Medical Record Coders use the information mentioned in the records when treating patients. These records contain the details about the medical history of the patient, observations done by the doctors, surgical treatments, results of the treatment, description of the symptoms of the disease, details of X-ray’s and other reports, reports of the labs, diagnoses done by the doctors and the procedure of the treatment followed by the doctors. Hence, medical records are defined as the record of complete and detailed information about a patient.
Coders of Medical Records
The Medical Record Coders ascertain that the patient’s record is completed, and filled in the correct manner, and that the information mentioned in the forms is accurate. The Medical Record Coder is also required to have the proper knowledge of the diseases and diagnostic processes. The medical coder remains in regular contact with the physicians, and has a conversation about the further developments in the treatment and diagnoses for the patient.
The records maintained by the medical coders are very useful for any future analysis and treatment. This record is also required for private companies reimbursing the medical treatment costs; and legal actions if required can also be taken by considering the authenticated report of this medical record. After assigning the codes to the record, the medical coder is required to assign the one diagnostic related-group or DRG to the patient. This information stored in DRG is essential for calculating the cost of treatment that is to be recovered by the insurance agency.
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The record maintained by the medical coder is also very useful in the procedures and activities of various departments of the hospital like medical branches, administration, and legal departments. The basic duties and responsibilities of the medical coder follow:
- The medical coder processes admissions and patient discharge documents.
- They are required to review the records regularly to check the accuracy and watch that the rules are followed properly.
- Enter the information in the computer regarding the disease history, diagnoses and treatment provided to the patient.
- Provide the information to the patient and the private agency that needs it for reimbursement processes.
- Keep the medical record of the patient confidential.
- They are also responsible for developing the proper system that makes the storage and access of the records easy.
The Medical Record Coders do not have the direct contact with the patients during the coding transcription. The basic qualification required for the medical coder is an Associate Degree from the Commission on Accreditation for Health Informatics and Information Management Education. And for higher positions, an individual can clear the written examination of American Health Information Management Association.