Apart from grabbing a cup of coffee every morning, a medical coder’s shift starts by looking at previous day’s patients’ records. The medical coder is responsible to assign a code to each patient’s condition and the type of treatment done. He does that by reading the patient treatment notes provided with the file. These notes are filled by the physicians as they go about with the treatment. Each day’s treatment is carefully defined.
The medical coders read the treatment notes and assign codes.
For example: If a patient came for a mole removal and doctor removed the mole. The medical note might look something like this:
The area around the mole was prepped with a solution and injected with 5cc lidocaine. I applied liquid nitrogen to freeze the mole for the destruction of the lesion. Then I dress the area to prevent irritation by patient’s clothing. The patient showed no complications. I told him to return to office next week for a follow-up.
After reading the above procedure-statement by the doctor, a medical coder will assign the following code to the patient’s treatment.
CPT Code: 17110 – Destruction of benign lesions other than skin tags.
ICD-9-CM code: D22.5 Melanocytic nevi of trunk
The code is taken from the CPT Code book, which is a general code book for coding patient information in claims across the United States. The advanced medical coders know about CPT codes as they develop a detailed understanding of the procedures by in-depth research and interviewing the doctors.
In order to stay up-to-date, many medical coders attend seminars, network meetings and research medical coding material from time to time. They also try to keep a large network so they can consult fellow medical coders in a time of need. Also, on-the-job training and reading coding-related periodicals help them keep abreast with the latest coding practices.
Most professional coders work independently. But, they stay in touch with the coding staff, medical billers, and physicians, as that is an essential part of their job.
They are usually on a tight deadline because the medical claim report of a patient needs to be prepared in maximum five days. They are expected to complete a number of notes each day and keep their lag days at a specified time frame. Where lag days are the days it takes the medical coders to research information related to the case and to document notes, to the actual claim submission dates.
Depending on the hospital’s setting, the work of medical coders is evaluated through internal and external auditors for accuracy and completeness. The audit is a significant part of the job appraisal process of most medical coders.
At a day’s end, a medical coder return unprocessed work, check productivity through a system report and cleans his desk because now it is the time of the second medical coder. The medical coders work in shifts in the hospitals because there is too much work that cannot be done by a single coder. As they grow in experience, they become more specialized in specific medical fields.
Some move towards management, while others remain in the medical coding profession and become senior professionals.
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