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medical_coding

What is Medical Coding?

Medical coding professionals provide a key step in the billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS.

 Is Medical Coding the same as Medical Billing?

No. While the medical coder and medical biller may be the same person or may work closely together to make sure all invoices are paid properly, the medical coder is primarily responsible for abstracting and assigning the appropriate coding on the claims. In order to accomplish this, the coder checks a variety of sources within the patient’s medical record, (i.e. the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources) to verify the work that was done. Then the coder must assign CPT® codes, ICD-9 codes and HCPCS codes to both report the procedures that were performed and to provide the medical biller with the information necessary to process a claim for reimbursement by the appropriate insurance agency.

What does a Medical Coder Do?

It takes a good deal of education and training to become a skilled medical coder. To begin, coders must have a thorough knowledge of anatomy and medical terminology. It is also important to become familiar with different types of insurance plans, regulations, compliance, and the coding community’s three critical resource books: CPT®, HCPCS Level II and ICD-9-CM along with their corresponding codes and guidelines. Using code books the medical coder assigns correct codes to record the service levels for the procedures performed and to account for supplies used to treat the patient during an encounter with the physician. Proper assignment of ICD-9-CM codes corresponds with the physician’s diagnoses and completes the “story” of the patient’s illness or injury.

What Education and Medical Coding Training is Required to Become a Medical Coder?

While many coding professionals have strengthened their career by earning their bachelor’s degrees and master’s degrees, neither is required for a career in medical coding. What is required is a solid understanding of anatomy, physiology and medical terminology. It is also highly recommended for serious coders to complete a medical coding course of study, pass the CPC exam and earn their certification as a Certified Professional Coder, or CPC®. Certified Professional Coders, or CPCs®, are in high demand because employers know that these individuals can perform the job of medical coder with the utmost proficiency.