Imagine losing $50,000 because one code was wrong. It happened to a real orthopedic practice last year. A mistyped CPT modifier led to cascading claim denials, delayed payments, and a year-end shortfall. This isn’t an outlier—it’s an epidemic in practices across the country. The misunderstanding between medical billing and medical coding is at the heart of the problem.
This article breaks it down: what makes coding and billing distinct, how they work together, what top experts are saying, and how to protect your revenue with practical, field-tested strategies.
Why This Matters Now
In 2025, payer rules are more complex, compliance audits more aggressive, and AI automation in revenue cycle management is both a promise and a pitfall. Understanding the difference between coding and billing is no longer optional—it’s essential.
Medical Coding is the process of translating healthcare diagnoses, procedures, and equipment into standardized alphanumeric codes (ICD-10, CPT, HCPCS).
Medical Billing takes those codes and uses them to prepare and submit claims to insurers and patients to collect payment.
These processes must work in harmony. When they don’t, denials, audits, and lost revenue follow.
Expert Insights
1. Dr. Karen Lopez, CPC, CCS – Clinical Coding Specialist
"Documentation is the DNA of coding. If it’s not documented, it didn’t happen—period. Every coder must audit documentation constantly, and every clinician needs basic training in how their words turn into codes."
2. Michel Stevens, CPB – Director of RCM at a Midwestern FQHC
"Eligibility verification is the most overlooked part of billing. Every denied claim for ineligibility is 100% preventable. Automate this and review your EDI errors weekly."
3. Dr. Emily Chen, PhD – Revenue Integrity Consultant
"The gap is cultural. Coders see documentation. Billers see dollars. You need a revenue cycle huddle every week so they start seeing the same story."
4. Alex Torres, RHIA – HIM Program Director
"Training should be ongoing, not once a year. Billing and coding professionals need refreshers every quarter, especially with code set updates, payer guidelines, and software changes."
5. Reena Patel, MD – Family Medicine, Revenue Cycle Lead
"I used to think billing had nothing to do with me until I was audited. Now I train every resident in documentation essentials. It’s malpractice protection."
Story: One Small Mistake, One Big Loss
A small outpatient surgical center in Texas filed 70 claims with incorrect CPT modifiers due to a system update that wasn’t communicated to the coding team. The error wasn’t discovered until an audit flagged 20 denials, and the follow-up revealed over $50,000 in unpaid claims. Had their coders and billers conducted even one joint denial review, the issue would have been caught earlier. Now, they have a 3-tier claim review process—and haven’t had a single related denial in eight months.
Another example: A pediatric practice in California routinely billed for well-child visits using outdated ICD-10 codes. After repeated payer rejections, they brought in a coding audit team who uncovered over 900 incorrect claims. Their recovery took four months and required over 250 corrected resubmissions.
Tactical Tips for Busy Professionals
Create a shared workflow map – from intake to payment. Visualize each handoff.
Run monthly denial reports – and break them down by denial code, provider, and service line.
Set dual reviews – coders check claims before submission; billers audit remits.
Integrate payer updates quarterly – and hold payer education meetings.
Host denial huddles – 15 minutes weekly to review problem areas.
Audit notes for code support – especially for high-risk specialties (e.g., orthopedics, cardiology).
Train clinicians quarterly – include real-life denied examples.
Standardize templates in EHRs – to reduce documentation gaps.
Use front-desk scripts – to capture insurance changes at every visit.
Reward clean claims – set monthly benchmarks and celebrate accuracy.
FAQs
Q: Can coders and billers be the same person?
A: Yes, especially in small practices. But dual roles can lead to blind spots unless backed by clear workflows and audits.
Q: What's the most common mistake coders make?
A: Upcoding or using non-specific ICD-10 codes. Both increase audit risk and can lead to payer clawbacks.
Q: What software helps bridge the gap?
A: Look for platforms offering integrated eligibility, coding suggestions, E/M calculators, and denial management dashboards.
Q: How often should coding audits be done?
A: At least quarterly; high-volume practices should consider monthly.
Q: What’s the best way to train new staff?
A: Start with shadowing, use case studies, and test knowledge with simulated claims. Certification prep helps retention.
Q: How can I detect a system-wide billing error?
A: Run reports by payer, CPT, and location. Look for patterns of denial in one service or one code group.
Q: How do I prevent burnout among billing/coding staff?
A: Rotate responsibilities, cross-train, and give team members time for continued education.
Q: Are virtual visits more error-prone?
A: Yes—telehealth codes and modifiers change often. Check payer updates monthly.
What the Data Says
According to CodeEMR, 15–20% of claims are denied on first pass in 2025, with coding errors being the leading cause. (codeemr.com)
The American Medical Association states that even small documentation lapses can lead to fraud investigations. (ama-assn.org)
The 2025 CPT update added 270 codes, deleted 112, and revised 38—especially impacting telehealth and AI-based care. (unislink.com)
The average practice loses 5–8% of revenue annually due to billing inefficiencies and claim errors. (MGMA data)
E/M coding changes in 2024–2025 created confusion in almost 60% of internal audits according to the National Association of Healthcare Revenue Integrity (NAHRI).
Questioning Industry "Best Practices"
Outsourcing everything? Dangerous. It can work, but hybrid in-house/outsourced billing provides better oversight.
AI for coding? Promising—but not mature enough to go unsupervised. Think of it as a suggestion engine, not a decision-maker.
No weekly reviews? Risky. Denials should never surprise you. If they do, you're already late.
One-size-fits-all templates? Ineffective. Specialties need tailored workflows.
Relying on EHR suggestions blindly? Dangerous. EHRs aren’t coders—they just provide prompts.
Call to Action
Get Involved — Start your audit journey, join a local medical billing association, attend payer webinars, be part of something bigger. The difference between a paid claim and a rejected one isn’t luck. It’s strategy, alignment, and training.
Be the change, take the first step, raise your hand. Let’s build smarter, more connected healthcare operations. Connect with others, share what’s working, and hold your systems to higher standards.
About the Author
Dr. Daniel Cham is a physician and medical consultant with deep experience in medical tech, healthcare management, and revenue cycle optimization. He specializes in helping organizations integrate clinical workflows with reimbursement strategies. Connect with him on LinkedIn: linkedin.com/in/daniel-cham-md-669036285
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