Medical Billing & Coding

After settling into work and grabbing a cup of coffee the medical coder usually begins the workday by reviewing the previous day's batch of patient notes to be coded. The type of records 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 reading 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 physicians' names, dates of procedures, etc.

Relying heavily on the ICD-10 and CPT code books coders begin translating the physician’s notes into useful medical codes.

Many cases are pretty straightforward to code and individual medical coders develop a detailed understanding of the procedures and commonality of their specific clinic or facility. No matter how experienced the coder may be, occasionally a coder encounters a difficult note that takes longer than normal to code correctly. Even among the more commonly used codes there are significant gray areas that are open for debate among coders. With very complex or unusual cases, coding guidelines can 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 conference, or with co-workers in the office to help understand the issues and determine the proper codes. Ongoing training and current coding-related periodicals also provide important opportunities to advance understanding and professionalism. 

Eventually the coder completes the chart and picks up the next patient record. This cycle of reading, note taking, assigning codes, and computer entry repeats with each chart throughout the day. Most coders will spend the majority of their day sitting at the computer reading notes and using the computer to enter data into a billing system or search for information to clarify the documentation in the notes. 

Coding is fairly independent work but interaction with other coders, medical billers, physicians, and ancillary office staff is essential. Medical coders are usually placed on fairly tight production schedules and are expected to complete a certain number of notes each day.

Job Outlook & Average Salary

Coders earn an average of $35,000 to $50,000 per year. Coders with specialty credentials tend to be on the higher end of that scale and can earn substantially more based on experience and specialty (averaging a little less than $55,000 per year).

According to AAPC, certified coders earn 21% more than non-certified coders. Many employers now require certification for newly hired coders.

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