Those working as medical coders are responsible for transferring diagnostic and treatment terms from doctors and other health professionals into coded form for record keeping, use of other medical professionals, and often for billing and insurance purposes. This is accomplished by reviewing and analyzing patient health records to determine relevant diagnoses and treatment plans for individual patients. In addition, this process often requires contact with the providers of a patient’s healthcare in order to ensure proper coding.
Medical coders need to have an in-depth grasp of the content of the health records with which they work so they can find necessary information to properly code the records. Many coders receive certification that indicates they have received thorough training in the anatomy and physiology of the human body and illness forms so that they can properly recognize the different signs, symptoms, pathologies, diagnoses and other aspects of illnesses and treatments in order to translate them to a standardized code. This often requires being informed and up-to-date with illness forms and the procedures used in their treatment, often via continuing education courses in order to ensure proper coding.
Medical coders work in numerous medically related settings, including both in- and outpatient treatment locations. In addition, medical coders often work for insurance companies and software makers catering to the health industry. Many medical coders begin working as medical record clerks, and often a minimum of an associate’s degree is required to work in the field. Apart from successful completion of general educational, medical coders are usually expected to have further education in medical terminology, management of databases, coding of data and other courses directly related to the needs of the medical coding position.
Medical Coder Tasks
- Compile, abstract and maintain patient medical records to document condition and treatment.
- Review records for completeness, accuracy and compliance with regulations.
- Release information to persons and agencies according to regulations.
- Protect the security of medical records to ensure that confidentiality is maintained.
- Identify, compile and code patient data, using ICD-9-CM and CPT and other standard classification coding systems.