What Does a Medical Coder Do?
A medical coder is someone in an administrative position within the healthcare industry. They are responsible for translating details from a patient’s medical documents into medical codes to ensure that patient’s records are accurate. These documents may include physician’s notes, lab reports, procedures, diagnoses, or equipment.
Following this process, healthcare providers and insurance companies will use the transcribed codes for billing and record-keeping.
Medical coders play an essential role in the billing process. Their strong knowledge of anatomy, pathophysiology, and the medical procedures they are coding provides a direct bridge of understanding between payers and providers.
Another crucial contribution medical coders deliver with their compliant coding is reliable tracking statistics for disease and medical treatment. Diagnosis codes are used to analyze disease patterns in different population groups, which provides valuable information for national-level health trends and potential prevention plans.
What to expect during a shift
Once the medical coder selects a patient’s note from their stack of assignments, they begin carefully reviewing the documentation to understand the diagnoses and procedures performed during the patient’s visit. They also take note of any other key information from the chart, such as physician names and dates of procedures.
Coders rely on ICD-10 and CPT code books to begin translating the physician’s notes into useful medical codes. They must purchase new versions of these books yearly to ensure their coding stays up to date with the latest coding guidelines.
An example of basic procedure documentation and subsequently assigned codes:
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 (e.g., 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: D22.5 Melanocytic nevi of trunk
Finally, the coder completes the chart and begins the next patient record. This cycle of reading, note-taking, assigning codes, and computer entry repeats for each chart. Most coders spend the majority of their day sitting at the computer reading notes and using their computer to enter data into a billing system or to search for information to clarify the documentation in the notes.
They 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.
Because coding audits help organizations maintain accuracy and compliance, internal or external auditors will periodically perform audits of the coding and documentation. The results of these coding audits are maintained by the compliance department or the department supervisor and are a significant part of job evaluations.
Unlike many other healthcare careers, medical coders can enjoy a predictable schedule where they are not required to be on-call or work weekends. At the end of their shift, coders return unprocessed work, check productivity either by a manual count or running a system report, and then finish by cleaning 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.
Where do medical coders work?
Medical coders have a variety of workplaces to choose from. Some of the most common facilities that employ them are:
Outpatient surgery centers or clinics
Healthcare consulting services
Because of the available technology that enables HIPAA-compliant remote access to electronic health records (EHR), many coders can also work from the comfort of their own homes.
Typically, most employers will require two to five years of coding experience for remote positions. They often prefer to have newer coders learn in-house guidelines under supervision. But there is speculation that entry-level coders will begin to have access to more remote options as telecommuting continues to grow in popularity.
Who do coders work with?
Because medical coding is more of a behind-the-scenes job, coders can complete most of their work independently. However, while they don’t have to interact with patients firsthand, they often are still expected to participate in team calls or answer to directors.
Coders will also contact doctors, nurses, and medical assistants when further explanation is needed to understand a patient’s medical documents better. Then, after coders transcribe a patient’s visit, they pass that information to a medical biller, who will submit a medical claim to the insurance company.
What are important medical coding skills?
Technical skills that are necessary for the job include:
However, in addition to these, a medical coder will also need professional skills such as:
Critical thinking / problem-solving
Attention to detail
Is it the right career for you?
Medical coding is a great career option for a recent high school graduate looking for an alternative to the standard college route – or anyone looking to switch to a stable career that allows room for growth.
Starting a career in medical coding doesn’t require spending a fortune on an education that takes several years to complete. The tuition for a college program can be as high as $19,000. In contrast, with training and education through AAPC, someone can be career ready within six months after spending less than $3,000.
Employers recognize the hard work that goes into passing a medical coding certification exam. When coders earn a credential, they prove they are reliable and can do the job well. Because of this, employers prefer certified coders over degreed coders.
Another benefit to this career is that medical coders are in high demand. Throughout the U.S., physicians see roughly 860.4 million patients each year - and every patient encounter requires a medical coder to report the office visit.
Medical coding salary
There is plenty of room for growth in the medical coding career.
On average, medical coders who are not certified earn approximately $47,200 per year. In contrast, certified medical coding specialists can make $11,000 more — an annual salary of $58,055 or $27.91 per hour on average.
What factors affect salaries for medical coders?
Certification pays. The average salary for professional coders with two credentials rises to $64,712. Coding specialists with three or more credentials earn approximately $69,942 per year. A medical coder can expect their salary to increase the most after earning a CIC, CPB®, or CDEO certification.
Experience shows expertise. The more experience a coder has, the more an employer will pay them. While a CPC® with one to three years of experience earns about $45,456 per year, a CPC® with eight to ten years of coding experience has an average yearly salary of $57,769.
The bigger the employer, the bigger the paycheck. The size of the employer will determine how much they can afford to pay their medical coders. For example, the largest type of employer is the health system, which pays 19% more than a physician’s office would.
The AAPC salary calculator can be used to find an estimate based on certain factors such as location, years of experience, and certification(s).
About the author
Thought Leadership Team
Editorial Staff / AAPC
The AAPC Thought Leadership Team is a distinguished consortium of experts, visionaries, and thought leaders committed to shaping the landscape in the industry. With a deep understanding of the profound impact our industry has on society, this council serves as a guiding force, driving the development and implementation of ethical standards in coding practices.