Medical Billing and Coding Job Description

A medical biller and coder's day revolves around translating healthcare encounters into standardized codes and making sure providers get paid accurately. The medical billing and coding job description breaks down into several core tasks.

Reviewing clinical documentation. Coders start each encounter by reading the physician's notes, operative reports, lab results, and other clinical records. The goal is to understand exactly what happened during the patient visit: what conditions were diagnosed, what procedures were performed, and what supplies or drugs were used.

Assigning diagnosis and procedure codes. Based on the documentation, coders select the appropriate ICD-10-CM codes for diagnoses and CPT/HCPCS codes for procedures and services. Accuracy matters enormously. Incorrect codes can lead to claim denials, underpayment, overpayment, or compliance violations.

Querying physicians. When documentation is incomplete, ambiguous, or contradictory, coders submit queries to the treating physician asking for clarification. This is a normal part of the workflow and requires diplomacy. You need to be specific about what's missing without suggesting a particular code or diagnosis.

Building and submitting claims. Billers take the coded encounter and assemble an insurance claim, adding patient demographics, provider information, place of service, and any required modifiers. Claims are submitted electronically through a clearinghouse to the appropriate payer (Medicare, Medicaid, commercial insurance).

Medical coding and medical billing are related but distinct functions within the revenue cycle. Understanding the difference helps you target the right roles when job searching.

Medical coding is the process of reviewing clinical documentation and translating it into standardized alphanumeric codes. Coders need deep knowledge of ICD-10-CM (diagnosis codes), CPT (procedure codes), and HCPCS Level II (supplies, drugs, and durable medical equipment codes). The work requires strong analytical skills and the ability to interpret medical records.

Medical billing picks up where coding leaves off. Billers take the coded information, build insurance claims, submit them to payers, track payments, and handle denials and appeals. The work requires knowledge of payer contracts, insurance regulations, and financial processes.

In smaller practices, one person often handles both coding and billing. In larger organizations like hospitals, health systems, and major billing companies, the functions are typically split between separate teams with specialized staff and supervisors. For a deeper comparison, see our billing vs. coding page.

Employers expect medical billing and coding professionals to demonstrate competence in several technical areas. Here's what you'll see listed most often in job postings.

ICD-10-CM. The International Classification of Diseases, 10th Revision, Clinical Modification is the U.S. standard for diagnosis coding. It contains more than 72,000 codes and is updated annually by the CDC and CMS. You'll need to navigate its conventions, guidelines, and alphanumeric structure efficiently.

CPT (Current Procedural Terminology). Maintained by the American Medical Association, CPT is the primary code set for reporting medical procedures and services, including evaluation and management (E/M) visits, surgical procedures, radiology, pathology, and medicine services.

HCPCS Level II. This covers items not included in CPT, primarily supplies, durable medical equipment, drugs, and ambulance services. HCPCS codes are essential for Medicare and Medicaid billing.

Revenue cycle management. Understanding the full revenue cycle, from patient registration and insurance verification through coding, billing, payment posting, and collections, gives you context for your role within the larger financial operation. For the full education path, see our how to become a medical biller and coder guide.

Medical billing and coding work is entirely computer-based. Here are the categories of software you'll encounter on the job.

Electronic health record (EHR) systems. Epic is the dominant EHR in the U.S., used by most large health systems. Cerner (now Oracle Health) is second most common, followed by Meditech, Allscripts, athenahealth, and eClinicalWorks. Coders access clinical documentation through these systems.

Encoder software. Encoders are specialized tools that help coders select the correct codes. Major encoders include 3M CodeFinder, Optum360 EncoderPro, TruCode, and AAPC's Codify. They include code lookup, cross-references, coding guidelines, and edits that flag potential errors.

Practice management systems and clearinghouses. Billers use practice management systems (Epic, Kareo, AdvancedMD, Greenway) to manage claim submission, payment posting, and accounts receivable. Electronic clearinghouses (Availity, Change Healthcare/Optum, Trizetto) transmit claims between providers and payers.

Computer-assisted coding (CAC) tools. An emerging category of software that uses natural language processing to suggest codes based on clinical documentation. CAC tools don't replace coders but can increase productivity by pre-populating code suggestions that you review and validate.

Hospitals are the largest employment sector for this role. Hospital coding is often more complex (inpatient DRG assignment, surgical coding, ED coding) and typically pays more than outpatient settings. Hospitals employ dedicated coding, billing, and HIM departments.

Physician offices represent a significant share of employment. The work focuses on outpatient E/M coding and may combine coding with front-office duties in smaller practices. The pace is generally less intense than hospital coding.

Third-party billing companies. Revenue cycle management firms like Optum, Conifer Health Solutions, and R1 RCM employ large numbers of coders and billers who serve multiple healthcare clients. These positions often offer remote work and exposure to a variety of specialties.

Home office. As noted in our remote jobs guide, about 64.8% of medical coders now work from home at least part-time. Remote work is especially common in outpatient coding, risk adjustment, and coding audit roles.

Entry-level coding and billing positions serve as the foundation for a defined career ladder. With experience and additional certifications, you can advance into specialty coding (HCC risk adjustment, surgical coding, oncology), coding auditing and compliance, clinical documentation improvement (CDI), revenue cycle management, and health information management (HIM) leadership.

The BLS median salary for medical records specialists is $50,250, but the top 10% earn more than $80,950. Management-level positions like HIM managers and revenue cycle directors can exceed $100,000. AAPC data shows that professionals with three or more certifications average $81,227 per year. For starting positions, see our entry-level jobs guide.