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In all U.S. medical facilities, all patients have a medical record that includes all aspects of their treatment. The records include medical history, conditions, examination results, laboratory tests and x-ray results, documentation, and plans of treatment. Medical records coders evaluate these records and assign recognizable medical codes.
Medical records coders review medical records and allocate and order procedural and diagnostic codes for conditions, diseases, symptoms, procedures, and treatments according to specific numeric classification system that is recognized by the medical facility. Once the information is properly coded, the medical records coder may assign the patient to one of various diagnostic related groups. They often use computer programs or classification systems software for assistance with this task.
For insurance purposes, medical records coders check to ensure the proper codes are attached to medical claims. They make sure the codes are valid and correct before the paperwork moves to the next process.
Medical records coders typically need an associate degree with a strong background in medical terminology, computer science, anatomy and physiology, coding, legal matters related to health care, standards of health data, and other areas. Many employers prefer applicants who are Registered Health Information Technicians (RHIT). Most positions also offer on the job training.
To become a Registered Health Information Technician applicants must pass a written examination administered by the American Health Information Management Association (AHIMA). Candidates must have graduated from an associate degree program that is recognized by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).
Medical records coders can become certified from many different organizations such as the American Academy of Professional Coders (AAPC) or the Board of Medical Specialty Coding and the Professional Association of Healthcare Coding Specialist (PAHCS). Continuing education credits are required to keep up to date with the certifications.
Employment of medical records coders is projected to grow faster than average for all professions, increasing 18% from 2006 to 2016 (1).
Job prospects are expected to be very good, especially for medical records coders with a strong medical background and extensive experience. Job openings will also arise from the need to replace workers who retire or leave the profession for other reasons.
As of August 2009, medical records coders with less than 1 year experience earned annual salaries between $25,014 and $34,988. Those with 1 to 4 years experience earned annual salaries between $29,375 and $40,349 (2).
A career as a medical records coder is a great choice for individuals who are interested in working with numbers in the medical field. Medical record coders must have good communication skills, good hand-eye coordination, and pay close attention to detail to be very accurate in their work.
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(1) SOURCE: Bureau of Labor Statistics, Occupational Outlook Handbook, 2008-2009 Edition
(2) SOURCE: Payscale.com, Salary Survey Report
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