medical coding

What Medical Coding Means and What the Job Entails

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If you are considering a career as a medical coder, it may be useful to know what you can expect to do on a day-to-day basis. Although the exact tasks will depend on where you work (which could be a small clinic, a large hospital, or even a home office) most medical coders follow a standard routine, which looks something like the following.

Beginning the Day

Medical coding specialists tend to work shifts, meaning their working day may start early in the morning, late in the evening, or anywhere in between. Typically, they begin their shifts by reviewing the patient notes that need coding. Those who work in a large facility with many other coders may specialize in certain medical conditions, whereas workers at a physician’s office are more likely to be responsible for coding all patients’ records.

Coders takes the first patient note or billing sheet and reads through the documentation. They then turn the diagnoses, treatments, and procedures into Current Procedural Terminology (CPT) or International Classification of Diseases (ICD) codes. Third-party payers use this information for reimbursement purposes.

Dealing with Problems

Coders may encounter a couple types of issues when working through documentation. Firstly, a chart may be missing information or the information may be unclear. In these cases, the medical coder contacts the physician or nurse for clarification. This is essential, as incorrect code can lead to the lack of reimbursement for a patient.

Another difficulty occurs when it is not obvious which code to use. This may happen in unusual or complex cases. Even experienced coders may face this problem on occasions. The best way to resolve such an issue is to discuss the case with coworkers or other professionals, while maintaining patient confidentiality.

Other Tasks

The majority of a medical coder’s day is spent dealing with the above, and it is necessary to work as quickly as possible to meet deadlines. However, coders also spend time interacting with other coding specialists, medical billers, physicians, and office staff. For instance, they may need to help coworkers locate a piece of code or they may come together with other coders to share ideas. Medical coders also need to keep up with training to improve their productivity and learn new types of code.

Finishing the Day

At the end of their shifts, coders return unprocessed work and check their productivity for the day, either by counting or running a computer report. Those who share a workspace with another professional must also clean up the area.

If medical coding sounds like a job you would enjoy, the best way to get started is to take a medical billing and coding course from an accredited school. Look for programs that lead to the Certified Billing and Coding Specialist (CBCS) certification for increased opportunities after you graduate.