medical coding exam 1

Lecture Notes

EMPLOYMENT, FACILITIES, JOB TITLES, PROFESSIONAL MEMBERSHIPS, AND CERTIFICATIONS

Health insurance has been evolving since the late 1920s and early 1930s. Some of the most dramatic changes, such as employer-sponsored health plans, occurred as a result of World War II. In the 1950s, demand for medical and health insurance surged. Many new insurance companies were born, with each organization having its own unique billing procedures and requirements.

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Much confusion resulted from the explosive growth of new insurance companies. With all the hospitals and doctors across the country using different terminology and procedures, it became necessary to implement a standardized system. Coding became the method of choice for providing standardized data. Coding is simply translating words that describe procedures or diagnoses into numbers, and in some cases, alphanumeric combinations. These numbers (codes) provide a uniform language for everyone. They’re defined in coding books, just as words are defined in a dictionary. These codes will become very important to you as a medical insurance billing specialist. You’ll spend much time and energy during this course learning how to use these codes, and they’ll become a second language to you once you use them regularly in your job.

We’ve already established that the complexities of the health insurance and medical care industries require standardized coding systems. But, what are these systems? Actually, there are two main systems. One coding system uses a publication called the International Classification of Diseases, or the ICD-10-CM. The ICD-10-CM system is used to code diagnoses and procedures that describe the patient’s clinical picture.

The second coding system uses a publication called the Current Procedural Terminology, or CPT. The CPT coding system is used by providers (e.g., physicians, hospitals, therapists) to report procedures and services performed. CPT codes are only one part of an entire coding structure known as HCPCS (Health Care Financing Administration Common Procedure Coding System, pronounced “HIC-pics”).

Don’t worry if you don’t understand these systems and how they’re used. We’ll be discussing them in more detail throughout this course along with explanations of the medical billing specialist’s roles and responsibilities, the development of government-sponsored) programs, and the rise of managed care plans.

Demand in Healthcare Careers

No matter the state of the economy, many healthcare careers remain in high demand. Even if the economy is in a decline, people still get sick, so there’s still a need for healthcare workers. Additionally, the need for health information professionals such as billers and coders is increasing. Isn’t that great news?

According to the Bureau of Labor and Statistics, jobs for health information professionals such as billers and coders are expected to increase 13% through 2026, faster than the average for other occupations. Additionally, the demand for healthcare careers is expected to continue to increase as the population ages.

Healthcare professionals have the opportunity to work in many different healthcare environments, including

  • Physician practices
  • Multispecialty clinics
  • Hospitals
  • Billing offices

Job Titles and Responsibilities

The responsibilities of medical office specialists vary based on the type of organization and the specific position. For example, medical office specialists will probably service different roles if they work for a private practice versus a large healthcare system. Common job titles for people who work in medical coding include

  • Medical office assistant
  • Medical biller
  • Medical coder
  • Registered health information technician
  • Payment poster
  • Medical collector
  • Refund specialist
  • Insurance verification representative
  • Admitting clerk or front desk representative
  • Privacy compliance officer

In some facilities, you may fulfill the responsibilities across several of these job titles. However, in larger facilities, it’s likely that one person fulfills each role. In many physician offices, the medical coder and the medical biller jobs may be staffed by the same person because these positions are so closely related. We’ll discuss these roles in more detail later in the course.

Importance of Professional Memberships

Professional organizations are an important part of your healthcare career. They require you to stay up to date on your skills and knowledge, and they can also help you understand changes in the medical industry. Once you’ve completed the educational component, you should voluntarily join a professional organization. The type of organization you join will depend on your career goals and specialty. For example, the American Health Information Management Association (AHIMA) is a well-known and trusted professional organization for the health information management industry.

Professional organizations sometimes provide credentials, or the ability for different healthcare professionals to prove their level of expertise and commitment to their profession. Receiving a certification is a voluntary process that professionals can choose to receive once they go through a period of schooling or training or have received a degree. Although you don’t have to receive a certification to work in this field, it does show a level of dedication and commitment, so many healthcare organizations today look for a certification in addition to the completion of schooling.

Through AHIMA, health information management professionals can receive various voluntary credentials, including the following:

  • Certified Coding Associate (CCA)
  • Certified Coding Specialist (CCS)
  • Registered Health Information Technician (RHIT)
  • Registered Health Information Administrator (RHIA)

Other professional organizations also provide credentials. The National Healthcareer Association (NHA) provides the Certified Electronic Health Records Specialist (CEHRS) credential, and the American Academy of Professional Coders (AAPC) provides credentials such as the Certified Professional Coder (CPC) and Certified Professional Coder, Hospital-Based (CPC-H).

Be sure to review Table 1.1 in your textbook for an overview of facilities, jobs, and corresponding certifications.

Professional Credentials

One of benefits of joining a professional organization is that you have the opportunity to receive a professional credential. Obtaining a professional credential may offer the following benefits:

  • More job opportunities
  • Higher salary
  • Wider variety of job opportunities

We’ve briefly mentioned some of the organizations and credentials they provide. Now let’s take a closer look at some of the professional organization credentials available in the medical billing and coding industry.

AHIMA

AHIMA offers the following credentials in health information management (HIM):

  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)

Note that these credentials require either an associate’s degree or a bachelor’s degree, with an emphasis in health information technology/administration.

AHIMA also offers credentials specifically for coding professionals:

  • Certified Coding Associate (CCA)
  • Certified Coding Specialist (CCS)
  • Certified Coding Specialist-Physician-based (CCS-P)

The CCA credential is a good initial certification in the field of medical coding. At least two years of work experience is required to apply for the CCS and CCS-P credentials.

AHIMA also offers the following specialty credentials:

  • Certified Documentation Improvement Practitioner (CDIP)
  • Certified Health Data Analyst (CHDA)
  • Certified in Healthcare Privacy and Security (CHPS)
  • Certified Healthcare Technology Specialist (CHTS)
  • Certified Professional in Health Informatics (CPHI)

To be eligible to sit for these certification exams, a candidate must have at least a baccalaureate degree and two to four years of experience in healthcare management.

AAPC

The AAPC offers the following certifications:

  • Certified Professional Coder (CPC)
  • Certified Outpatient Coder (COC)
  • Certified Inpatient Coder (CIC)
  • Certified Risk Adjustment Coder (CRC)
  • Certified Professional Coder-Payer (CPC-P)
  • Certified Professional Biller (CPB)
  • Certified Professional Medical Auditor (CPMA)
  • Certified Professional Compliance Officer (CPCO)
  • Certified Physician Practice Manager (CPPM)
  • Certified Documentation Expert Outpatient (CDEO)

The AAPC also offers a variety of different specialty certifications that are tailored to a specific area like internal medicine, ambulatory surgery, dermatology and more.

An AAPC-certified coder is the first line of defense against noncompliance and downcoding for any medical provider. Certified coders can help prevent legal difficulties and ensure that providers receive full reimbursement in a timely manner.

Because there are distinct differences in CPT coding for physician services versus outpatient facility services, the AAPC has two accreditation examinations to meet this need: the CPC for physician coding and the COC for outpatient facility coding. To be eligible to apply for these certification exams, a candidate must have at least two years of work experience in medical coding.

As you’ve read, there are many different organizations with different types of credentialing. We’ve provided these as examples. Prior to seeking professional credentialing, you should thoroughly investigate the organization and how the credentials may or may not benefit you so that you ensure the best credential for your job role.

Your role in health care and how dedicated you are to your career are very important. Changes in health care over the years have required healthcare professionals to step up and take their roles more seriously. These changes have also created an increasing demand for specialized medical coding, billing, and office personnel. This, in turn, has opened new doors for our specialized field in health care and will create more opportunities for many.

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