Medical Coder Overview

Medical records and health information technicians, commonly referred to as health information technicians, organize and manage health information data by ensuring that it maintains its quality, accuracy, accessibility, and security in both paper files and electronic systems. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.

Health information technicians typically do the following:

• Review patients’ records for timeliness, completeness, accuracy, and appropriateness of data
• Organize and maintain data for clinical databases and registries
• Track patient outcomes for quality assessment
• Use classification software to assign clinical codes for reimbursement and data analysis 
• Electronically record data for collection, storage, analysis, retrieval, and reporting
• Maintain confidentiality of patients’ records

Health information technicians document patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services that are provided to patients. Their duties vary by employer and by the size of the facility in which they work.

Although health information technicians do not provide direct patient care, they work regularly with registered nurses and other healthcare professionals. They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.

The increasing adaptation and use of electronic health records (EHRs) will continue to change the job responsibilities of health information technicians. Technicians will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information, as more healthcare providers and hospitals adopt EHR systems.

Health information technicians can specialize in many aspects of health information. Some work as medical coders, sometimes called coding specialists, or as cancer registrars.

Medical coders typically do the following:

• Review patient information for preexisting conditions, such as diabetes
• Assign appropriate diagnoses and procedure codes for patient care, population health statistics, and billing purposes
• Work as a liaison between the health clinician and billing offices

Cancer registrars typically do the following:

• Review patients’ records and pathology reports to verify completeness and accuracy
• Assign classification codes to represent the diagnosis and treatment of cancers and benign tumors
• Conduct annual followups to track treatment, survival, and recovery
• Compile and analyze cancer patient information for research purposes
• Maintain facility, regional, and national databases of cancer patients