Medical Coding

Medical Coding Professionals organize and manage health information data. These individuals transform written descriptions of disease, injuries, and procedures into numerical designations. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories. These numerical medical codes provide accuracy and clarity for health care reimbursement, which is vital for the success and stability of the health care provider. Medical Coders code each medical diagnosis and procedure and may communicate with physicians to clarify diagnoses or obtain additional information. This information is then used for clinical decisions, reimbursement of insurance claims, and indexing statistics and research.

Vast amounts of medical information pass through every hospital, medical facility, and medical practice daily. The Medical Coding Specialist is responsible for translating and sequencing this medical documentation into formal standardized, numerical codes for diagnoses and procedures. The Medical Coding Specialist works closely with healthcare providers to ensure the accuracy of the translation. Medical coding is a vital behind-the-scenes activity that supports the billing process and quality patient care. Coders may help prevent delays in patient billing and provider payment.

This program is designed to prepare the student for entry level placement for medical records coding, in either an inpatient or outpatient setting. It offers training in medical terminology; inpatient and outpatient medical office administrative practice; pathophysiology and pharmacology for medical coding; medical records management; ICD-CM, CPT, and HCPCS coding; coding regulatory issues; medical legal and ethical issues; computer usage and medical data entry; and insurance and billing practices. It is appropriate for entry-level job candidates, as well as for those wishing to build on a current skill base in order to make a career change.

Upon completion of the Medical Coding Certificate, the student will be able to:

• Review health records for completeness and accuracy.
• Identify components of appropriate and adequate documentation of health care.
• Code, classify and index diagnosis and procedures for the purposes of reimbursement.
• Abstract information from patient records to complete a claim properly.

Graduates of the Medical Coding program will:

• Accurately code diagnoses and procedures in a variety of healthcare settings using currently accepted coding systems;
• Differentiate among the different reimbursement methodologies;
• Interpret health data content to support the assignment of correct medical codes and for reimbursement;
• Follow health information requirements and standards;
• Apply computer technology in the completion of health information processes;
• Model professional behavior and ethics in a diverse population;
• Comply with established legal and ethical standards of health information practice;
• Communicate effectively using appropriate terminology;
• Connect coding concepts to anatomy and pathophysiology.

It is recommended that potential students have a good working knowledge of computers, are detail-oriented and analytical, and have excellent organization skills. Medical Coders often work with little supervision; therefore, candidates should also be self-starters who are able to work independently.

Analytical skills. Health information technicians must be able to understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records.

Detail oriented. Health information technicians must be accurate when recording and coding patient information.

Integrity. Health information technicians work with patient data that are required, by law, to be kept confidential. They must exercise caution and a strong sense of ethics when working with this information in order to protect patient confidentiality.

Interpersonal skills. Health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel.

Technical skills. Health information technicians must be able to use coding and classification software and the electronic health record (EHR) system that their healthcare organization or physician practice has adopted. They must be competent in the use of EHR computer software, following EHR security and privacy practices, and analyzing electronic data to improve healthcare information.

Students who complete this course are eligible to sit for the American Academy of Professional Coders (AAPC) - Certified Professional Coder Exam (CPC) or Certified Professional Coder Apprentice Exam (CPC-A) and other National Certification Exams.

Medical Coders discuss patient information with other professionals such as physicians and finance personnel. Most Medical Coders work in hospitals or physicians’ offices. Medical Coders typically work in offices and may spend many hours in front of computer monitors. Some technicians may work from home. In healthcare facilities that are always open, such as hospitals, Medical Coders may work evening or overnight shifts.