A medical coder's job is to translate information from patient records into medical codes that can be used by billers to submit claims. This information can include diagnoses, procedures, supply information, lab reports, physician's notes, and equipment. Medical coders need to be knowledgeable about medical terminology and anatomy to accurately code procedures and diagnoses. They also need to be proficient in a variety of medical codes and adhere to the medical coding code of ethics.
Here are some of the responsibilities of a medical coder:
Review medical documents
Examine medical records and documents for missing information, and ensure all documents are grammatically correct
Transcribe information
Translate information from patient records into medical codes, such as diagnosis codes, treatment codes, and medical hardware codes
Communicate
Communicate with medical providers and insurance companies to confirm details or get information to code more specifically
Use digital tools
Use coding software and patient record platforms
Comply with guidelines
Comply with medical coding guidelines, policies, and accrediting organizations, as well as federal and state regulations, and the Centers for Medicare and Medicaid Services (CMS) guidelines
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