Meticulous, organized, detail-oriented people are valued in many fields, and one of the most important is health care. Getting the details right is crucial when lives are at stake, and accurate patient records are a primary example. This is especially true of outpatient services, where a patient's records might pass through dozens of hands over a period of years. Outpatient medical coders play a vital role in record-keeping, ensuring that each patient's file contains an accurate record of diagnoses and medical services provided.
Since the late 20th century, the health-care system has seen a transition from paper-based patient records to computer-based records. Part of that process has been the development of standardized sets of codes to describe patient care, including more than 9,000 CPT codes for services and another 13,500 ICD-9 codes for diagnoses. These codes streamline patient record-keeping, enabling a fast and efficient exchange of information between caregivers and quicker, more accurate billing. This system of record-keeping relies on the work of medical coders, who must convert the notes of doctors and other caregivers into codes and enter them into appropriate computer programs.
Outpatient coders work in a range of facilities, including hospitals, ambulatory surgical centers and walk-in clinics. After a physician, physician assistant, nurse practitioner or other caregiver has seen the patient, the coder reviews that caregiver's written notes. Each aspect of patient care, whether as simple as a vaccination or as complex as outpatient surgery, can be represented by a combination of codes. The coder must know enough about human anatomy, medical terminology and medical procedures to understand the caregiver's notes and match the procedures to the correct codes.
Accurate use of codes, and accurate data entry, are your core duties as a coder. Using record-management software, you'll look up and enter appropriate codes in the patient's record for every procedure or diagnosis. This provides future health-care providers with accurate information on the patient's prior care. It also provides the basis for accurate billing, a crucial detail regardless of the clinical setting. If the coder overlooks billable services, it impairs the facility's profitability. On the other hand, mistaken billing or overbilling can slow payment, lead to chargebacks, or in some situations, provoke disciplinary action against the physician.
The importance of coders, and the potential repercussions of incomplete or inaccurate coding, have placed a premium on formal training and professional certification for coders. Certification is voluntary, but demonstrates an objectively measured standard of competence and a commitment to professionalism. Once you're certified, most of those organizations require you to maintain your certification through continuing education or periodic exams. This is important to employers, because the codes themselves and the regulatory environment change frequently. Keeping up a certification lets them know you're up-to-date with the requirements of your profession.
2016 Salary Information for Medical Records and Health Information Technicians
Medical records and health information technicians earned a median annual salary of $38,040 in 2016, according to the U.S. Bureau of Labor Statistics. On the low end, medical records and health information technicians earned a 25th percentile salary of $29,940, meaning 75 percent earned more than this amount. The 75th percentile salary is $49,770, meaning 25 percent earn more. In 2016, 206,300 people were employed in the U.S. as medical records and health information technicians.
- American Medical Association: Health Care Careers Directory -- Medical Coder
- Explore Health Careers: Medical Coder
- U.S. Bureau of Labor Statistics: Occupational Outlook Handbook -- Medical Records and Health Information Technicians
- U.S. Bureau of Labor Statistics: Occupational Outlook Handbook: Medical Records and Health Information Technicians
- Career Trend: Medical Records and Health Information Technicians
Fred Decker is a trained chef and certified food-safety trainer. Decker wrote for the Saint John, New Brunswick Telegraph-Journal, and has been published in Canada's Hospitality and Foodservice magazine. He's held positions selling computers, insurance and mutual funds, and was educated at Memorial University of Newfoundland and the Northern Alberta Institute of Technology.