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Coding

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Clinical Coder

A clinical coder – also known as a medical coder – is a health information professional whose main duties are to analyze clinical notes and assign standard codes using a classification system. The data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.

A clinical coder may use a set of published codes on medical diagnoses and procedures, for reporting to the health insurance provider of the recipient of the care.The use of standard codes allows insurance providers to map equivalencies across different service providers who may use different terminologies or abbreviations in their written claims forms, and be used to justify reimbursement of fees and expenses. The codes may cover topics related to diagnoses, procedures, pharmaceuticals or topography. The medical notes may also be divided into specialities for example cardiology, gastroenterology, nephrology, neurology , pulmonology or orthopedic care.

 

Competency Levels

Entry-level / trainee coder

An entry level coder has completed (or nearly completed) an introductory training program in using clinical classifications. 

Intermediate level coder

An intermediate level coder has acquired the skills necessary to code many cases independently. Coders at this level are also able to code cases with incomplete information. They have a good understanding of anatomy and physiology along with disease processes. 

Advanced level / senior coder

Advanced level and senior coders are authorized to code all cases including the most complex. Advanced coders will usually be credentialed and will have several years of experience. 

In Practice

A clinical coder requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information, health data standards, classification conventions, and computer- or paper-based data management.

The basic task of a clinical coder is to classify medical and health care concepts using a standardized classification. Inpatient, mortality events, outpatient episodes, general practitioner visits and population health studies can all be coded.

Clinical coders read the entire record of the health encounter and analyses the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation notes.

Clinical coders must ask themselves, "does this code set fairly represent what happened to this patient in this health encounter at this facility?" By doing this, clinical coders are checking that they have covered everything that they must, but not used extraneous codes. For health encounters that are funded through a case mix mechanism, the clinical coder will also review the diagnosis-related group (DRG) to ensure that it does fairly represent the health encounter.

Medical Coding Bootcamp

Become a Certified Medical Coding Specialist

By certifying as a medical coder, you are beginning your journey towards an in-demand career within the healthcare industry. According to the U.S. Bureau of Labor Statistics, medical coding is one of the fastest growing professions in the nation. Additionally, certified medical coders typically earn 20 percent more than non-certified coders.

The purpose of this certification is to promote ethical and professional medical coding through certification of qualified individuals. This voluntary credential formally recognizes a medical coder’s competency and proficiency, encourages continued professional personal best development, and provides a national standard assessment based on industry knowledge.

Tuition Includes ($3,500):

  • Laptop
  • Software
  • Background Check
  • Drug Test
  • 8 weeks of intense virtual classroom training (Phase I)
  • HIPAA Certification
  • CMCS
  • Preparation
  • CMCS Mock Exams
  • Resume Building 
  • Certificate of Completion 

Phase II Training (16 weeks):

  • Must successfully complete Phase I training to be eligible for Phase II of the program
  • Clinic Assignments
  • Over-the-Shoulder Training (OTS)
  • CMCS Mock Exams and Tutoring (as needed)

Phase III Training (24 weeks):

  • Must successfully complete Phase II training 
  • Clinic Support
  • Students receive a stipend ($10.50/hr)
  • Sit for CMCS

Open Enrollment… Apply Today!