Medical Biller or Coder — How Do I Obtain Certification Part 1

Medical Biller or Coder — How Do I Obtain Certification Part 1

Becoming a medical biller or coder requires certification. Those who choose a career path that will place them in a hospital environment should become familiar with the American Health Information Management Association (AHIMA). Nitin Chhoda shares how a highly respected organization  such as AHIMA, issues multiple levels of certifications for its members.

medical biller or coderThe organization recommends that medical biller or coder completes a training program prior to certification testing.

Depending on the desired certification, students may be required to participate in a short-term program or acquire a four-year degree before being eligible to take a specific certification exam.

Benefit of Joining AHIMA

The focus at AHIMA is providing certification for hospital-based medical biller or coder. The group has yearly conventions, issues certifications and conducts training programs.

It offers continuing education options and networking opportunities designed to keep medical biller or coder abreast of issues that affect them in the professional arena.

AHIMA offers online education courses, programs and webinars and exam preparation.

Students can participate in a virtual lab featuring multiple state-of-the-art software applications they will encounter in their professional capacity.

Different Certification Levels

The group only offers entry level credentials and is available to those who already have first-hand knowledge of coding. AHIMA issues certifications for those who plan a career working in hospitals and strives for excellence in medical record integrity.

AHIMA provides three medical biller or coder certifications:

  • certified coding associate (CCA)
  • correct coding specialist (CCS)
  • correct coding specialist-physician based (CCS-P)

All types of medical biller or coder are recognized and accepted by hospitals, physicians and practice management companies.

Correct Coding Associate

To earn a CCA designation, coders must exhibit competency with in-patient and out-patient coding. It’s an overall certification that allows medical biller or coder to work in multiple venues. It demonstrates competency but not mastery.

Certified Coding Specialist

The CCS is AHIMA’s primary certification that shows a coder has a higher level of skill with procedural and diagnosis coding, are experts in CPT and ICD coding, and knowledgeable in anatomy and medical terminology.

Those earning CCS certification must also know about pharmacology and the disease process.medical billing and coding

Correct Coding Specialist-Physician

Those receiving a CCS-P certification specialize in working within physician offices, clinics and practices with multiple clinicians.

They’re highly skilled professionals who are adept at billing accurately to obtain the highest level of reimbursement for practitioners.

They assign ICD and CPT codes on patient records and may be responsible for transmitting claims to clearinghouses.

Healthcare Privacy and Security

The organization also offers the only combined privacy and security certification. Those medical biller or coder with healthcare privacy and security (CHPS®) certification must demonstrate competence in the design, implementation and administration of security protection programs for all types of healthcare-related organizations.

AHIMA provides medical biller or coder who wants to follow a career path in hospital medical billing and coding with the information, requirements, education and certification they need. The professional organization is one of the most respected in the industry, offering the multiple certification levels those in the medical billing and coding industry require to take their career from associate to specialist.

Watch out for the part two of this two-part series of articles entitled “Medical Biller or Coder — How Do I Obtain Certification?”

Insurance Claim: How to Handle and Appeal

Insurance Claim: How to Handle and Appeal

When a reimbursement denial is received, medical insurance billers (MIBs) may need to initiate an appeal process to collect disputed funds for practitioners. In this informative article, Nitin Chhoda reveals the most common reasons for denials and the best strategies for handling claim disputes.

insurance claimEach insurance claim goes through an adjudication process at a clearinghouse to check the data for errors before forwarding it to the appropriate insurance carrier.

An insurance claim examiner conducts another exploration of the claim and renders a decision. The examiner can choose to pay the billed expenses, reimburse at a reduced rate, or deny the insurance claim.

Insurance carriers usually deny payment for one of six typical reasons. Some of the factors are the following:

  1. Carrier’s procedures
  2. Medical necessity
  3. Inactive policies
  4. Out-of-network
  5. Level of care
  6. Pre-existing conditions
  7. Pre-authorization

Unknown Carrier’s Procedures

MIBs should be aware of each payer’s procedures and policies for handling claims. Each insurance company has its own hierarchy and protocols for reviewing an insurance claim.

MIBs should also check the contract between the clinician and the insurance company to determine that all conditions have been met.

Medical Documentation is Necessary

When an insurance claim is denied on this basis, it’s up to the MIB to provide documentation, physical therapy documentation for example, that the appropriate diagnosis and procedural codes were employed. Sometimes a coding change and resubmitting the claim will result in a satisfactory resolution.

If the codes are accurate, a letter must be provided that clearly states why the treatment was necessary, along with any extenuating circumstances.

Patient’s Insurance Policy is Now Inactive

It’s essential that the MIB has proof that the patient has an active insurance policy at the time treatment was provided.

This can be accomplished through a copy of the individual’s medical card, a letter from their employer, or a statement from the insurer.

Out-of-Companies-Network of Physicians

Some carriers require patients to only see practitioners within the company’s network of physicians, but situations arise when an in-network clinician isn’t available.

A simple letter explaining, in detail, why the patient didn’t have access to the carrier’s network of clinicians can easily turn an insurance claim denial into a payment.

Having Too Much Level of Care

Insurance claim examiners may determine the level of treatment that was billed exceeded the usual care for a particular ailment. The culprit in insurance claim denial is usually a lack of documentation that fully explains why additional treatment or procedures were required.

Providing supporting documentation usually takes care of the problem.

The Most Common – Having Pre-Existing Conditions

Most insurance policies won’t cover treatment for conditions and diseases that patients were afflicted with prior to when their policy became active.

If treatment can be linked to any prior health problem, the need for an appeal is negated.

If it wasn’t related to a previous health issue, MIBs should provide a written explanation, accompanied in the insurance claim, as to why the ailment wasn’t related to a pre-existing condition.

Unable to Meet Pre-Authorizationinsurance claim

A wide variety of treatments require pre-authorization for insurance claim reimbursements. MIBs can reverse a denial if they provide proof the treatment would have been approved, as in the case of an emergency.

A convincing argument can result in full payment and waiving of penalties for not obtaining the pre-authorization.

An insurance claim denial doesn’t always result in an appeal.

Providing documentation and a convincing argument as to why the denial was in error is essential when disputing reimbursement rejections. Clear and concise communications are critical elements of strategies to obtain payment for denied claims.

The Backbone of Obamacare — Health Insurance Exchange 101

The Backbone of Obamacare — Health Insurance Exchange 101

Open enrollment at the Healthcare Insurance Marketplace began Oct. 1, 2013 and continues through March 31, 2014. It’s estimated that the majority of Americans will have signed up and be covered by an insurance plan by that time. Those who don’t will be subject to penalties and fines on their income tax returns.

ObamacareThe Marketplace is the backbone of Obamacare and will determine how healthcare insurance will be delivered.

The Marketplace provides consumers with a central location to purchase the healthcare that best fits their individual needs.

Prices vary and are dependent upon the applicant’s annual income and geographic location.

Purchasing A Plan

There are four types of coverage that consumers should be aware of and with which clinicians should be familiar if they’re to talk with patients about their plans.

The Marketplace offers a Bronze, Silver, Gold, Platinum and Catastrophic policy, each with its own set of parameters.

Bronze and Silver plans can cost up to 9.5 percent of an individual’s income.

Gold and Platinum policies can be 12.5 percent of the applicant’s yearly income.

Samples prices and coverage can be viewed on the Marketplace website, but the only way to ascertain actual costs is to apply.

Catastrophic plans are available for those under the age of 30. Individuals over 30 who have received an exemption are also eligible for the coverage.

These types of plans typically cost less but have very high deductibles. In 2014, the maximum out-of-pocket for any Marketplace plan is $6,350 for individuals and $12,700 for families.

Many consumers will be eligible for federal subsidies to help them pay for insurance on the Marketplace, but consumers need to examine a plan’s monthly premium, co-pays and deductibles carefully before committing to an insurance policy.

Costs are expected to change and many predict they will go higher. Clinicians need to understand what’s offered if they’re to advise patients on costs and options that will best fit individual health needs.

Facing Fines

People who don’t qualify for Medicare, Medicaid or an employer plan must enroll in healthcare coverage at the Marketplace.

Those who haven’t enrolled or received an exemption will be fined on their income tax return through Obamacare’s Individual Mandate Tax.

In 2014, the fine for no insurance will be $95 per adult and $47.50 for children, or 1 percent of taxable income.

ObamacareThose amounts increase to $325 per adult and $162.50 on children, or 2 percent of income in 2015.

The penalty for non-compliance in 2016 jumps to $695 for adults and $332.50 for children, or 2.5 of taxable income.

After 2016, fines will be adjusted upward for cost of living increases.

To remain current on Obamacare and be able to advise patients, clinicians will need the In Touch EMR and In Touch Biller PRO.

The integrated systems can be used to educate patients about their healthcare insurance and the core preventative services provided, while facilitating quick turnarounds on reimbursements.

The Marketplace is the backbone of Obamacare, changing how healthcare insurance in the U.S. is purchased, determining how care is delivered, and redefining the role of clinicians.

How Obamacare Attempts to Tackle Overutilization

How Obamacare Attempts to Tackle Overutilization

The skyrocketing cost of healthcare was one of the motivating forces behind the passage of the Affordable Health Care Act. Known as Obamacare, one of the legislation’s goals is to reduce costs and it attempts to do that with a multi-faceted approach that seeks to reduce overutilization of healthcare services.

ObamacareToo Much Care

Supporters of Obamacare claim that healthcare costs have soared due to demanding patients requesting unnecessary tests and clinicians that are prolonging patient treatments.

Obamacare assumes that patients are overindulging in expensive treatments, tests and medications, and attempts to address that through limiting the use of services deemed as too costly.

Luxury Services And Care

Dr. Ezekiel Emanuel was a primary advisor and architect of Obamacare. He called for scaling back on what he viewed as luxury services, conveniences and self-indulgent excess to curb costs.

He included comfortable waiting rooms, convenient parking and access, and the privacy of examination rooms as needless amenities that would reduce costs.

To curb costs, elderly patients will receive many services at home instead of being admitted to hospitals or making multiple visits to their physician.

Technology will be used to monitor, track and transmit patient data to healthcare providers.

The Obamacare model relies more on lower paid support staff and less on clinicians.

Less Is More

Obamacare addresses cost reduction through paying less to providers and bundling services that were previously billed separately.

It rewards clinicians who get patients better faster and prevent hospitalizations.

Obamacare rewards physicians who increase efficiency and productivity within their practice to accelerate the number of patients treated.

The legislation calls for patients to be responsible for a greater financial amount of their care through increased co-pays, deductibles and premiums; restricting tests to only those that are absolutely essential and utilizing low-cost tests whenever possible; and bringing prescription costs more in line with those of other countries.

Prevention And Patient Accountability

Consumers are tasked with improving their health and working to prevent disease and healthcare problems before they arise.


Obamacare encourages employers and insurance companies to promote improved health with incentive programs that reward individuals who meet specified guidelines.

In the Obamacare economy, clinicians will need to focus on outcomes and be able to prove it with tools like those in the In Touch EMR and In Touch Biller PRO.

The software improves efficiency, productivity and reimbursements.

The current trend in healthcare is toward prevention, getting patients better quicker, and doing it with the least amount of testing and medication, all of which will be instrumental in changing the way healthcare is delivered.


Obamacare 101: The Impact on Your Patients

Obamacare 101: The Impact on Your Patients

Obamacare means major changes for virtually every segment of the population and clinicians will need to educate their patients about those changes and how it will impact them on a personal level. The healthcare climate will also affect practitioners and how they deliver healthcare services.

ObamacareTo keep up with changes in Obamacare, remain compliant and receive timely reimbursements, it’s essential to have the right software tools.

In Touch EMR offers a complete system that grows with practices. In Touch Biller PRO can be fully integrated with EMR technology.

Together, the systems make practices more efficient, help educate patients and obtain payments quickly.

Upcoming Changes

For many, Obamacare means healthcare coverage for the very first time through the Health Insurance Marketplace and the expansion of Medicaid, for others it will mean no change at all.

Parents can now keep their adult children on their policies until the age of 26 and no one with a pre-existing condition can be turned down for insurance.

A $63 fee will be levied on all policies to help pay for high-risk patients.

Most individuals with employer-based insurance won’t have to purchase coverage through the Marketplace. If their cost is more than 9.5 percent of their annual income, they can apply for coverage in the Marketplace.

Marketplace insurance plans don’t automatically extend coverage to spouses. Employer-based plans typically offer spousal coverage, but companies are not obligated to do so.

Employee spouses may have to purchase personal coverage through the Marketplace or their own workplace.

Married couples may have to purchase coverage independent of the other through the Marketplace.

Medicare recipients will still be able to choose their own physician and Obamacare closes the donut hole, allowing seniors to pay less for prescriptions.

Seniors with high medical costs will be able to receive in-home care. Seniors with annual incomes of $200,000 or more will see an increase of .9 percent in Medicare payroll taxes.

Penalty Fees

The individual mandate tax (IMT) fines anyone without healthcare insurance, Medicaid or Medicare, though there are a few exemptions. Beginning in 2014 the IMT is $95 on adults and $47.50 for children.

The tax increases each year to a maximum of $695 for adults in 2016 and $397.50 for children.

After that, the fee is adjusted each year for inflation.

Buying Marketplace Insurance

A bronze, silver, gold or platinum policy can be purchased on the Marketplace. According to the Department of Health and Human Services, the average price for a policy on the Marketplace will be about $328 per month.

Consumers can also purchase what’s known as a catastrophic policy for around $129 per month. The actual cost will depend on the level of coverage purchased and the geographic location of the buyer.

Federal subsidies are available to help individuals purchase Marketplace insurance coverage.

Subsidy amounts will depend on household income, family size and geographic location.

Core ServicesObamacare

Under Obamacare, each consumer is entitled to a core group of services ranging from hospitalization to prescription coverage.

The emphasis is on preventative services and those will be offered free, with no co-pays from patients.

Consumers can receive free cancer screenings and vaccinations, along with consultations on nutrition, diabetes, and HIV and STDs.

Obamacare will affect patient coverage, how insurance is purchased and used, and the way clinicians dispense healthcare services in the U.S.

The exact impact remains to be seen, but it’s imperative that practitioners educate patients about their options and how their decisions will affect their coverage and finances.

How Obamacare Increases Patient Responsibility

How Obamacare Increases Patient Responsibility

The focus of Obamacare is on prevention rather than the cure to reduce the cost of treatment. To accomplish, this, the Affordable Health Care Act makes patient more responsible for their own healthcare through better decision making, more exercise and purchasing healthier foods.

ObamacareIn the Obamacare economy, clinicians must spend more time educating patients and trying to modify their behavior.

The In Touch EMR provides an essential tool for working toward that goal.

Combined with the In Touch Biller PRO software, practitioners have a full complement of tools for successfully pursuing all the goals of the nation’s healthcare law and obtaining quick reimbursements for the services they provide.

Improving Access

As part of developing a nation of healthier individuals, Obamacare has established the Healthcare Insurance Exchange, providing patients with access to affordable healthcare coverage.

Eligibility requirements have been increased so more low income families can obtain Medicaid.

Obamacare ensures compliance by assessing a penalty through the Individual Tax Mandate for not having insurance.

Prevention Is The Cure

There’s a little known initiative within Obamacare that provides a variety of free screenings, tests and consultations that doesn’t require a co-pay from patients.

The Natural Prevention Health Promotion and Public Health Council will aid people in obtaining no-cost access to services, study the impact on strategies and create a list of things to do in the future.

While the list of services has not been finalized, it may include certain things like cancer screenings, stop smoking medications, depression, diabetes, HIV and even birth control.

The strategy is for patients to be more responsible for their health by doing things that will keep them healthy and avoid costly treatment later on.


There is a genetic component that makes people predisposed toward some diseases and health problems, but it’s unknown how this will factor into the program.

Prevention And Education

To work within the Obamacare economy, clinicians must spend more time on prevention, education and inducing patients to make healthier choices.

Obamacare seeks to increase the health of Americans at every stage of their life.

By making free tests, assessments, screenings and consultations available, the authors of Obamacare hope to create a nation of healthier people that require less treatment for a variety of diseases, thereby reducing the cost of healthcare.

Only time will tell if the Obamacare legislation will have a significant impact on changing the way people think and behave.