Does Your Practice Employ a Certified Professional Coder?

Written by Jill Fahy

When practice managers ask Donelle Holle whether they should have a Certified Pediatric Coder (CPC) on staff, the veteran pediatric coding and reimbursement consultant usually responds with a few questions of her own.

“It depends on the office, it depends on how big they are, it depends on what they need,” said Holle.

Certified Professional Coders have been formally recognized, through the successful completion of a standardized exam, as having the skills and knowledge to review and code services, procedures and diagnoses on medical claims in physician-office or other health care provider setting.

CPCs, according to the American Academy of Professional Coders (AAPC), have a thorough understanding of medical coding rules and regulations related to compliance and reimbursement, they know how to apply this knowledge to a practice’s reimbursement process, and they have acquired the anatomy, physiology and medical terminology necessary to correctly code provider diagnosis and services.

Employment of medical coders and health information technicians is expected to increase by 20 percent through 2018 as the population continues to age and more medically-related tests and procedures are performed, according to the U.S. Bureau of Labor and Statistics. And certified coders earn an average of 17 percent more than non-certified coders, according to an AAPC survey.

While having a dedicated professional coder or other employee who has received his certification on staff at every office would be the best case scenario, says Holle, it is neither necessary nor always practical or cost-effective, particularly for the medium- or smaller-sized offices with employees whose combined job is multitasking billing and coding.

Holle, who criss-crosses the U.S. six months a year imparting 30 years worth of coding and billing experience to clinicians and medical practice staff, asserts it’s less about the certification and more about the ability to follow-through. For those practice billing specialists who know their job inside-out and are willing to go the extra mile for their employer’s bottom line, she says, having a CPC after their name is detailing on an already well-oiled machine.

“For me, it’s all about attitude,” said Holle, an RN who began her billing career in a single doctor pediatric practice and later became director of billing for the University of Michigan’s pediatrics department. “These people know what they’re doing, they work hard and go the distance. They’re the ones who say, ‘we’re getting paid one way or another.’”

Those who may benefit most from earning their CPC or similar certification, Holle suggests, are men and women who are entering the job market for the first time, and those looking for jobs at hospitals or health care facilities where coding-specific knowledge is in great demand.

There are also those people – many of them employed as billing specialists in the medical practice setting – who seek CPC certification as a way to take their knowledge to another level.

Jayme Spangler is one such example. “I liked what I was doing and I wanted to learn more to make sure I was giving the office the best I could give,” said Spangler, the billing specialist for Hershey Pediatric Center – a four-provider practice in Pennsylvania.

The knowledge she has gained as a CPC, said Spangler, has helped her catch missed modifiers and to pick up on diagnoses that might not otherwise fit, which has led to fewer payer rejections and a shorter turnaround on payments.

“I think it’s good to have at least one person in the office that knows coding,” Spangler said.

Obtaining certification requires a commitment of both time and money. The required courses (offered online) and standardized exam for the CPC certification can cost upwards of $1,300. Once certified, CPCs must maintain their professional coding status by earning 36 Continuing Education Units (CEUs) every two years. While larger practices and hospitals may offer to foot the bill, the expense is often the responsibility of the person who seeks certification.

PCC covered the expenses associated with Jan Blanchard’s pursuit of CPC and CPEDC certification. Blanchard, who is PCC’s Technical Support Team leader, agrees with Spangler that someone in the office must be well-versed in coding concepts.

Blanchard, who began her career in the billing department of University Hospital at Stony Brook, said the certification boosted her confidence and credibility as an auditor of the coding process. But, she added, echoing Holle’s opinion, one doesn’t need to be certified to be a good coder.

“Certification doesn’t teach the outrageous behaviors of the insurance carriers, who are often in direct contradiction of coding manuals,” Blanchard said.

“Coding certification doesn’t teach you about the appeals process or wrestling with carriers. For that, you need to be like a dog with a bone.”