Clinical coder

Clinical coders read patients’ medical records. They analyse and interpret medical statements about diseases, injuries and procedures. Clinical coders convert this information into health classification codes in order to calculate treatment reimbursements, to produce statistics and to monitor health care performance.

The duties of a clinical coder include, but are not limited to:

• Making sure that codes are assigned correctly and sequenced appropriately as per government and insurance regulations
• Complying with medical coding guidelines and policies
• Receiving and reviewing patients’ charts and documents for verification and accuracy
• Following up and clarifying any information that is not clear to other staff members
• Collecting information made by the Physician from different sources to prepare monthly reports 
• Implementing strategic procedures and choosing strategies and evaluation methods that provide correct results
• Examining any medical malpractice that has been reported by analyzing and identifying the medical procedures, diagnoses or events that lead to the negligence

The following job titles also refer to clinical coder:

medical coding officer
clinical records technician
medical coder
clinical coding expert
accredited medical coder
diagnostic coder
accredited clinical coder
clinical coding officer

Clinical coders must have a high school diploma or equivalent at least. Candidates with degree in health information technology, medical coding or a related field are definitely advantaged

ISCO skill level is defined as a function of the complexity and range of tasks and duties to be performed in an occupation. It is measured on a scale from 1 to 4, with 1 the lowest level and 4 the highest, by considering:

• the nature of the work performed in an occupation in relation to the characteristic tasks and duties
• the level of formal education required for competent performance of the tasks and duties involved and
• the amount of informal on-the-job training and/or previous experience in a related occupation required for competent performance of these tasks and duties.

Clinical coder is a Skill level 3 occupation.

These occupations, although different, require a lot of knowledge and skills similar to clinical coder.

medical transcriptionist
medical records clerk
medical records manager
waiting list coordinator
chiropractic assistant

These occupations require some skills and knowledge of clinical coder. They also require other skills and knowledge, but at a higher ISCO skill level, meaning these occupations are accessible from a position of clinical coder with a significant experience and/or extensive training.

podiatry assistant
orthoptist
clinical informatics manager
podiatrist
specialist pharmacist

This knowledge should be acquired through learning to fulfill the role of clinical coder.

• Medical terminology: The meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.
• Professional documentation in health care: The written standards applied in the health care professional environments for documentation purposes of one`s activity.
• Clinical coding: The matching of clinical statements with standard codes of illnesses and treatments through use of a classification system.
• Document management: The methodology of tracking, managing and storing documents in a systematic and organised manner as well as keeping a record of the versions created and modified by specific users (history tracking).

These skills are necessary for the role of clinical coder.

• Manage healthcare users’ data: Keep accurate client records which also satisfy legal and professional standards and ethical obligations in order to facilitate client management, ensuring that all clients’ data (including verbal, written and electronic) are treated confidentially.
• Maintain healthcare user data confidentiality: Comply with and maintain the confidentiality of healthcare users` illness and treatment information.
• Use electronic health records management system: Use specific software for the management of health care records, following appropriate codes of practice.
• Communicate effectively in healthcare: Communicate effectively with patients, families and other caregivers, health care professionals, and community partners.
• Follow clinical guidelines: Follow agreed protocols and guidelines in support of healthcare practice which are provided by healthcare institutions, professional associations, or authorities and also scientific organisations.
• Adhere to organisational guidelines: Adhere to organisational or department specific standards and guidelines. Understand the motives of the organisation and the common agreements and act accordingly.
• Review patient’s medical data: Assess and review relevant medical data of patients such as X-rays, medical history and laboratory reports.
• Perform clinical coding procedures: Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.

This knowledge is sometimes, but not always, required for the role of clinical coder. However, mastering this knowledge allows you to have more opportunities for career development.

• Human physiology: The science that studies the human organs and its interactions and mechanisms.
• Health records management: The procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of records.
• Health care system: The structure and function of health care services.
• Human anatomy: The dynamic relationship of human structure and function and the muscosceletal, cardiovascular, respiratory, digestive, endocrine, urinary, reproductive, integumentary and nervous systems; normal and altered anatomy and physiology throughout the human lifespan.
• Medical informatics: The processes and tools used for the analysis and dissemination of medical data through computerized systems.

These skills and competences are sometimes, but not always, required for the role of clinical coder. However, mastering these skills and competences allows you to have more opportunities for career development.

• Archive healthcare users’ records: Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.
• Collect healthcare user’s general data: Collect qualitative and quantitative data related to the healthcare user’s anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.
• Identify patients’ medical records: Locate, retrieve and present medical records, as requested by authorized medical personnel.
• Collect statistics on medical records: Perform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.

3252 – Medical records and health information technicians

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References

1. Clinical coder – ESCO
2. Medical Code Job Description – Indeed.com
3. Clinical Code Job Description – Indeed.com UK
4. Featured image: By U.S. Navy photo by Rod Duren, Public Domain