Medical coding is a diverse field with numerous opportunities for advancement. Due to the current regulatory climate designed to prevent healthcare fraud and abuse, jobs are steadily increasing as statutes and guidelines become more complex. Professional, certified medical coders are at the forefront of this dense thicket of laws and rules, working to ensure that physicians and healthcare facilities receive accurate reimbursement for provided, medically necessary services.

Medical coders are not the same as medical billers, though many certified medical coders often begin their careers as billers. Some remain in billing for their entire careers, while others pursue further education opportunities to advance into the field of medical coding compliance and medical auditing.

A Medical Coder’s Job

Certified medical coders translate medical records into industry-standard code that is read by insurance companies, government healthcare programs, and organizations that gather healthcare statistics. Their primary responsibility is not to manage the financial matters of healthcare, so much as it is to manage the quality of information used to describe medical services and conditions.

When medical bills are coded correctly, medical billers can submit claims for timely, legally justifiable reimbursement. This does not only include procedure codes and diagnosis codes, it also includes place-of-service codes, type-of-service codes, revenue codes, and National Drug Codes (NDCs), as well as codes that are used to monitor the quality of patient care . The codes in question need to be assigned and combined according to established protocols in order to accurately describe a medical encounter in compliance with federal and state laws, as well as contractual obligations.

A Medical Coder’s Skills

Certified medical coders are fluent in the language of medical code. The foundation of the medical reimbursement system is Current Procedural Terminology (CPT codes), the Healthcare Common Procedure Coding System (HCPCS), and the International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM), which includes diagnosis codes, and codes used to describe inpatient medical procedures. ICD-9-CM also includes codes that justify a medical encounter when an active disease process is not present, as well as codes that describe the causes of injuries.

The use of all medical codes requires a thorough understanding of both theoretical and practical applications. The theoretical understanding comes into play by being able to read a patient’s medical record and understand the specialized terminology used. It requires a familiarity with anatomy and physiology, as well as how and why procedures are performed. The practical aspect is an ongoing awareness of the requirements of individual third parties who will receive the codes after they are assigned. Codes are used differently in different situations.

The National Correct Coding Initiative (NCCI), is a program administered by the Centers for Medicare and Medicaid Services (CMS). Tables of procedure codes are arranged to identify codes that are medically unlikely to be reported together. NCCI is updated quarterly, with additions being made, and nuances clarified, on a continuing basis. Medical coverage policies administered by commercial healthcare insurance carriers, and by CMS, dictate when a procedure is appropriate for a given medical condition, as that condition is described by ICD-9-CM.

Being able to assign codes accurately and literally, using the right code to describe what it is intended to describe, is the most important skill the certified medical coder brings to his or her workplace. Documentation in the patient’s medical record must support the use of the codes assigned. If not, other codes have to be used. Professional medical coders are not influenced by how much a service costs, only that the codes they use most accurately describe the patient’s encounter with a healthcare provider.

When the codes are accurate, clean claims will be submitted. The information that these claims contain is used for statistical purposes by insurers, CMS, and researchers who track the performance of the national healthcare system. For instance, when the federal Center for Disease Control and Prevention (CDC) reports that emergency room visits for motorcycle accidents were up last year, it bases its observation on the data gathered from the codes submitted on medical claims.

Medical Coding Jobs

With their wide knowledge base on coding and its ramifications, certified medical coders perform a variety of functions in the healthcare industry. Professional medical coders are an integral part of the administrative aspects of medicine. Their work promotes transparency in the reimbursement system, reducing liability due to charges of healthcare fraud or abuse. Their work also promotes transparency of the healthcare system as a whole, as statistical models are constructed from the specific information codes contain. Trends in disease occurrence and in the effectiveness of certain treatment regimens can be tracked. Populations can be identified that are susceptible to certain conditions, and prevailing trends in treatment can be examined by locale. This is one of the primary goals of the CDC’s examination of medical codes.

At the entry level, medical coders often act in close concert with medical billers to construct accurate healthcare claims for payment. This is the typical scenario in a physician practice or outpatient clinic. Outpatient services that are paid and monitored by Medicare Part B, state Medicaid programs, or by commercial healthcare insurance carriers, are relatively straightforward compared to medical coding in the inpatient environment, medical coding for ambulatory surgery centers (ASCs), skilled nursing facilities (SNFs), and for Durable Medical Equipment (DME), or medical coding of ambulance services. Wherever healthcare is provided, in every situation, there is a need for certified medical coders.

Inpatient coders, especially those found in large hospitals, are usually required to have completed an advanced program of study, usually at least a Baccalaureate in Health Information Administration. These coders are certified by the applicable professional body of health information administrators. They have the proven skills to extrapolate information from a patient’s medical record and assign the appropriate codes in a hierarchy based on the available documentation and the applicable published guidelines. Inpatient coders assign codes that describe medical services that were provided over the course of a patient’s inpatient stay at a healthcare facility. They assign diagnosis codes, for instance, for suspected medical conditions, whereas outpatient coders only assign diagnosis codes if the diagnosis is established. The use of codes is different in application in the inpatient setting, but no matter where medical coders work, their foundation is in the literal interpretation of the documented patient encounter.

Medical coding compliance is performed by experienced professionals who are aware of correct coding guidelines. They offer informed opinions of which codes are applicable in a given situation, and they help devise documentation strategies to justify the use of specific codes. They are active in the ongoing business of medical documentation. Medical coding auditors perform their duties both before and after claims have been submitted and paid. Professional medical auditors review medical records to ensure that the codes used match the codes reported.

Tumor registrars code all cancer cases and report them to the CDC using the International Classification of Diseases-10th Edition (ICD-10). Soon, the entire healthcare industry will be converting to the use of ICD-10, requiring personnel who are familiar with this new coding system.

Medical Coding Education

Most certified medical coders have undergone some degree of formal education, whether it is from online classes, in a community college, or in a local university that offers degrees in health information management. Additionally, maintaining current certification often requires continuing education. Regulations and guidelines change on an ongoing basis, and employers value applicants who keep abreast of the current standards. New editions of HCPCS, CPT, and ICD-9-CM are issued annually. Without a proper education, it may be difficult to find a job in this growing, but competitive field. Education is the key to advancing through the ranks, either as an employee, or as a self-employed coding consultant.