What Does a Medical Coder Do?
Coders work in a variety of settings and their individual workdays differ based on size
of facility, type of physician, etc.. The following example outlines what may be a typical
day in the life of a Medical Coder.
After settling into work and grabbing a cup of coffee the medical coder usually begins the
workday by reviewing the previous day’s batch of patient notes to be coded. The
type of records depends on the clinical setting (outpatient or facility), and may require
a certain degree of specialization. (Larger facilities may have individuals who focus
on medical specialties while coders who work in smaller, or more general offices, may
have a broad range of patients and medical conditions.)
Selecting the top patient note or billing sheet on the stack, the coder begins reading the
documentation to understand the patient's diagnoses assigned and procedures performed during
their visit. Coders also abstract other key information from the documentation, including
physicians' names, dates of procedures, etc..
Relying heavily on the ICD-9 and CPT
codebooks coders begin translating the physician’s notes into useful medical
codes. An example of basic procedure documentation and subsequently assigned codes can
be seen below.
Date of Procedure: 6/5/20xx
Patient Name: John Smith
Diagnosis: Pigmented mole
Procedure Performed: Cryoablation of pigmented mole
Indications: Mr. Smith is a 50-year-old male who comes into the office today to have a pigmented
mole removed. The mole is located on the patient’s back right at the level of his waistband,
which is causing discomfort and irritation. He is requesting removal of the offending mole.
The plan today is to remove the mole via cryoablation.
Procedure: The area around the mole was prepped with a Betadine solution and injected with
1 cc of lidocaine mixed with epinephrine. We proceeded to apply liquid nitrogen to the mole
to freeze it down to the cutaneous level for adequate destruction of the lesion. I placed
a dressing on the area to avoid irritation by the patient’s clothing. The patient tolerated
the procedure well with no complications, with the plan to return to the office in a week
Based on the previous note the medical coder would assign the following codes:
CPT code: 17110 - Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical
curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions;
up to 14 lesions
ICD-9-CM code: 216.5 - Benign neoplasm of skin of trunk, except scrotum
Many cases are pretty straightforward to code and individual medical coders develop a detailed
understanding of the procedures and commonality of their specific clinic or facility. No
matter how experienced the coder may be, occasionally a coder encounters a difficult note
that takes longer than normal to code correctly. Even among the more commonly used codes
there are significant gray areas that are open for debate among coders. With very complex
or unusual cases, coding guidelines can be confusing to interpret. Experienced coders will
rely on their network of peers and professionals to discuss nuances in online
forums, networking with specialists they have met at national conference, or with
co-workers in the office to help understand the issues and determine the proper codes. Ongoing
training and current coding-related
periodicals also provide important opportunities to advance understanding and
Eventually the coder completes the chart and picks up the next patient record. This cycle
of reading, note taking, assigning codes, and computer entry repeats with each chart throughout
the day. Most coders will spend the majority of their day sitting at the computer reading
notes and using the computer to enter data into a billing system or search for information
to clarify the documentation in the notes.
Coding is fairly independent work but interaction with other coders, medical billers, physicians,
and ancillary office staff is essential. Medical coders are usually placed on fairly tight
production schedules and are expected to complete a certain number of notes each day or to
keep their lag days at a specified timeframe. Lag days is the number of days it takes for
the note to be documented to the actual claims submission date. The prime date is usually
between 2 to 5 days at most.
Depending on the clinical setting, internal or external auditors will
periodically perform audits of the coding and documentation for accuracy and completeness.
The results of these coding audits are maintained by the compliance department
or the department supervisor and are a big part of job evaluations.
At the end of the day coders return unprocessed work, check productivity either by a manual
count or by running a computer report, and clean their working area. Depending on the clinical
setting medical coders may share a workspace with other coders assigned to other shifts where
coding may continue around the clock or they may work alone from their home office.
Today over 110,000 medical professionals are members of AAPC (American
Academy of Professional Coders). This professional association provides a variety of opportunities
to elevate the standards of medical coding by developing training, professional certification,
opportunities to network with other
related medical professionals and a variety of job search database and
career building opportunities.