What Does a Medical Coder Do?
Medical Coders work in a variety of settings and their individual workday may differ based on the size of facility, type of physician, type of specialty, etc. The following example outlines what a typical day in the life of a Medical Coder may look like.
After settling into the office and grabbing a cup of coffee, a medical coder usually begins the workday by reviewing the previous day's batch of patient notes for evaluation and coding. The type of records and notes 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 reviewing 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 physician names, dates of procedures, and other information.
Coders rely on ICD-10 and CPT code books to 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 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 simple to code. Individual medical coders develop a detailed understanding of the procedures and commonality of their specific clinic or facility. Coders occasionally encounter a difficult note requiring in-depth research, taking more time to code correctly. Even among the more commonly used codes are significant gray areas open for examination among coders. With very complex or unusual cases, coding guidelines may 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 conferences, or consult with co-workers to help understand the issue and determine the proper codes. Ongoing training and current coding-related periodicals also provide important opportunities to advance understanding and professionalism.
Finally, the coder completes the chart and begins the next patient record. This cycle of reading, note taking, assigning codes, and computer entry repeats with each chart. Most coders will spend the majority of their day sitting at the computer reading notes and using their computer to enter data into a billing system or search for information to clarify the documentation in the notes.
Professional coders largely work independently. However, interaction with coding staff, medical billers, physicians, and ancillary office staff is essential. Medical coders are usually placed on tight production schedules and expected to complete a determined number of notes each day or to keep their lag days at a specified timeframe. Lag days are the number of days it takes for the notes to be documented to the actual claims submission date. The prime date is usually between two to five days.
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 significant 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 system report, and clean their work area. Depending on the clinical setting, medical coders may share a workspace with other coders assigned to opposing shifts where coding may continue around the clock. Some coders work alone from their home office.
Today over 156,000 medical professionals are members of AAPC. AAPC elevates the standards of medical coding by developing training, professional certification, opportunities to network with other related medical professionals and providing a variety of job search and career building opportunities.
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