Medical records coders are hired by the hospitals, physicians or sometimes by a professional company dedicated to providing medical records coding services to hospitals or physicians. A medical coder does not come into direct contact with the patients because their jobs do not involve such contact and the coders may provide off-site medical records coding. Medical records coders are responsible for viewing the medical records and assigning numeric or alphanumeric codes to medical procedures and diagnoses done by the doctors or physicians.
Medical records coders assign the correct diagnostic group classifications to the patient after giving proper codes to the medical treatment(s) and procedure(s). They are also responsible for issuing proper and correct codes for the upkeep and documentation of medical records as this is essential for billing, insurance claims and reimbursements made to the hospitals or physicians from the insurance companies or Medicaid/Medicare.Medical records coders need to be in regular contact with the physicians or doctors in order to update the medical records of patients. Medical records upkeep documents the treatment(s), procedure(s), and health care billing.
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Certification and Training for Coders and RHIT Personnel
Medical records coders are required to have an associate degree and proper knowledge of medical terms used by the doctors or physicians; many companies require full certification or that coders are working towards full certification. They should also have the knowledge of computer science or information technology, coding standards and specifications, and maintain the medical data for billing, reimbursement and legal issues that may be involved in patient healthcare.
An individual can also become a Registered Health Information Technician (RHIT) after clearing the written exam organized by the American Health Information Management Association (AHIMA). Medical coders are also required to have a degree from a school accredited by the Commission on Accreditation for Health Informatics and Information Management Education to become a certified medical coder. All these degrees and certifications help him or her to reach the desired position in the medical field.
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Medical records coders should also understand the treatment methods of different types of healthcare facilities, clinics and private practices. They should also have a command over the data collection techniques and coding classification systems used by professional companies providing quality services to hospitals.
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CPT and ICD-9 Coding Methodologies
The most essential knowledge that a medical records coder should have is the knowledge of CPT and ICD-9 coding as these are the basic coding methodologies. The medical coders are required to work in shifts (i.e. morning, evening or overnight) as the healthcare facilities may be open for 24 hours a day (hospitals in particular) per week. Many facilities are required by policies and regulations to perform coding in a timely manner. Most of the coding companies provide professional training and ongoing education to hired medical coders. Accuracy in assigning the codes and maintaining the medical records is essential for the job of medical records coders.
In conclusion, medical coders provide the assistance physicians, clinics and hospitals require for handling documentation, medical records and billing issues.