Job Description for a Coder
Medical coding involves assigning numeric and alphanumeric codes to medical diagnoses and procedures. Performed by specially trained professionals called coders, medical coding provides information for billing and reimbursement, gathering statistics, reporting and marketing. Medical coders work in a variety of environments, such as doctor's offices, hospitals, outpatient clinics, insurance companies and governmental health care agencies. Even in different work environments, the overall medical coder job description basically remains the same.
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Review Information
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Medical coders first review patient health information to determine the patient's diagnoses assigned and procedures performed. Coders read through medical reports and physician and nursing notes, and review laboratory reports, pharmacology notes, X-rays and other information that provides supportive documentation.
Assign Codes
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Once a medical coder has determined the diagnoses and procedures for the patient, she assigns the corresponding codes. Each diagnosis and treatment in a patient's medical record has a corresponding numeric or alphanumeric code. The coder assigns codes generally by typing the diagnosis or treatment name into a software system. The coding software then takes the coder through a series of questions in order to assign the correct codes. In many cases, a coder may double-check unclear software code assignment by referring to specialty coding books.
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Sequence Codes
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In order to receive appropriate reimbursement, medical codes must be sequenced -- or listed -- according to coding rules. For example, if a patient was admitted to the hospital for a fractured hip with a hip replacement, but also had her diabetes treated while there, the fractured hip code is listed first, with other diagnoses listed as secondary. Coders receive special training in order to understand accurate code sequencing for reimbursement and reporting.
Review Reimbursement Assignment
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Medical codes, and sets of codes, have specific reimbursement amounts assigned to them. When working with the medical coding software, coders not only ensure correct code assignment and sequencing, but also review assignment of reimbursement. In smaller health care organizations, medical coders may perform both the coding and billing function by assigning the codes and then completing the billing claim paperwork and submitting it to the insurance company.
Discuss With Clinicians
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One of the responsibilities of a medical coder is to discuss documentation inconsistencies or questions with physicians and other clinicians. A medical coder cannot assign a code unless the diagnosis or procedure has been documented by the clinician. In some cases, a coder may see evidence that a patient is being treated for a specific diagnosis through drugs prescribed or tests ordered, but documentation does not clearly support the diagnosis. The coder works with the clinician to ensure that complete and accurate information appears in a patient's medical record.
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