What is a “Medical Coder”?
Per the American Academy of Professional Coders (AAPC):
“Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory and radiologic results, etc. Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.”
“Medical coding happens every time you see a healthcare provider. The healthcare provider reviews your complaint and medical history, makes an expert assessment of what’s wrong and how to treat you, and documents your visit. That documentation is not only the patient’s ongoing record, it’s how the healthcare provider gets paid.”
Too many times, I am asked “is a medical coder the same as a computer coder?”
My response to this question is “No”, however, with the medical record now moving to an electronic format, I am beginning to question my response. As a medical coder, I spend more and more time reviewing the electronic medical record to find information needed to complete the coding process. I even make recommendations to improve the format and structure of the electronic health record. So, maybe my response to the above question should be “Yes”.
As a medical coder, I convert physician documentation into a classification that is transmitted to third party payers. My goal is to get my healthcare provider paid for services rendered. Which classification I use to convert documentation, depends on the setting for which I am coding. (i.e. inpatient, outpatient, etc. vs ICD-10-CM/PCS, CPT, etc.)
What do Medical Coders Code?
Medical coders convert documentation in the medical record into a classification that identifies:
- Diagnosis
- Procedures
- Supplies (medications, equipment, devices, bandages, etc.)
- Ancillary services (x-rays, labs, anesthesia, etc.)
Who Does Medical Coding?
When trying to determine “who” will do the medical coding, I recommend someone that has an eye for detail. In addition to learning the Official Coding Guidelines for the coding classifications used, this individual should be able to identify documentation requirements of the providers to meet the needs of the code assignment as well as any accrediting bodies for standards of care.
When Is Medical Coding Completed?
Medical coding can be performed at various times;
Retrospectively: This type of medical coding is performed after the patient is discharged from the hospital and the record is either;
Paper Record: Pulled from the notebooks on the floor and sent down to the Medical Record Department, or
Electronic Record: This type of medical record is considered closed because the patient has been discharged and based on discharge date, sent to medical coding to capture the codes.
Concurrently: This type of medical coding is performed while the patient is still in the hospital. The goal of this type of medical coding is to obtain the necessary documentation for most accurate medical coding, while the patient is still in house and the provider can still order services and document what is needed to accurately document services.
Prospectively: This type of medical coding is performed before the patient enters the facility. This type of medical coding determines if it is in the best interest of a facility to render services to patients based on case mix analysis. Case mix analysis looks at a patient’s insurance and diagnoses to determine how it impacts your facility finances.
Where is Medical Coding Performed?
Medical coding takes place wherever the medical coder has access to the documentation.
Medical Coders in the hospital settings are now, more and more, moving to home. Hospitals have found that because the paper medical record is now electronic, that electronic record can be viewed online from home. This saves the hospital space to use for other necessary projects.
Medical Coders that work from home are considered “remote medical coders”. Remote medical coders can work for the hospital right down the street, in their home town or even in another state or country. If the medical record can be accessed online through internet access, the remote coder can work from home to complete the medical coding.
How Can You Become a Medical Coder?
- Do your research – What setting are you interested in working? Which medical coding certification are you interested in? Do you know which medical coding certifications are available?
- Find a medical coding program that meets your needs. If you are a learner that comprehends best with a face-to-face classroom setting, make sure to find a program that offers face-to-face classes. However, if you are an online learner and are disciplined and motivated to comprehend the material on your own, then an online program may be an option for you.
- CodeMasterCoachs’ Medical Coding Program provides both the face-to-face experience and the online experience.
Medical Coding can be a rewarding career because it will allow you to see healthcare from a lot of perspectives. You will see healthcare as a provider through documentation, as a patient, through ancillary services rendered as well as the financial side of healthcare by seeing the reimbursement models in your code submissions to third party payers.
I knew I wanted to work in healthcare, but I did not think I was strong enough to perform the day-to-day functions with a hands-on approach. Through Medical Coding, I see the day-to-day functions but from a business perspective. If this sounds like something you may be interested in, email me at CodeMasterCoach@gmail.com.
