Certified Medical Coder.
A clinical coder – also known as clinical coding officer, diagnostic coder, medical coder or medical records technician – is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification system. The data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.
For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the International Classification of Diseases (ICD) or the Common Coding System for Healthcare Procedures (HCPCS), for reporting to the health insurance provider of the recipient of the care.
The use of standard codes allows insurance providers to map equivalencies across different service providers who may use different terminologies or abbreviations in their written claims forms, and be used to justify reimbursement of fees and expenses. The codes may cover topics related to diagnoses, procedures, pharmaceuticals or topography. The medical notes may also be divided into specialities for example cardiology, gastroenterology, nephrology, neurology , pulmonology or orthopedic care.
A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information, health data standards, classification conventions, and computer- or paper-based data management, usually as obtained through formal education and/or on-the-job training.
Competency levels Offered:
Clinical coders may have different competency levels depending on the specific tasks and employment setting
Entry-level / trainee coder
An entry level coder has completed (or nearly completed) an introductory training program in using clinical classifications. Depending on the country; this program may be in the form of a certificate, or even a degree; which has to be earned before the trainee is allowed to start coding. All trainee coders will have some form of continuous, on-the-job training; often being overseen by a more senior coder.
Intermediate level coder
An intermediate level coder has acquired the skills necessary to code many cases independently. Coders at this level are also able to code cases with incomplete information. They have a good understanding of anatomy and physiology along with disease processes. Intermediate level coders have their work audited periodically by an Advanced coder.
Advanced level / senior coder
Advanced level and senior coders are authorized to code all cases including the most complex. Advanced coders will usually be credentialed and will have several years of experience. An advanced coder is also able to train entry-level coders.
Nosology A nosologist understands how the classification is underpinned. Nosologists consult nationally and internationally to resolve issues in the classification and are viewed as experts who can not only code, but design and deliver education, assist in the development of the classification and the rules for using it. Nosologists are usually expert in more than one classification, including morbidity, mortality and casemix. In some countries the term “nosologist” is used as a catch-all term for all levels.