Many practices are stymied by the difference between a “biller” and a “coder”. Why would a practice need both? Are there any other alternatives?
Well, there is a major difference and it is possible to find one person who can do both…if you are lucky!
A “Coder” is trained in CPT and Medicare coding guidelines. They should understand Documentation Guidelines in determining coding for Evaluation and Management services. In addition, they are trained in coding HCPCS and ICD-9, as well. The coder is usually more “black and white”, they look at coding as somewhat of an exact science. The problem that I see is when you put five coders in the same room and ask them to code the same thing, you will probably have five different answers!
The “Biller” will be more the “gray-area” thinker. They see how claims are paid by each health plan. They know that each health plan has their own reimbursement policies and that the “rules” are consistently inconsistent. They may not be as well versed in the exact coding of services, but they know how each health plan reimburses specific codes and coding combinations. If I have a question regarding how a specific health plan reimburses an office visit on the same day as a preventive medicine visit, I will ask my Biller.
Typically, you will find that an employee has either a “coder” or “biller” perspective. Each are good and needed by physicians; however, there are some people out there who have both perspectives and they are Golden! If a practice is fortunate enough to bring on an employee with both viewpoints, they will have a valuable asset on staff.
conundrum 
I absolutely agree with this. I have seen it with my own eyes. Just wanted to comment.
Most people do not understand the difference (including many coders), so your blog will hopefully enlighten many. Please keep it up.
Don
Now I can show this to our billers and make them understand that I just cant go in there and change a code just to make the claim pass. I have a credential to protect and they don’t. That ha always been our argument. They really don’t understand what is at stake.
Ray
Although I agree with most of what you are saying, especially the fact about the credential since I also am Certified; however, there are some occasions when changing a code would be appropriate. For example, if a claim goes out with V70.0 General Medical Examination, but the patient has an EKG and has hypertension. The EKG should be changed to show the diagnosis for the hypertension. Another example is when a woman is having her breast, pelvic and Pap; some plans will allow the G0101 & Q0091 and others will allow S0610-2 and Q0091. A biller would know which plans reimburse for one combination or another, or which plans don’t reimburse when coded with a preventive medicine visit 9938x-9939x.
My point is that Coders and Billers have a place and both should communicate their knowledge and experience to one another. The insurance industry is not “black and white”…it is very “gray”.
Point well taken. I am refering to Medicare and LCDs for medical necessity. Example procedures that dont meet med. nec. such as Rhizotomy,etc. with no documentation or queries that don’t meet the med. nec.
I am a biller and a fairly new coder and I just wanted to add some input if I may. I understand medical necessity. A good biller should know what Medicare does not cover and should inform your nursing staff. What Medicare does not cover, an ABN should be signed before the procedure is even done. Then, your biller should have a modifier informing Medicare that the patient signed the ABN. It is my understanding that if the ABN is not signed for a Medicare patient, you cannot bill that Medicare patient. I have also found that many procedures that were denied by Medicare as not medically necessary were because they were billed under the wrong codes. Medicare uses many HCPCS for procedures. If your biller is using the same CPT codes that they would for BCBS, you most likely will get a denial for not medically necessary from Medicare. I hope that I have helped or enlightened the topic.
Well, I am both, a coder and a biller. One thing our organization has done and shows an incredible opportunity for many of us is to bundle both positions, for example. We do have a Biller (OPAR) and we have a coder for each clinic and each specialty. So the benefit is for me you get cross training. We “the Coders” make sure our physicians meet the CMS and Medicare (government) compliance guideline, rules and regulations and we all know must Commercial Carriers follow the same guidelines. It is true that many Commercial Insurance “pass” certain claim in a way they get into the “gray area”, but not necessarily because it was paid it mean it is correct. Our billers knows this and if they are unsure of a claim or are uncomfortable “letting it go” even when they know will get paid they also know is incorrect then we all meet and discusses the issue and also consult with the carrier. Having both in any practice is the safest way for a physician office, you do deserve to get paid for the work you do if the physician office can have 2 positions fill by one person it is great and cheap but at the end is a lot better if you have to brains making sure no dollar is walking out of your door and doing it CORRECTLY.
Thanks Charlene, this is very helpful.
Hi, very interesting post, greetings from Greece!
Thank you for such good comments from every one, i am a medical coder,but we are working as a team with billing guys and always try to enhance the communication,which on the whole is very good for any Doctor to get good reimbursement.Both are different but working for the same cause.
Hi there, I enjoy reading all of your article post.
I wanted to write a little comment to support you.