Certified Billing and Coding Specialist

1. Medical Terminology and Anatomy : Introduces medical terminology, common abbreviations, body systems, basic anatomy and physiology, and the clinical language used to interpret healthcare documentation.

2. Medical Coding Principles : Covers diagnosis and procedure coding, ICD-10-CM, CPT and HCPCS Level II concepts, coding guidelines, code selection, sequencing and the importance of accurate clinical documentation.

3. Medical Billing and Claims Processing : Examines patient registration, insurance verification, claim preparation, charge entry, claim submission, billing records and common causes of claim errors.

4. Healthcare Insurance and Reimbursement : Develops knowledge of insurance plans, payer requirements, patient financial responsibility, reimbursement methods, medical necessity and coordination of benefits.

5. Revenue Cycle and Payment Management : Covers revenue cycle stages, payment posting, account reconciliation, accounts receivable, outstanding balances, collections and financial record accuracy.

6. Coding Compliance and Medical Records : Examines documentation requirements, coding accuracy, confidentiality, healthcare privacy, billing regulations, audit procedures, fraud prevention and ethical professional practice.

7. Claim Denials, Appeals and Practical Application : Develops skills in identifying claim denials, correcting errors, preparing appeals, following up with payers and completing an integrated billing and coding case study.

• Develops foundational medical billing and coding knowledge.

• Improves understanding of diagnosis and procedure coding systems.

• Builds skills in insurance verification and claims preparation.

• Strengthens knowledge of reimbursement and revenue cycle processes.

• Develops awareness of medical documentation and coding compliance.

• Improves skills in payment posting and accounts receivable.

• Builds confidence in identifying and resolving claim denials.

• Supports progression into healthcare billing, coding and administration roles.

This qualification is suitable for:

• Aspiring medical billing and coding specialists.

• Healthcare administrative assistants.

• Hospital and clinic billing personnel.

• Medical records and health information staff.

• Insurance claims processing personnel.

• Healthcare revenue cycle support staff.

• Learners seeking entry into healthcare administration.

Assessment Format: Written knowledge examination, coding exercises, billing assignments and practical case study.

Total Questions: 50 questions in the principal written examination, supplemented by coding exercises and practical assignments.

Passing Score: Minimum 60% in the written examination, with all mandatory practical assessments completed successfully.

Duration: 90 minutes for the principal written examination. Practical assignments and the case study are assessed separately.

Certification: Successful learners may be awarded the HiQual UK Certified Billing and Coding Specialist qualification, subject to formal programme approval and applicable certification procedures.

To deliver this Qualification, HiQual UK Approved ATPs must demonstrate the capability to deliver, assess, and internally quality assure qualifications in line with recognised regulatory principles and the expectations of the Regulated Qualifications Framework (RQF).

Approved centres must operate effective systems to ensure the validity, reliability, fairness, consistency, and security of assessment.

1. Centre Recognition and Legal Compliance

Centres must be formally recognised by HiQual UK prior to the delivery or assessment of any qualification. To maintain recognition, centres must: Be a legally constituted organisation operating in compliance with applicable legislation and regulatory requirements. Demonstrate effective governance, management oversight, and clear lines of accountability. Comply with all HiQual UK policies, procedures, and conditions of centre recognition. Notify HiQual UK promptly of any material changes that may affect delivery, assessment, or internal quality assurance arrangements.

2. Resources, Facilities, and Learning Environment

Centres must ensure that sufficient and appropriate resources are in place to support learning and assessment. This includes: Learning environments appropriate to the mode of delivery, including classrooms and, where applicable, specialist or practical facilities. Access to learning and assessment resources that enable learners to meet qualification outcomes. Secure systems for managing learner data, assessment records, and certification claims. Arrangements that support equality of access and reasonable adjustments for learners where required.

3. Staff Competence and Occupational Expertise

Centres must ensure that all staff involved in delivery, assessment, and internal quality assurance are competent and suitably qualified. Centres must: Appoint tutors with appropriate subject knowledge, teaching competence, and relevant occupational or professional experience. Ensure assessors are trained and competent in applying HiQual UK assessment requirements and standards. Appoint a qualified Internal Quality Assurer (IQA) responsible for monitoring assessment practice and decisions. Maintain records of staff qualifications, experience, training, and continuing professional development (CPD).

4. Assessment Practice and Internal Quality Assurance (IQA)

Centres must operate robust internal quality assurance systems to ensure assessment integrity. Centres must: Ensure assessment is valid, fit for purpose, and conducted in line with HiQual UK requirements. Implement effective IQA procedures to monitor assessor performance and confirm the consistency of assessment decisions. Maintain accurate, complete, and auditable records of learner registration, assessment evidence, and outcomes. Carry out regular internal reviews and standardisation activities to support continuous improvement.

5. Integrity, Risk Management, and Malpractice

Centres must take appropriate measures to protect the integrity of assessment. Centres must: Maintain policies and procedures for the prevention, identification, and management of malpractice and maladministration. Ensure secure handling, storage, and retention of assessment materials and learner evidence. Report any suspected or confirmed malpractice to HiQual UK in accordance with published procedures.

6. Health, Safety, Safeguarding, and Learner Protection

Centres must provide a safe, inclusive, and supportive learning environment. Centres must: Comply with applicable health and safety and safeguarding legislation. Conduct risk assessments for learning activities, particularly where practical or technical work is involved. Maintain procedures to safeguard learner welfare and wellbeing.

7. Learner Information, Support, and Fair Treatment

Centres must ensure learners are informed, supported, and treated fairly. Centres must: Provide clear and accurate information on programme requirements, assessment methods, and certification. Ensure learners receive timely and constructive feedback on assessment outcomes. Operate transparent complaints and appeals procedures aligned with HiQual UK requirements. Manage learner information securely in compliance with data protection legislation.

Successful learners may progress to:

• Further study in Medical Coding, Medical Billing or Health Information Management.

• Specialist training in diagnosis coding, procedure coding and healthcare reimbursement.

• Advanced professional development in medical auditing, claims review and revenue cycle management.

• Roles such as Medical Billing Specialist, Medical Coding Assistant, Claims Processing Specialist, Medical Records Assistant or Revenue Cycle Associate, subject to employer requirements.

• Further study in Healthcare Administration, Health Information Systems or Medical Office Management.