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.

Example:

Date of Procedure: 6/5/20xx
Patient Name: John Smith
DOB: 10/13/19xx

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 for follow-up.

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 professionalism.

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.