The Medical Coder Job Description can be somewhat variable depending on where and for when the medical coder works. Some medical records and health information technicians specialize in coding patients’ medical information for insurance purposes.
Technicians who specialize in coding are called health information coders, medical record coders, coder abstractors, or coding specialists. These technicians assign a code to each diagnosis and procedure.
They consult classification manuals and also rely on their knowledge of disease processes. Technicians then use computer software to assign the patient to one of several hundred “diagnosis-related groups,” or DRGs.
The DRG determines the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system. In addition to the DRG system, coders use other coding systems, such as those geared toward ambulatory settings or long-term care.
The medical coder job description can encompass a basic transcriptionist to a department supervisor. Medical records and health information technicians’ duties vary with the size of the facility where they work.
In large to medium-sized facilities, technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptionists while a medical records and health information administrator manages the department. In small facilities, a credentialed medical records and health information technician sometimes manages the department.
Medical coders usually work a 40-hour week. Some overtime may be required. In hospitals—where health information departments often are open 24 hours a day, 7 days a week—medical coders may work day, evening, and night shifts.
Medical coders work in pleasant and comfortable offices. This is one of the few health occupations in which there is little or no direct contact with patients. Because accuracy is essential in their jobs, Medical Coders must pay close attention to detail. Coders who work at computer monitors for prolonged periods must guard against eyestrain, muscle strain and injury related to repetitive motions or carpal tunnel syndrome.
Education and Training
Medical Coders usually enter the field as medical records clerks and have an associate degree from a community or junior college. In addition to general education, coursework includes medical terminology, anatomy and physiology, legal aspects of health information, coding and abstraction of data, statistics, database management, quality improvement methods, and computer science. Applicants can improve their chances of admission into a program by taking biology, chemistry, health, and computer science courses in high school.
Medical coders usually take advanced classes in coding and the DRG system.
Licensing and Credentialing
There is no actual licensing requirement although some states may require registration or certification. Most employers prefer to hire Registered Health Information Technicians (RHIT), who must pass a written examination offered by the American Health Information Management Association (AHIMA).
To take the examination, a person must graduate from a 2-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). Technicians trained in non-CAHIIM-accredited programs or trained on the job are not eligible to take the examination. In 2005, CAHIIM accredited 184 programs for health information technicians.
Employment is expected to grow much faster than average.
Job prospects should be very good; technicians with a strong background in medical coding will be in particularly high demand.
Entrants usually have an associate degree; courses include anatomy, physiology, medical terminology, statistics, and computer science.
This is one of the few health occupations in which there is little or no direct contact with patients.
Experienced medical records and health information technicians usually advance in one of two ways—by specializing or managing. Many senior technicians specialize in coding, particularly Medicare coding, or in cancer registry.
Most coding and registry skills are learned on the job. Some schools offer certificates in coding as part of the associate degree program for health information technicians, although there are no formal degree programs in coding.
For cancer registry, there were 11 formal 2-year certificate programs in 2005 approved by the National Cancer Registrars Association (NCRA). Some schools and employers offer intensive 1- to 2-week training programs in either coding or cancer registry.
Once coders and registrars gain some on-the-job experience, many choose to become certified. Certifications in coding are available either from AHIMA or from the American Academy of Professional Coders. Certification in cancer registry is available from the NCRA.
In large medical records and health information departments, experienced technicians may advance to section supervisor, overseeing the work of the coding, correspondence, or discharge sections.
Senior technicians with RHIT credentials may become director or assistant director of a medical records and health information department in a small facility. However, in larger institutions, the director usually is an administrator with a bachelor’s degree in medical records and health information administration.
Resources for Medical Coder Job Description:
AAPC: Medical Coding - Medical Billing - Medical Auditing American Association of Professional Coders