Medical Coders work in a variety of settings and their individual workday may differ based on the size of facility, type of physician, type of specialty, etc. The following example outlines what a typical day in the life of a Medical Coder may look like.

    After settling into the office and grabbing a cup of coffee, a medical coder usually begins the workday by reviewing the previous day's batch of patient notes for evaluation and coding. The type of records and notes 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 reviewing 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 physician names, dates of procedures, and other information.

    Coders rely on ICD-10 and CPT code books to begin translating the physician’s notes into useful medical codes. An example of basic procedure documentation and subsequently assigned codes can be seen below.

    Example:

    Date of Procedure: 6/5/20xx Patient Name: John Smith DOB: 10/13/19xx

    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 (eg, 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

    Many cases are simple to code. Individual medical coders develop a detailed understanding of the procedures and commonality of their specific clinic or facility. Coders occasionally encounter a difficult note requiring in-depth research, taking more time to code correctly. Even among the more commonly used codes are significant gray areas open for examination among coders. With very complex or unusual cases, coding guidelines may 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 conferences , or consult with co-workers to help understand the issue and determine the proper codes. Ongoing training and current coding-related periodicals also provide important opportunities to advance understanding and professionalism.

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

    Professional coders largely work independently. However, interaction with coding staff, medical billers, physicians, and ancillary office staff is essential. Medical coders 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.

    Depending on the clinical setting, internal or external auditors will periodically perform audits of the coding and documentation for accuracy and completeness. The results of these coding audits are maintained by the compliance department or the department supervisor and are a significant part of job evaluations.

    At the end of the day coders return unprocessed work, check productivity either by a manual count or by running a system report, and clean 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. Some coders work alone from their home office.

    Today over 200,000 medical professionals are members of AAPC . AAPC elevates the standards of medical coding by developing training, professional certification, and opportunities to network with other related medical professionals, as well as providing a variety of job search and career building opportunities.

    USEFUL CODING LINKS:

    What is the responsibility of a medical coder?
    A medical coding specialist, also known as a medical coder, knows how to create that story. This data management professional transforms healthcare diagnoses, procedures, medical services, and equipment into universal medical alphanumeric codes, which are applied during the medical billing process. more
    What is a cardiology coder?
    Certification Description The Certified Cardiology Coder (CCC) credential certifies individuals in their ability to accurately assign medical codes for procedures and services within the field of cardiology (heart and blood vessels). more
    What is a facility coder?
    Hospital Facility Coding Background Manager of a team of certified coders. Coding to address specific hospital areas including inpatient coding, emergency departments, ambulatory care, radiology (including interventional radiology), ambulatory surgery centers/same day surgery centers. more
    What is the difference between coder 1 and coder 2?
    Our coder 1 is from certification to the end of your first year working as a coder. Coder 2 is from the end of year one forward. More businesses need to realize that hiring and training an inexperienced coder can be beneficial. more
    Is a medical coder boring?
    You might imagine that the job of medical coders is highly repetitive and boring, but there is much more to the job than sitting at a desk and writing codes in the proper place. more
    Can a coder work remotely?
    If you love to be presented with a problem that you can figure out and fix, then a coding career could actually be your dream career. Better yet, many coding careers can be done remotely — in fact, remote tech jobs have been common, both for full-time roles and freelance jobs, even before the pandemic. more
    What is coder productivity?
    Productivity is measured by how much work you complete in a given time period. For coding professionals, this usually pertains to the number of surgeries/procedures or evaluation and management (E/M) encounters coded, records audited, providers educated, corrective action plans issued, and so forth. more
    What makes a good coder?
    A great programmer is able to understand problems clearly, break them down into hypotheses, and propose solutions in a coherent manner. They understand concepts quickly, or ask the right questions to help make them clear, and don't need to have everything written down in a specifications document. more
    What a medical coder does?
    What Is a Medical Coder? Medical coders update patient records with standardized information needed for data management and billing purposes. Every time a doctor, nurse, or other healthcare provider performs a service, a code needs to be assigned to each diagnosis and procedure. more
    What is smart medic?
    Introducing SmartMedic – the comprehensive medical rider for investment-linked insurance plans that offers you healthcare protection up to age 99 years next birthday. With this rider, you have protection to cushion the effects of unexpected medical emergencies. more
    What makes a great coder?
    A great programmer is able to understand problems clearly, break them down into hypotheses, and propose solutions in a coherent manner. They understand concepts quickly, or ask the right questions to help make them clear, and don't need to have everything written down in a specifications document. more

    Source: www.aapc.com

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