Medical Biller and Coder Job Description

A medical biller and coder turns a patient visit into a payable insurance claim, then works that claim until the money arrives or the denial is settled. BLS files the coding half of the job under medical records specialists and describes it in one line: medical coders assign the diagnosis and procedure codes used for patient care, population health statistics and billing. The billing half is claims work: building the claim, sending it to the payer, posting what comes back and chasing what does not.

Coding the encounter. The work starts with the provider's documentation in the EHR. The coder reads the progress note, operative report or discharge summary and assigns ICD-10-CM diagnosis codes, CPT and HCPCS Level II codes for procedures and supplies, and the modifiers that tell a payer why two services on the same date are distinct. On the hospital side, inpatient coders also assign ICD-10-PCS procedure codes, which feed the MS-DRG grouper behind the Medicare inpatient payment. When a note does not support the level of service or the specificity a code calls for, the coder sends the provider a query rather than guessing.

Building and sending the claim. Professional services go out on the CMS-1500, or its electronic 837P equivalent, and facility charges on the UB-04, the 837I. Before a claim leaves the practice management system, the biller checks eligibility, confirms that any required prior authorization is on file and clears the scrubber edits a clearinghouse or payer would otherwise bounce back: NCCI bundling pairs, medically unlikely edits, a missing referring provider, a place-of-service mismatch.

Working the back end. Payments return as 835 electronic remittances or paper explanations of benefits. The biller posts payments, contractual adjustments and patient balances, then works denials by their CARC and RARC reason codes. Some denials need only a data fix and a resubmission; others need a written appeal with the chart attached, filed before the payer's deadline. The accounts receivable aging report, sorted by payer and days outstanding, sets the daily worklist.

Where the two halves meet. In a small practice, one person may code a visit in the morning and appeal its denial that afternoon. A larger health system may split the same work across coding, charge entry, payment posting and denial teams. This title describes a role that spans both coding and claims, and that position is what makes it useful: a run of denials for the same reason points back to a documentation habit, a charge master error or a payer policy that changed, and the person who codes and bills is placed to spot it and take it to the right provider or manager.

The calendar. Code sets change on a fixed cycle. CMS's FY 2027 ICD-10-CM and ICD-10-PCS files apply to discharges and encounters from October 1, 2026, and the AMA's CPT 2027 code set, released September 9, 2026, carries 299 new codes, 74 revisions and 80 deletions that take effect on January 1, 2027. Payer policy bulletins, Medicare coverage determinations and NCCI updates arrive between those dates, and keeping the encoder, the scrubber rules and the team's habits current is part of the job.

Education. BLS says medical records specialists, the occupation that includes coders, typically need a postsecondary certificate to enter, although some qualify with a high school diploma and others hold an associate's or bachelor's degree. As a rough guide, a certificate program in medical billing and coding runs from several months to about a year and covers anatomy, physiology, medical terminology, pharmacology basics, the three code sets and payer rules. An associate degree in health information technology adds HIM coursework and, when the program is CAHIIM-accredited, meets the academic requirement for AHIMA's RHIT exam, a step toward health information management.

Credentials. BLS notes that certification may be required or preferred. The ones a reader would pursue:

• Certified Professional Coder (CPC), AAPC: coding for outpatient and physician services.
• Certified Professional Biller (CPB), AAPC: claims, payer rules, denials and accounts receivable.
• Certified Coding Specialist (CCS), AHIMA: coding inpatient and outpatient records, including ICD-10-PCS procedure codes.
• Certified Coding Associate (CCA), AHIMA: a coding credential AHIMA describes as ideal for early-career professionals.
• Certified Risk Adjustment Coder (CRC), AAPC: HCC coding for risk-adjusted plans such as Medicare Advantage.
• Certified Outpatient Coder (COC), AAPC: outpatient hospital and facility coding, including same-day surgery and emergency department visits.

Each body sets its own exam, renewal cycle and continuing education requirement, so check the current terms on the credential page before booking an exam.

Technical knowledge.

• ICD-10-CM, ICD-10-PCS, CPT and HCPCS Level II, including the official guidelines and modifier rules
• NCCI edits, Medicare coverage determinations and the claim forms: CMS-1500, UB-04 and their 837P and 837I electronic formats
• Remittance data: 835 files, CARC and RARC denial codes, contractual adjustment logic
• EHR and practice management systems such as Epic, Oracle Health, athenaOne or eClinicalWorks, plus an encoder and a clearinghouse portal
• Payer portals for eligibility, prior authorization status and claim status

Working habits that show up in a good hire. A coder who reads a note for what it supports, not what the provider intended, and who writes a short, specific query. A biller who sorts the aging report by dollars at risk and timely filing date, not by alphabet. Comfort with Excel or a reporting tool to group denials by reason, payer and provider. Clean HIPAA habits: minimum necessary access, no protected health information in personal email, and secure handling of appeal packets.

Experience path. As a rough guide, the path can start in charge entry, payment posting or front-desk registration and move into coding after a credential. Specialty coding in areas such as cardiology, orthopedics or interventional radiology, inpatient coding and coding audit are later steps that build on a few years of production coding.

BLS projects employment of medical records specialists, the occupation that includes medical coders, to grow 8 percent from 2025 to 2035, which it classifies as much faster than the average for all occupations, with about 14,000 openings a year on average over the decade. BLS adds a caveat aimed at the coding half of this job: the increase in adoption of AI-powered solutions that make the medical coding process more efficient may affect demand for these workers. Read those two statements together: the projected openings are there, and BLS itself names AI coding tools as a factor that may affect demand.

Where the pay sits. Setting matters. For medical records specialists in May 2025, BLS reports a median wage of $59,120 in hospitals and $47,120 in offices of physicians. The billing side is tracked separately as billing and posting clerks, whose median in offices of physicians was $47,570. BLS does not report a combined biller and coder title.

Denials are where the money is lost. In a January 6, 2026 MGMA Stat poll with 288 applicable responses, 48% of medical practice respondents named denials and appeals as the biggest revenue cycle leak, followed by front-end issues at 23%, billing and collections at 14% and coding at 13%. For a biller and coder, that ranking points at the core of the job: preventing denials through clean eligibility checks and specific coding, and overturning them through well-built appeals.

Medicare is testing prior authorization in traditional fee-for-service. CMS's WISeR model began on January 1, 2026 and, for its first performance year, operates in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Model participants review prior authorization requests for a set list of items and services, using what CMS calls enhanced technologies, but a recommendation not to affirm must come from an appropriately licensed human clinician, not a machine. The billing consequence is direct: CMS says claims for associated codes will be denied, or their payments recouped, if the primary WISeR service has a non-affirmed prior authorization. For billers in those six states, WISeR status belongs on the pre-claim checklist next to commercial payer authorizations.

Career moves. The skills carry into several adjacent roles: coding auditor or coding educator, clinical documentation integrity specialist (with a clinical background or added training), denial management lead, charge master analyst, and revenue cycle supervisor or manager. Risk adjustment coding for Medicare Advantage and payer-side work, such as claims editing or payment integrity at an insurance carrier, are two other directions; BLS counts medical records specialists in insurance carriers too, at a May 2025 median of $62,650.

What to watch. Three open questions for this job: how far autonomous coding tools move from suggestion to final assignment in each employer's workflow, how payers use the prior authorization and denial-reason requirements now in force, and how the annual code-set cycle keeps adding specificity that software and people both have to learn.

Dear Hiring Manager,

Please consider me for the Medical Biller and Coder opening at Lakeshore Orthopedic and Spine Associates. I hold the CPC credential and have spent two and a half years at a nine-provider family medicine and urgent care group, where I code visits and procedures and own the commercial payer denial queue.

Most of my coding work is evaluation and management, injections, laceration repairs and fracture care in urgent care, which means I read every note for medical decision making, laterality and the modifier a payer will expect. When the documentation does not support a code, I send the provider a short query with the specific missing element, and I track those queries so our physicians can see which gaps come up again.

On the billing side, I took over a denial queue that had fallen behind after a staffing change. I sorted it by timely filing date and dollar value, cleared the eligibility and authorization denials first, and built a simple log by payer and reason code. That log showed one plan repeatedly denying fracture care follow-up visits as bundled. I pulled the payer's own policy, wrote a template appeal citing it, and had the first batch paid on appeal. The front desk now flags those patients at check-in.

Your practice interests me because orthopedic coding would take me deeper into surgical packages, implants and global periods, and I would like to add the COC as I learn hospital outpatient work. I am comfortable in Epic and athenaOne and would be glad to complete a coding test.

Thank you for your time and consideration.

Jordan Ellis