What is a medical record coder?
A coder is a skilled non-clinical person who reads and interprets medical record documentation to identify all diagnoses, conditions, reasons for treatment, services and procedures performed and then transforms the verbal descriptions of these into numerical codes. Coders assess the quality and quantity of clinical documentation in order to accurately identify and capture all codeable and billable diagnoses, services, and supplies during an inpatient or outpatient encounter. The codes assigned for each encounter are then abstracted onto a claim form and submitted to insurance companies for physician and facility reimbursement for services rendered.
Coders are very vital to the accuracy of information abstracted and submitted to insurance companies and state data repositories. Abstracted information is also used nation wide in health care research, trending, marketing, healthcare cost containment, physician profiling, etc. If information is inaccurate, data used to make important decisions about insurance coverage, patient outcomes, and government spending would be skewed. As one of the fastest growing occupations in one of the fastest growing industries, a coding or HIM career places you right where the expanding arena of healthcare meets the cutting edge of technology.
What training do medical record coders receive?
Coders require a strong knowledge of medical terminology, anatomy and physiology, disease processes, and pharmacology. These courses along with office simulation, billing and reimbursement, computer training, ICD-9 CM, CPT-4, HCPCS coding systems in coordination with hands on coding, are all taught in our coding curriculum. The last semester of the program is a hands-on coding internship at various hospitals, physician offices, outpatient clinics, and billing services throughout the low country. Coding students are encouraged to take additional computer classes to prepare them for the prospects of working with a completely computerized medical record and possibilities of working off-site where technical support is at a minimum.
Where do medical record coders work?
Coding professionals can work in a vast array of settings world wide which include: hospitals, outpatient clinics, physician offices, coding software venders, insurance companies, consulting firms, attorney offices, accounting firms that specialize in healthcare, billing services, text book publishing companies, American Medical Association, state medical review agencies, nursing homes, FBI, to name a few.
Positions and professional job titles include:
- Charge Master Specialist
- Clinical Abstractor
- Coder Level I, II, or III (depends on certification)
- Compliance Officer
- APC Coordinator
- DRG Coordinator
- Biller
- Insurance Claims Analyst
- Auditor
- Education Consultant
What type of person is successful in a medical record coding career?
Anyone who is detail-oriented, loves to read, has a genuine interest in the human body and how it works would be a great candidate. Individuals who have a desire to work in the health care industry but do not want to have hands on patient care should research this career. If you have an interest in healthcare and information technology, health information management (HIM) may be the right career choice for you. Being a coder is a lot like being a detective. Coders must be able to read a patient story, ask questions, look for any inconsistencies in the story and pick out the “clues” they need to put the pieces of the episode of care “puzzle” together. That story begins with his history, who took care of them, how he was treated, and what happened while he was cared for. Being able to analyze data, maneuver around in the computer, and communicate effectively with clinical staff are important skills to achieve.
What is the future job outlook for medical record coders?
The opportunity and demand of the future job market for coders is bright. There is a national shortage of credentialed coders at this time and is not projected to improve over the next seven years. The US Department of Labor, Bureau of Labor Statistics projects a 49 percent growth in the number of health information management (HIM) workers by 2010, making this occupation one of the fastest-growing health occupations. Approximately 6,000 new HIM workers are needed each year to fill new positions and replace those who retire or leave the field. Today, 2,000 new graduates enter the HIM field each year.
In 2001 according to this study, 136,000 medical record and health information technician jobs were vacant. The study projected that by 2010, there would be 202,000 job openings nationwide.
How much money will I make?
According to national surveys conducted by AHIMA and AAPC in 2002, salary ranges are as follows for the Southeast:
- Claims Analyst $27,733
- Coding Specialist $31,758
- Coder-physician $30,316
According to AAPC’s 2003 salary survey, salary ranges are as follows:
- Claims Analyst $30,894
- Coding Specialist $33,388
- Coder-physician $31,409
Salaries varied by job title, place of employment, years of experience, education, and credentials (CCS, CCA, CPC, CPC-H, CCS-P). Range falls between $27,000-$41,000.
Where can I go to learn more about the coding profession?
There are two things prospective students should do to learn more about this expanding profession. First, search the AHIMA and AAPC websites for coding trends, job outlook, resources, etc. Provided below are links to specific areas within these sites. Second, contact a person practicing as a coder and interview them. She can provide you with real life success stories and advice for entering the field. And finally, contact the Medical Record Program Coordinator at Trident Technical College.
American Health Information Management Association (AHIMA)
American Academy of Professional Coders (AAPC)
