As the healthcare industry is so complex and the process of medical coding and medical billing both are important for making sure providers get paid timely and that patients’ records are properly maintained. These two processes are closely related to each other, but they fulfill very different functions within healthcare revenue cycle management. And if you’re new in the healthcare profession, it’s important that you understand the differences between these two and the distinct roles they play in healthcare provider finances. Although they might sound similar, medical coding and medical billing; but they aren’t the same in the healthcare system. So, what exactly sets them apart?

In this blog, we’ll break down the key differences between medical billing and medical coding to help you understand their unique roles in the healthcare organization.

What is Medical Billing?

Medical billing is the process of submitting and following up on claims with health insurance companies to ensure healthcare providers receive payment for their services. After a patient receives health care, a medical biller’s job begins. Basically, medical billing is divided into two categories: front-end and back-end. Front-end billing tasks include initial documentation and patient information collection before the services are provided like: patient demographics, insurance eligibility, and prior-authorization. 

Back-end billing occurs after the healthcare services are provided by the provider. Once billing teams receive the medical codes describing a patient visit, they generate an itemized claim , and submit it to insurance companies for reimbursement. After the claim is sent, medical billing specialists keep a track for all the unpaid claims and other unfulfilled invoices until the provider receives full-payment. Billers also finalize all details and send out final statements for remaining balances to the patient with proper invoices. 

Ideally, medical billers ensure providers are reimbursed with secure payments while minimizing the chances of claim being denied and also optimize revenue for medical practices. As these billing is usually performed by certified medical billing specialists under strict code of information, and confidentiality that must be observed between providers and those who process insurance claims. 

Key Responsibilities of a Medical Billers:

• Preparing and Submitting Claims: Specialist medical billers ensure that the claims for healthcare services are correctly filled out and timely sent to the appropriate insurance companies or government programs like Medicare and Medicaid.
• Verifying Insurance Information: Billers confirm that the patient’s insurance coverage is valid and active to prevent any delays in payment process.
• Claim Follow-Up, Dispute Resolution: Billers also monitor the claims after submission to ensure they’re processed accurately. With their strong knowledge of medical terminology, coding, and insurance guidelines. They can also easily resolve any issue or delay in the claim process, while communicating with the insurance company directly.
• Handling Patient Billing Inquiries: They also handle patient questions and queries regarding their bills, payments, and insurance claims.
  

What is Medical Coding?

While medical billing involves the financial side of healthcare administration, medical coding deals with the clinical and technical aspects. Medical coding is the process of translating diagnoses, procedures, medical services, and equipment used during patient care into standardized codes set. These alphanumeric codes are used to create accurate records for patient treatment and billing purposes. 

Accurate medical coding is important for healthcare providers to ensure a timely reimbursement process and can also impact the quality of patient care. This coding specialist must be trained and certified while having all the necessary knowledge of medical terminologies, annual updates and changes in the medical code system.

Classification of Medical Codes: 

Medical coding used three main types of standardized codes to ensure accurate billing and clean-claim submission process. Standardized medical billing codes are categorized as follow:

• CPT Codes (Current Procedural Terminology) used to describe medical procedures and services rendered by the healthcare provider. 
• ICD Codes (International Classification of Diseases) are used to classify diseases conditions, and other health-related problems.
• HCPCS Codes (Healthcare Common Procedure Coding System) are primarily for medical services, supplies, tools, and durable medical equipment that are not covered under CPT codes.  

Key Responsibilities of Medical Coders:

• Assigning Codes to Diagnoses and Procedures: Coders must accurately translate a physician’s notes and medical documentation into alphanumeric codes that represent diagnoses, treatments, surgeries, and other services provided to the patient.
• Ensuring Compliance: Coders need to ensure that the coding is accurate and compliant with both federal laws, regulations, and insurance requirements.
• Collaboration with Healthcare Providers: Coders often communicate with physicians and other healthcare providers to clarify document information if needed.
• Maintaining Records: Coders help maintain detailed, accurate patient records by using standardized codes for diagnosis and treatment.
  

What is the difference between Medical Billing and Coding?

Medical billing and coding both are two important aspects of the healthcare system that closely work together to ensure patients receive appropriate quality care and providers get paid faster for their services. But they still have some common differences as follow: 

Aspect	Medical Billing	Medical Coding
Primary Focused	Ensures healthcare providers receive timely payment for their services, with complete patient satisfaction.	Accurately translates healthcare services and diagnoses into standardized codes.
Workflow	Takes over after coding; prepares claims using codes and submits them for reimbursement.	Comes first; assigns appropriate codes to diagnoses and procedures based on medical records.
Claim Management	Investigate denied, delayed, and rejected claims.	Performing medical chart audits when claim is denied
Skilled Requirement	Strong communication skills, attention to detail, knowledge of health insurance policies and compliances.	Solid understanding of medical terminology, anatomy, and coding systems (ICD, CPT, HCPCS). Precision and technical skills required.
Certifications	Often holds certifications like Certified Billing and Coding Specialist (CBCS).	May hold certifications like Certified Professional Coder (CPC) from AAPC.

How Billing and Coding Work Together

Although distinct, medical billing and coding are important for maintaining accurate patient records, ensuring smooth communication among healthcare providers, and managing overall healthcare financial costs. The process begins with medical coders, who review the patient’s treatment and assign codes based on the services provided. Once coding is complete, medical billers step in to use these codes to create and submit insurance claims for reimbursement, which helps to maintain financial stability.

Final Thoughts 

While medical billing and coding are often grouped together, they have distinct roles with different purposes to serve in the healthcare department. Medical billers are responsible for ensuring healthcare providers receive payment for their services, while medical coders are tasked with converting medical information into standardized codes. Both of these are important for maximizing healthcare revenue cycle, and understanding the differences between them is essential.

But if you find medical billing and coding challenging and time-consuming, outsourcing to a reliable and professional company like Nexus io can help minimize your administrative burden. Our medical billing services are handled by a team of highly trained and experienced billing and coding specialists who have a deep understanding of the latest coding systems, regulations, and industry best practices.