Medical Coding and Billing Certification: What to Know

Many behind-the-scenes positions help run the healthcare industry. One such role is a medical coder and biller. These professionals support communication between healthcare providers and payers, also playing a part in the healthcare reimbursement process.

Medical billing and coding classes can prepare individuals for this role, and some pursue industry certification to demonstrate their expertise. Here, we cover what you need to know about medical coding and billing certification, and how you can get started on this career path.

First, What Is a Medical Coder and Biller?

Before you decide to pursue a medical biller and coder career , it’s important to understand what someone in this role does. Technically, this position is two job functions rolled into one, although some healthcare organizations hire one professional to perform both sets of duties.

• Medical coders help translate the medical world into a common language shared between healthcare providers, insurers, statisticians, and others. These codes help stakeholders understand what conditions and services are associated with a patient’s medical visit, which involves assigning universal identifiers to each diagnosis, illness, injury, procedure, and treatment.
• Medical billers help healthcare facilities get reimbursed for products and services rendered. This specialist prepares and sends invoices for payment, verifying that all aspects of a hospital admission, office appointment, or other medical visit have been properly coded before submitting the claim to an insurance company, Medicare, Medicaid, or another payer. If a claim is rejected, the medical biller is responsible for resolving the issue and resubmitting the claim.

Both medical coding and billing job functions support healthcare reimbursement efficiency. Without a coder, an insurance company might not be clear what is being billed for, so it may deny the claim. Without a biller, the healthcare provider might not get paid.

Importance of Medical Coding and Billing Certification

Employers hiring for medical billing and coding roles may want to verify that candidates understand medical terminology and applicable coding systems. So, they might look for individuals with medical coding and billing certification.

The three coding systems commonly used by medical billers and coders are:

• Current Procedural Terminology (CPT) codes: These identify procedures like office visits, physical examinations, flu shots, and more.I
• nternational Classification of Diseases (ICD) codes: These indicate diagnoses like diseases of the digestive or nervous systems, pregnancy complications, injuries, and more.
• Healthcare Common Procedure Coding System (HCPCS) Level II codes: These represent devices and supplies like prosthetics and durable medical equipment, as well as non-physician services like ambulance transportation.

Insurance companies use medical codes within these systems to determine the amount of reimbursement a healthcare provider receives for products or services provided to patients. The use of standardized codes ensures an orderly and consistent claims process.¹

Medical Billing and Coding Certification: The CPC Exam

To achieve industry certification, you must demonstrate your knowledge by passing an exam administered by a major certifying body. The AAPC, originally known as the American Academy of Professional Coders, administers the Certified Professional Coder (CPC) exam, which covers the healthcare industry’s most used code sets.

Benefits of CPC certification

Some employers prefer to hire candidates with medical coding and billing certification. The CPC credential from the AAPC is widely recognized² and signifies that a candidate should know how to:

• Review patient records and assign the correct medical codes for symptoms, tests, treatments, diagnoses, medical products, and other services
• Apply knowledge of medical coding rules, procedures, compliance, and reimbursementManage issues related to claims denials, medically necessary procedures, and bundling
• Understand key medical terminology, anatomy, and physiology

About the CPC examination

The CPC certification exam consists of 100 multiple-choice questions and must be completed in four hours. It is designed to evaluate the candidate’s knowledge in 17 areas, including their ability to apply the proper codes, and requires a 70% or higher to pass.³ You can take the exam in person at a testing center or remotely with a live proctor who monitors you via webcam during the test.

CPC certification exam eligibility

To sit for the CPC exam, learners must meet the AAPC’s CPC eligibility criteria. According to these criteria, candidates must have either two years of work experience or 80 contact hours of a coding preparation course plus one year of on-the-job experience.² Those who pass the exam but don’t yet meet the eligibility requirements are awarded the CPC Apprentice (CPC-A) designation, which can be updated to full CPC status with proof of experience.

Steps to CPC Certification

Whether you aim to work as a medical coder, a medical biller, or in a combined role that handles both tasks, earning your CPC or CPC-A credential conveys your understanding of medical terminology and universal coding systems. Preparing for medical coding and billing certification takes some work, but remember that you’re doing it to aid in advancing your career. Be prepared to dig in and stay committed to the process.

Step 1: Enroll in medical billing and coding training

Medical billing and coding training can help you become familiar with CPT, ICD, and HCPCS Level II codes. You also learn how to process healthcare claims, accurately code medical procedures, and use the proper medical terminology. Earning a credential from an accredited health education school is one way to show preparation for this field.

If you know the type of healthcare setting you want to work in, review local job postings to see what employers are looking for in terms of training. For instance, are they seeking candidates with a medical billing and coding certificate, diploma, or degree? This can help give you an idea of where to start.

You may also choose from campus-based courses or online medical billing and coding programs. While on-campus, in-person instruction can be helpful for students who are preparing for clinical healthcare roles (such as nursing assistant or phlebotomy technician), computer-based work like medical coding and billing is suited to an online learning environment.

Step 2: Gain medical billing and coding experience

Remember that one of the eligibility criteria for the CPC exam is either two years’ experience or 80 contact hours in a coding preparation course plus one year of experience.² If these criteria are met before taking and passing the certification exam, candidates earn the CPC designation. If not, the CPC-A designation is awarded until the required experience is met.

Step 3: Schedule and prepare for the certification exam

Once you feel ready to take your medical coding and billing certification exam, it’s time to schedule the test. You do need an AAPC membership before you can do this.² After you’ve submitted payment and registered for a date to take the exam, it’s a good time to brush up on the topics that will be covered.

Step 4: Take the CPC exam

Candidates are not expected to memorize the thousands of codes used in this field, so the AAPC allows applicants to reference approved manuals during the exam. Only hard copies may be used, as electronic devices are not allowed in the exam room.² Prepare to spend up to the allotted time (four hours) so you don’t have to leave before you’re finished, or the time expires.

Want Help Preparing to Sit for Medical Billing and Coding Certification?

Are you interested in pursuing medical coding and billing certification? Ultimate Medical Academy can help you prepare to sit for the CPC exam, should you meet the AAPC’s eligibility requirements, because it is included in both of our online Medical Billing and Coding programs:

• Medical Billing and Coding Diploma program – 11 months or more to complete⁴
• Medical Billing and Coding Associate of Science / Associate of Applied Science Degree program – 18 months or more to complete⁴

Head to our Admissions page to start your journey. We look forward to helping you achieve your healthcare career goals!

FAQs

• What is medical billing and coding? Medical billing and coding involves the transformation of patient health information into universally accepted codes, then using these codes to bill insurance providers, patients, and/or other responsible parties.
• What do medical billers do? Medical billing specialists prepare and send invoices so healthcare providers can get reimbursed for their products and services. They also help resolve rejected claims or other payment issues.
• What do medical coders do? Medical coders transform patient health information into universal alphanumeric codes. Healthcare providers use these codes when seeking reimbursement from health insurance companies.
• What certifications are available for medical billing and coding? Credentialing agencies, such as the American Academy of Professional Coders (AAPC), offer a variety of medical billing and coding certifications. They range from the more general Certified Professional Coder (CPC) designation to specialized certifications in specific areas, including outpatient and inpatient coding.
• What jobs can you get with a medical billing and coding certification? Some employers may prefer or require certification for medical billing, medical coding, or dual medical billing and coding positions. Other roles that sometimes have medical billing and coding functions and, therefore, could benefit from certification include insurance benefits specialist, medical receptionist, and medical office assistant.
• How can I prepare for the Certified Professional Coder (CPC) exam? It can help to first familiarize yourself with the CPC exam requirements. Students enrolled in UMA’s Medical Billing and Coding Diploma program or Medical Billing and Coding Associate of Science / Associate of Applied Science Degree program also receive preparation to sit for the CPC exam.⁵ Contact us to learn more about our programs or to discuss how we can help you feel more confident when pursuing medical billing and coding certification.