Medical coding is a specialized profession within the wider field of healthcare administration. Professional medical coders review the documentation contained in patients’ medical records, then they translate the written documentation into universally accepted, industry-standard medical code. These codes are used to submit claims to third party payers, and to gather statistical information, both by tracking incidents of specific diseases, and by discerning developing trends in treatment protocols.
Accurate medical coding is essential to the healthcare industry. It is how claims for payment are reported for appropriate reimbursement of provided medically necessary services. Above and beyond that, the granulated, specific data contained in medical codes provides a picture of a given patient’s health history. When collected in aggregate, this information is used by actuaries to determine how to allocate capital for future healthcare needs. It is also used to steer incentives to specific programs that encourage quality of care that focus the healthcare industry on providing services that are considered to be of benefit to the general population.
In practice, medical coding is primarily used to file healthcare claims, but the data contained in these claims has further uses for accurate diagnosis and procedure codes, long after individual claims are paid.
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Medical Coding is not Medical Billing
In some settings, a medical biller also serves as a medical coder and, in fact, medical billers are familiar with the basic precepts of accurate medical coding. Professional medical coders are aware of the reimbursement implications of the codes they assign, but their primary concern is not with money, but with the accuracy of the information communicated by their work.
Professional certified medical coders essentially act as translators. They review a patient’s medical record as written by physicians, therapists, nurses, technicians, and other healthcare providers. After comparing the documentation to the standards established by the American Medical Association, the Centers for Medicare and Medicaid Services, and contractual agreements with commercial health insurance plans, certified medical coders abstract the pages of written information, and they distill it into standardized codes. Procedures are translated into codes contained in the indices of Current Procedural Terminology (CPT codes), the Healthcare Common Procedural Coding System (HCPCS Level II codes), and the codes contained in Volume 3 of the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM). Diagnosis codes that describe a patient’s condition at the time services were rendered are rendered into codes found in Volume 2 of ICD-9-CM.
Medical billers use these codes to submit claims to describe medically necessary services that should be reimbursed at agreed-upon rates by third-party payers. Statisticians, researchers, public health officials, and internal auditors use these codes to determine what services were provided, and why, to a patient population. Accurate medical coding has many ramifications that affect not only the fiscal health of a healthcare institution, but they also affect public policy on a grander scale.
Is Medical Coding a Viable Career?
According to the American Academy of Professional Coders (AAPC), there are over 110,000 certified medical coders who carry credentials from this professional organization. The basic credential offered by AAPC is the title of Certified Professional Coder (CPC). Specialty certifications are also offered by AAPC, such as Certified Professional Coder-Hospital Outpatient (CPC-H), or Certified Interventional Radiology Cardiovascular Coder (CIRCC).
The American Health Information Management Association (AHIMA) also offers credentials to trained coding professionals. AHIMA offers the designation of Certified Coding Specialist (CCS), and Certified Coding Specialist-Physician-Based (CCS-P).
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AAPC credentials tend to focus on the mastery of coding issues in the outpatient professional setting, while AHIMA, which has a broader mandate that covers aspects of health information management beyond only coding, focuses on issues that occur in the inpatient hospital setting. AHIMA offers other credentials that do not center on medical coding, though accurate medical coding is always a component of the required core competencies. Likewise, AAPC offers credentials, such as Certified Professional Medical Auditor (CPMA), or Certified Compliance Officer (CCPO), that have coding as their basis, but also have wider applications.
There are other professional bodies that offer certification to professional medical coders. The reason there are so many specialized credentials available is because there is a demand for them. Employers expect professional medical coders to be certified in the roles they fulfill within an organization. This can be by assigning codes for reimbursement, reviewing healthcare claims for accuracy before or after payment has been received, educating healthcare providers in proper medical coding methodology, and identifying weaknesses in medical documentation.
How to Become a Professional Medical Coder
As indicated only briefly above, becoming a professional medical coder in today’s competitive job market requires an investment in education. The issues involved in medical coding are ever-changing as new policies are introduced or reversed. Coding methodology has changed over the years since CPT, HCPCS, and ICD-9-CM codes became the reporting standards in the early 1980s. In October, 2013, the United States is set to convert from Volumes 1, 2, and 3 of ICD-9-CM to ICD-10-CM and ICD-10-PCS. Professionals with a solid foundation in ICD-9-CM are expected to make the transition smoothly, while professionals who do not have as thorough an understanding of the methodology of ICD-9-CM are expected to overwhelmed by the increased specificity and granularity of data that ICD-10 will introduce to the system.
Certified medical coders have passed tests that prove their professional understanding of medical terminology, anatomy and physiology, and the practice of medicine. They also understand the components that are required to be documented in order for a code to be assigned to a given procedure or condition. They are as fluent in the technical language of medicine as it is practiced, as they are in the technical language of medical code, through which the practice of medicine is reported.
No layperson can pass a medical coding certification exam without accredited training and experience. Formal programs of study are offered through community colleges, private schools, and online study courses. Most medical coding programs require an externship working in the industry to gain appropriate experience in the field. Before a medical coder can become a CPC, he or she must complete a year as a Certified Professional Coder Apprentice (CPC-A). AHIMA offers the credential of Certified Coding Associate (CCA), which means that the holder of this credential is competent in the application of codes, but has not yet exhibited mastery of all the issues involved.
What the CPC-A, and the CCA show to employers is that an applicant for a coding job has competed the scholastic requirements of a professional medical coder, they have not yet been seasoned by direct practice of the skills they have learned. Reputable credentials, offered by other professional organizations, have established similar requirements. There is no shame in holding any credential. All professional credentials, no matter what professional body issues them, are proof that a job applicant has succeeded in absorbing all the information that will be required to perform their job. The commitment to success in their chosen profession is obvious, and all that is left is the chance to excel. Having proven their dedication to their learning how to assign medical codes by completing a program of study, the only thing left to do is exercise the knowledge introductory certification holders have gained.
Where do Medical Coders Work?
Professional certified medical coders are employed by hospitals, physician group and individual practices, skilled nursing facilities, laboratories, outpatient clinics, ambulatory surgical centers, home health agencies, durable medical equipment suppliers, and mental health facilities. When medically necessary healthcare services are provided, medical coders are employed.
After they have mastered their core competencies, certified medical coders ply their trade in numerous settings in which they build successful and rewarding careers.