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Medical Billing and Coding in Pennsylvania

Why do doctors need to be savvy about their coding? Pennsylvania MD Lori Rousche recently shared some of the issues on the Modern Medicine Network (http://medicaleconomics.modernmedicine.com/medical-economics/news/importance-hcc-coding). One reason is value-based care. In order to provide the best care, practitioners need to start with a sufficient pool of money. That means they need to be able to describe what their patients have. If a patient has coronary heart disease and associated chest pain, the practitioner can't code for just heart disease. If the patient has diabetes and diabetes-induced kidney disease, the codes need to reflect this. At the same time, doctors need to be sure they can substantiate what they claim -- and that their patients are as sick as they say they are. Upcoding is unethical

Even traditional procedure-based coding is highly complex. This precision is important for purposes other than payment. Medical research is increasingly dependently on knowing exactly what patients have and exactly what is done... under exactly what conditions.

Medical billing and coding is its own discipline, and those who are versed in it need, at the very minimum, to be offering oversight to those who write in codes or enter them in computer programs. That's one reason hospitals and practices in Pennsylvania and around the nation are hiring professionals with titles like CPC, CSS, and RHIT. These are among the credentials issued by respected third party certifying organizations.

Certification as a medical coder is based largely on examination. Candidates must meet prerequisites; these will vary depending on the certification sought.

Select a Pennsylvania Medical Billing and Coding Topic:

Medical Billing and Coding Employment in Pennsylvania

High school education or equivalency is often listed as the minimum education level. Some employers note a preference for degrees. Employers may also note a preference or requirement for formal coding education even if it did not result in a degree. The employer may, for example, note completion of an AHIMA self-study program among the options. Both major certifying organizations offer training programs.

Formal education programs can be beneficial even when not mandated at the employment level. In order to be certified, an individual will need to pass an examination that is comprehensive as well as difficult. Some certifications have prerequisites. A person who seeks certification as a Certified Professional Coder (CPC) can shorten his or her experience requirement considerably by enrolling in even a short medical coding program.

Medical coders often specialize. Some employers seek candidates with particular types of experience, from phlebotomy to Evaluation and Management (E/M).

Billing and coding professionals should be familiar with regulations as well as coding systems. They should also be tech-savvy. Prior experience with particular programs can be helpful. There are many that may be referenced: Excel, DRG Grouper Software, 3M Encoder, Epic.

A healthcare background can be a plus for some positions. There are many opportunities for advancement and many careers where a person can potentially make use of both coding knowledge and a related degree. Among the positions recently advertised in Pennsylvania: Provider Contract Analyst.

Achieving Certification

An early 2017 job search reveals that a number of Pennsylvania employers will accept AHIMA’s Certified Coding Associate (CCA). The CCA is a generalist certification. Many want the higher credentials, though -- and often note minimum experience as well.

A person who seeks the CCA is required only to demonstrate education at the level of high school graduation. However, individuals who lack six months of coding coursework are encouraged to have basic coursework in ICD-10 and CPT coding as well as medical terminology and anatomy and physiology. The examination is two hours. An examination outline is available on the AHIMA website (http://www.ahima.org/certification).

The Certified Coding Specialist (CCS) is one of the industry’s premier credentials. It emphasizes hospital coding. The CCS-P is designed for practice settings. An individual who seeks to take the CCS or CCS-P examination must have intermediate/ advanced medical coding coursework unless he or she qualifies by another pathway. The curriculum must also include reimbursement methodology and medical sciences coursework such as pathophysiology and medical terminology. The examination includes scenarios. It is four hours.

Students who complete accredited health information programs may be hired into coding positions on the strength of the AHIMA Registered Health Information Technician (RHIT) credential.

The Certified Professional Coder is the best-known AAPC credential. It is relevant to multiple settings but is especially relevant to physician’s office/ practice settings; there is a good deal of emphasis on CPT procedural coding. A person who seeks the AAPC Certified Professional Coder (CPC) may take the examination before meeting prerequisites. He or she will receive the designation Certified Professional Coder Apprentice (CPC-A).

Nationwide, new professionals sometimes turn to their professional organizations for practicum or apprenticeship opportunities as well as for other career resources.

The AAPC offers billing and auditing certifications as well as certifications in a number of coding specialties. Evaluation and management coding and risk adjustment coding are among the many career possibilities.

Employers occasionally reference certifications granted by other organizations, for example, the Home Care Coding Specialist-Diagnosis (HCS-D) or Home Care Coding Specialist – Hospice (HCS-H) granted by the Association of Home Care Coding & Compliance.

Additional Resources

Pennsylvania boasts 18 local AAPC chapters (https://www.aapc.com/localchapters/list-all-local-chapter.aspx). Learning events are not standardized; they will depend on chapter. The following are among the 2017 offerings:

  • Cardiothoracic Surgery
  • Clinical Documentation Improvements for the E/M Service
  • Modifier Overview - Navigating NCCI
  • Auditing: Risk Analysis and Communication

The Pennsylvania Health Information Management Association is the local chapter of AHIMA (http://www.phima.org). There are five regional PHIMA associations.