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Certified medical coders are fluent in the language of medical code. The foundation of the medical reimbursement system is Current Procedural Terminology (CPT codes), the Healthcare Common Procedure Coding System (HCPCS), and the International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM), which includes diagnosis codes, and codes used to describe inpatient medical procedures. ICD-9-CM also includes codes that justify a medical encounter when an active disease process is not present, as well as codes that describe the causes of injuries.
The use of all medical codes requires a thorough understanding of both theoretical and practical applications. The theoretical understanding comes into play by being able to read a patient???s medical record and understand the specialized terminology used. It requires a familiarity with anatomy and physiology, as well as how and why procedures are performed. The practical aspect is an ongoing awareness of the requirements of individual third parties who will receive the codes after they are assigned. Codes are used differently in different situations.
The National Correct Coding Initiative (NCCI), is a program administered by the Centers for Medicare and Medicaid Services (CMS). Tables of procedure codes are arranged to identify codes that are medically unlikely to be reported together. NCCI is updated quarterly, with additions being made, and nuances clarified, on a continuing basis. Medical coverage policies administered by commercial healthcare insurance carriers, and by CMS, dictate when a procedure is appropriate for a given medical condition, as that condition is described by ICD-9-CM.
Being able to assign codes accurately and literally, using the right code to describe what it is intended to describe, is the most important skill the certified medical coder brings to his or her workplace. Documentation in the patient???s medical record must support the use of the codes assigned. If not, other codes have to be used. Professional medical coders are not influenced by how much a service costs, only that the codes they use most accurately describe the patient???s encounter with a healthcare provider.
Becoming a Medical Coder
Choose a medical coding program. Many community colleges offer associate degrees in medical coding or medical coding certificates. Classes may be in person, online, or a combination. Make sure you enroll in a school that is accredited by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC). Both of these organizations maintain a list of accredited programs on their websites.
Ask the school about their pass rate on medical coder certification exams and the career placement services they offer.
If you have plans to attend a four year institution later on you should enroll in an associate's degree program instead of a certificate program. You should also clarify which courses you will be able to transfer to another school.
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