health Care, and Prudential.

Key Differences Between Government and Commercial Insurance Providers

It is important to keep in mind that commercial insurance providers are for-profit institutions whose success depends on the premiums that they receive from insured businesses and individuals. As such, commercial insurance providers are likely to provide coverage for people who have an uneventful medical history rather than someone with a long history of medical problems. Commercial insurance providers make money by avoiding as much risk as possible in their health plans. If a private insurance company mostly covers people who need constant medical attention for chronic illnesses or conditions, that company would be in danger of offsetting the revenue generated by its premiums.

Government insurance providers are a reliable alternative for certain people denied coverage by commercial insurance providers. Because government insurance providers aren’t interested in generating a profit from premiums, they can afford to cover “riskier” people.

About Blue Cross Blue Shield

Blue Cross Blue Shield is an exception to typical health insurance providers because it is neither a for-profit privately owned company nor a program run by the federal government. Blue Cross Blue Shield is a federation of 38 independent health insurance companies across the U.S. that covers over 100 million Americans. Blue Cross Blue Shield has partnered with a number of government insurance providers like Medicare to help process claims associated with Parts A and B of Medicare coverage. Blue Cross Blue Shield companies also enroll in the Federal Employee Program (FEP), providing private health insurance to over 5 million federal employees. As a medical billing specialist, you should become more familiar with Blue Cross Blue Shield’s role in the American healthcare system.

Types of Health Insurance Coverage

There are a number of ways in which health insurance carriers provide coverage. Health insurance coverage can be quite complex, as it involves the coordination between a healthcare provider, the health insurance provider, and the actual person receiving care. As a medical billing specialist, you will need to be especially aware of the role that each party plays in these coverage plans as you process claims. Some of the methods of coverage include managed care, indemnity policies, and high-deductible plans.

Managed care

Managed care is the most common form of health insurance coverage. Managed care coverage is administered by organizations that contract with healthcare providers to create an active network of participating providers. The three main components of managed care are preferred provider organizations, health maintenance organizations, and point of service plans.

• Preferred provider organizations (PPOs): PPOs operate off a list of preferred healthcare providers that patients can choose from for their coverage. Patients save the most money on their healthcare plans by selecting the preferred providers affiliated with a PPO. Providers on the preferred list are considered “in-network,” while those not on the preferred list are “out-of-network” providers. Sometimes an insurance carrier will not cover a person who receives treatment from an out-of-network provider, though PPOs tend to have more coverage options for out-of-network providers than HMOs.
• Health maintenance organizations (HMOs): HMOs are groups of physicians, medical facilities, and healthcare services that work to keep patients under the care of providers within their network. Healthcare providers in HMOs coordinate a patient’s healthcare decisions and suggest a suitable hospital for urgent care. Because of the close-knit healthcare community in HMOs, members enrolled with these organizations tend to have limited provider options. The upside to HMO membership is that patients tend to pay less in deductibles and receive higher quality medical care coverage at facilities within the HMO network.
• Point-of-service Plans: Point-of-service plans form a hybrid between PPOs and HMOs. As with HMOs, point-of-service plans allow you to select physicians and services from within a dedicated network of providers. Unlike HMOs, you have the option of coverage for care received from out-of-network providers. Note that patients in point-of-service plans have to get a referral before being covered by out-of-network providers, and they likely have to pay a deductible. Some HMOs offer point-of-service plans to people who want more options with their healthcare coverage.

Indemnity policies

Indemnity policies, or fee-for-service insurance, allows people the freedom to choose whatever healthcare provider they want and receive some form of coverage for these services. Patients covered by an indemnity policy can go to any healthcare provider and receive care, even when traveling across state lines.

The caveat to indemnity policies is that patients are typically required to pay a deductible or out-of-pocket fee before they start to receive coverage. This means patients with an indemnity policy can able to receive emergency room care at a hospital of their choosing, but they might have to pay a sizable deductible (ranging from a few hundred to several thousand dollars) before insurance carriers will pay for their care. Many indemnity policies allow patients to choose how much they pay for their deductible, and that amount is commensurate with the level of coverage they receive from insurance carriers.

High-deductible plans

High-deductible plans have low premiums and high deductibles, which make them enticing to those who don’t want to pay for health insurance up front. High-deductible plans may be a preferable coverage option for people with a clean bill of health who don’t anticipate requiring any medical services in the near future. Of course, when those with a high-deductible plan do require care, they are responsible for covering the cost of their care until they reach the predetermined deductible. However, people with high-deductible plans don’t have to pay the deductible before receiving coverage for preventive care services. Some people opt to enroll in health savings accounts or health reimbursement arrangements to help mitigate the potential costs of high-deductible plans:

• Health savings account (HSA): HSAs allow people to pay for certain medical expenses (including expenses incurred before meeting a deductible) using nontaxed funds. Patients build their savings in an HSA by contributing a portion of their paycheck or other earnings on a regular basis. Funds that remain at the end of the year can often be rolled over to the next year. Furthermore, people with an HSA keep their funds once they leave a job and can continue contributing to their HSA with their next employer. However, there is a limit to the amount of earnings that can be contributed to an HSA.
• Health reimbursement arrangement (HRA): HRAs are different from HSAs in that employers, not the employees, contribute funds to the account that is used to offset healthcare costs. Employees lose their HRA funds if they leave or are terminated from a company, and any funds unused by the end of the year are no longer accessible in the following year.