What Does a Medical Coder Do?
Medical coders play a pivotal role in the healthcare industry by translating patient care services into standardized billing and data analysis codes. They examine clinical documents and apply appropriate classification codes to patient records, ensuring accurate representation for reimbursements from insurance companies and government agencies.
Beyond the immediate scope of billing, the role contributes to broader healthcare analytics and quality control. By consistently applying the correct codes, they enable healthcare providers to compile and analyze large data sets. These data sets are crucial for research, policy formulation, and identifying trends in healthcare, making the coder’s role essential for ongoing improvements in patient care.
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Medical Coder Compensation
Compensation for medical coders will vary based on experience, geographic location, and certifications. Working for larger healthcare systems or specializing in specific medical fields can also impact pay rates. Click below to explore salaries by local market.
The average national salary for a Medical Coder is:
$46,500
Medical Coder Roles and Responsibilities
- Code Diagnosis and Procedures: Interpret and assign medical codes for diagnoses and procedures from various types of healthcare documentation.
- Data Entry: Input data related to coded information and other healthcare data into computer systems.
- Review Records: Evaluate medical records for completeness and accuracy, confirming all required data is entered and properly coded.
- Quality Assurance: Regularly cross-reference and verify data across different sources to maintain high data quality.
- Communication with Healthcare Providers: Work closely with healthcare providers to clarify diagnostic and procedural details for accurate coding.
- Billing Support: Assist the billing department by providing accurate codes for patient treatments to streamline the reimbursement process.
- Compliance Monitoring: Maintain adherence to coding guidelines and regulations to maintain ethical standards and avoid legal consequences.
- Continuing Education: Keep up to date with changes in coding standards and participate in educational opportunities to improve job performance.
Medical Coder Job Requirements
A candidate qualified for a medical coder position should have a background in healthcare administration, with particular emphasis on medical coding. Knowledge of medical terminology, anatomy, and healthcare compliance is essential for effectively carrying out the roles and responsibilities. Familiarity with coding software is also critical.
Experience
- Minimum of 1-2 years of medical coding experience
- Prior work with Electronic Health Records (EHR)
- Experience in specialized fields like cardiology, orthopedics, or radiology is a plus
Hard Skills
- Proficiency in ICD-10-CM, CPT, and HCPCS Level II coding systems
- Familiarity with medical terminology
- Data entry skills
- Mastery of relevant software and EHR systems
Soft Skills
- Attention to detail
- Strong communication skills
- Ability to work independently
- Problem-solving capabilities
- Time management
Medical Coder Education and Certifications
The position requires a high school diploma or the equivalent, but a bachelor’s degree is typically preferred. Some employers accept candidates who have completed a certified medical coding program in place of a degree.
- Certified Professional Coder (CPC). A certified professional coder is a certification and exam process for healthcare and medical-based coding positions. This certification, which is provided by the American Academy of Professional Coders, is a well-known and widely recognized certification that can lead to immense benefit for a professional medical coder. Because of this, this is one of the key certifications for the position and job of a medical coder.
- Certified Inpatient Coder (CIC). This certification, offered by the AAPC, is specifically targeted toward coders who work in inpatient settings such as hospitals. The CIC certification validates expertise in inpatient medical coding and is considered highly valuable in the industry.
- Certified Coding Specialist (CCS). The CCS certification is another industry-recognized credential offered by the American Health Information Management Association (AHIMA). This certification is aimed at coders who can work in multiple settings and have advanced skills in classification and subsidiary systems.
- Registered Health Information Administrator (RHIA). Also from AHIMA, the RHIA certification is a more comprehensive credential incorporating medical coding as part of a broader skill set in health information management. While not exclusively a coding certification, many employers value the RHIA as an indicator of a candidate’s wider grasp of healthcare administration.
- Registered Health Information Technician (RHIT). Similar to the RHIA but more focused on the technical aspects of medical records and health information, the RHIT certification from AHIMA is widely recognized and respected in the industry.
- Certified Coding Associate (CCA). The CCA certification, another offering from AHIMA, is an entry-level certification for new coders. While not as advanced as other certifications, the CCA can be a good starting point for individuals new to the field.
- Certified Professional Coder-Hospital Outpatient (CPC-H). This certification is designed for coders in outpatient hospital settings and is administered by the AAPC. It focuses on the coder’s ability to apply coding principles to produce accurate and efficient outpatient medical records.
- Certified Professional in Healthcare Compliance (CPCH). Offered by AAPC, the CPCH certification focuses on healthcare compliance in medical coding. It provides coders with an understanding of legal regulations and guidelines, making them more versatile in their roles.
Sample Job Descriptions
The first step when hiring is to create a well-crafted medical coder job description. Below are real-world examples to use for a successful recruiting journey.
Certified Medical Coder Job Description
Responsibilities
Code patient health records for purposes of retrieval, analysis, and billing.
- Identify pertinent information in patient records.
- Assign the International Classification of Diseases, Clinical Modification (ICD), Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, creating Ambulatory Patient Classification (APC) or Diagnosis-Related Group (DRG).
- Complex coding.
- Maintain acceptable productivity/quality rates in accordance with coding policies.
- Consult physicians when coding assignments are unclear or documenting in the record is inadequate, ambiguous, or unclear.
- Maintain knowledge of and comply with coding guidelines and reimbursement reporting requirements.
- Audit charts for physician documentation requirements and internal coding.
- Provide physician education as appropriate.
- Abide by the American Health Information Management Association Standards of Ethical Coding
Requirements
Licensure / Certification / Registration:
- Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained before hire or job transfer.
- Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained before hire or job transfer. All specialties accepted.
- Coder specializing in Cardiac credentialed from the American Academy of Professional Coders (AAPC) obtained before hire or job transfer date.
- Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained before hire or job transfer date.
- Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained before hire or job transfer date.
Education
- HS diploma equivalency or 1 year of applicable job-specific experience required.
Health Network Medical Coder Job Description
A healthcare network in (City) is looking to add a new Medical Coder for a promising opportunity with their team in (City). In this role, the Medical Coder will be responsible for supporting medical professional corporations’ procedural and diagnostic coding of medical records for billing.
Responsibilities:
- Works with professional and non-professional staff for timely record review and ensuring the accuracy of medical documentation and sequencing ensuring that codes meet required legal and insurance rules
- Works with internal and external billing staff to ensure timely and complete billing of claims and encounters
- Collaborates and corresponds with insurance companies and healthcare professionals to resolve claim denials
- Maintains medical records both electronically and hard copies and maintains productivity and chart metrics
- Collaborates with management staff for process improvement, project work, etc.
- Performs compliance audits regarding billing, procedural and diagnostic coding to ensure documentation is accurate and timely
- Submits statistical data for analysis and research by other departments
- Performs other duties, as needed
Qualifications:
- 1+ years of Medical Record Coding & Record Review experience
- Associate’s Degree
- Certified as Professional Coder (CPC or CSS-P)
- ICD-10 certified, knowledge and experience in CPT codes required
- Proficiency with Electronic Medical Records (EMR) or Electronic Health Records (EHR) required
- Medical terminology and coding both ICD-9 and ICD-10, CPT
- Experience in Internal and External Audits
- Knowledge of the Billing Cycle
- Microsoft Office Suite proficient
- Solid problem-solving and time-management skills
- Great interpersonal skills
- Excellent communication skills (written and verbal)
- Strong attention to detail
- Highly organized
Desired skills:
- Bachelor’s Degree
- Certified Risk Adjustment Coder (CRC)
- Experience working within a Managed Care Health Organization and Outpatient Medical practice
Radiation Oncology Coder Job Description
RESPONSIBILITIES
• The Radiation Oncology Coder is responsible for ensuring all services rendered are captured timely, coded accurately, and meet documentation requirements when processed through the EMR and Billing Systems.
• Demonstrates working knowledge of all facets of role, relevant regulations, and organizational and departmental policies and procedures
• Primary Key Performance Areas: Coding Documentation, Authorization Billing, Collections, Radiation Coder Audits, & Integrity Report Findings.
QUALIFICATIONS
• Education: High school diploma or GED required.
• Certifications/Licenses: ROCC , CPC or COC preferred.
• Proficient knowledge of medical terminology, ICD-10 and CPT Coding.
• Minimum of 1 year of experience with ICD10 and CPT coding in the radiation oncology field is required.
• Proficiency in the use of the required programs to accomplish efficient coding.
• This includes, but is not limited to; Aria, Centricity, ONCO EMR, Excel, Word, Outlook, and Teams
Remote Medical Coder (HIMD) Job Description
Position function
Under the direction of the Coding Manager, functions as a coder for the Health Information Management Department to collect and classify diagnostic, procedural, and patient information from physicians and medical records. This position has the option to work remotely.
Education, qualifications, and standards
- Certified Coding Specialist (CCS) with at least one year of acute care coding experience
- OR a Registered Health Information Administrator (RHIA) with at least one year of acute care coding experience
- OR a Registered Health Information Technician (RHIT) with at least one year of acute care coding experience
- OR a Certified Coding Associate (CCA) with at least two years of acute care coding experience
- OR a Certified Professional Coder/Hospital (CPCH) with at least two years of acute care coding experience
- OR a Bachelor’s Degree with at least one year of acute care coding experience
- OR an Associate Degree with at least one year of acute care coding experience
- OR a High School Diploma with at least three years of acute care coding experience
- AND must score 80% or higher on the HIM Coding Screening competency.ICD-10, CPT-4, Medical Spelling, and Med Term Prefixes
Surgical Center Medical Coder Job Description
Job summary and qualifications
As a Medical Coder, you will contribute to the company’s mission and vision by reviewing medical record documentation. You will apply appropriate coding based on the diagnosis and procedure guidelines for code selections that adhere to the company’s Coding Compliance Policies and Procedures.
Responsibilities
- You will code outpatient surgery center(s) records in a timely manner, including the assignment of ICD-10-CM, E/M, Procedure Categories, and HCPCS/CPT procedure codes
- You will code an average of 80-150 charts per day
- You are responsible for resolving codes and diagnoses with conflicting or unclear information by utilizing the query tool to gather additional information
- You will ensure 3M encoder updates are timely and accurate
- You will bill cases by furnishing completed assessments of billing supplies and implants
- You will be assisting with the preparation for accrediting bodies and/or state reviews
- You are responsible for reviewing official data quality standards, coding guidelines, company policies, and procedures, and clinical resources to assure coding knowledge and skills remain current
Qualifications
- A registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) college degree preferred
- Minimum (2) years experience in outpatient coding and/or Health Information Management required
- Minimum (1) year of experience in a medical office setting highly preferred (i.e. ambulatory surgery center, hospital, doctor’s office)
- Completed coursework in Human Anatomy & Physiology, Medical Terminology, and Introduction to Coding (including ICD-10 and CPT) preferred
- Successful completion of an ICD-10-CM training or certification curriculum; or if currently pursuing such, then completion of 50% or more of the curriculum to date with an expectation of finishing within 2 months after hire
- Must provide certification from a recognized professional coding organization, transcript from an educational institution, or similar proof of successful completion (i.e., competency assessments)