November 30, 2012 by Holly Cassano

What Are A Medical Billers and Coder’s Daily Responsibilities?

Medical billers and coders assist with the business side of medicine by performing various data management tasks, either in a facility or outpatient/office setting. Coders translate diagnosis and procedures from patient encounters extracted from the medical record into correlating codes used in databases, for insurance reimbursement, and maintain a patient’s medical history.

A medical billing and coding specialist’s daily responsibilities generally include many of the following functions (list is not all inclusive):

  • Organizing and maintaining a clinical database
  • Retrieving patient records
  • Reviewing medical information with medical personnel
  • Working with the billing office to ensure the accuracy of patient records
  • Running and interpreting reports to identify trends/problems with rejected claims
  • Reviewing claim denials
  • Knowing CPT-4 procedure codes
  • Knowing ICD-9 diagnosis codes
  • Knowing HCPCS codes
  • Knowing modifiers
  • Knowing Office of the Inspector General (OIG) Compliance Guidelines regarding health care fraud and abuse

I will discuss a few of these on the list that are part of the day-to-day workflow processes in a coder’s life.

CPT-4 and ICD-9 codes are used by coders daily to help them tell a patient’s story to the payers via submitted claims. These codes are reviewed by the payers to aid in determining reimbursement back to a provider for the services rendered to members/patients of the payer/plan. CPT-4 and ICD-9 codes are the universal language for standardized medical billing and coding for all providers and payers.

ICD-9 codes represent the International Statistical Classification of Diseases and CPT-4 represents the Current Procedural Terminology. The WHO (World Health Organization) publishes ICD-9 codes and they are available for free to the health care community, unlike CPT-4 codes which are copyrighted by the American Medical Association (AMA). ICD-9 codes are represented with alphanumeric codes that indicate a patient’s diagnosis. CPT-4 codes are also alphanumerical and are used to represent a procedure or service provided by a health care clinician.

CPT modifiers provide additional information to payers that indicate a certain type or reason for a procedure or visit and modifying factors above and beyond a normal visit. These modifiers were developed by the AMA and Centers for Medicare & Medicaid Services (CMS) and are also copyrighted by the AMA. Modifiers are generally tied to reimbursement and it is the final coding process for claims submission. Modifiers are listed under Appendix A in the CPT-4 book.

Medical billing and coding professionals must also be aware of the increasing trend in erroneous claims being submitted as part of their responsibilities and so the OIG (Office of Inspector General) put together Compliance Guidelines in an effort to assist the health care community, and identify and prevent health care fraud and abuse. These guidelines were written for individual and small group practices and can be found in the Federal Register (Vol. 65, No. 194).

Part of the OIG’s Compliance Guidance includes Seven Elements for a Compliance Program and include the following guidelines:

  • Written polices and standards of conduct
  • Designating a compliance officer
  • Conducting training
  • Developing effective lines of communication
  • Enforcing standards using discipline
  • Internal monitoring and auditing
  • Prompt response to offenses and developing corrective action

Remember: At the end of the day, it is up to you to stay updated and informed of changes in medical billing and coding. These responsibilities may change depending on the size of the workplace and type of setting and so you should be prepared accordingly. It may be that a larger facility might employ specialists to deal with the large volume of work that needs to be done and a smaller setting would have less staff that handle multiple tasks. Knowledge is power.

Happy Coding!


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