A medical coder's job is to translate information from patient records into medical codes that healthcare providers and insurance companies can use for billing and record-keeping. Medical coder's work in an administrative role within the healthcare industry and are responsible for ensuring that patient records are accurate. Here are some of the responsibilities of a medical coder:
- Review medical documents: Examine medical records, such as physician's notes, lab reports, procedures, diagnoses, or equipment, for missing information
- Translate information: Transcribe patient information into medical codes, such as diagnosis codes, treatment/services codes, and medical hardware codes
- Assign codes: Assign codes such as American Society Anesthesiologists (ASA),Ambulatory Payment Classifications (APC),or Diagnosis related groups (DRG)
- Communicate: Communicate with medical providers and insurance companies to confirm details or get information to 'code to the highest degree of specificity'
- Comply with guidelines: Comply with medical coding guidelines and policies, as well as corporate policies, hospital policies, and Centers for Medicare and Medicaid Services (CMS) guidelines
- Provide guidance: Provide technical guidance and training on medical coding to physicians and staff
Medical coder need to be knowledgeable in medical terminology and anatomy, and proficient in a variety of medical codes. They also need to have excellent interpersonal skills to communicate effectively with providers and other staff members.