A medical records coder is the person working at a clinic or hospital who utilizes various medical charts and documentation from health care professionals to generate billing codes to be invoiced to patients and insurance companies. While it may sound fairly straightforward, skilled medical coders are a sought-after employee. Coding can be an intricate and difficult thing to do; any inaccuracies may result in an insurer refusing payment or reimbursing too little for what should be received. Coders provide the basic foundation that helps create efficiency in the system to allow medical care providers the financial stability they need to continue operations.
Coders must be extremely fluent with computers, but they must also have some knowledge regarding medical services and procedures. They must work closely with healthcare professionals to be clear on all charts and notes so that hard copy backup matches the billing codes on any invoices or requests for remittance sent out. Coders must then be familiar with the various codes and how they apply to private insurers, government insurers, and any other similar organizations (like the Veteran's Administration or a similar entity). The coder must also be clear on insurance plans and benefits schedules provided by the patient. Then the coder has to accurately account for deductibles and co-payments. In some situations, the medical records coder also helps facilitate the transfer of patient records between medical care providers so that specialists and associates receive accurate data regarding patients.
Typically, a medical records coder will get training and education in some sort of vocational school or an associate's degree from a community college. Coders must also pass certification tests. There are a variety of certification levels that exist, each with increasing amounts of job responsibility and commensurate salary. Coders typically work in an office environment in a hospital or clinic during standard daytime business hours.
Medical Records Coder Tasks
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.
Enter data, such as history and extent of disease, diagnostic procedures and treatment into computer database.
Compile, abstract and maintain patient medical records to document condition and treatment.
Review records for completeness, accuracy and compliance with regulations.