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Become A Medical Record Coder

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Working As A Medical Record Coder

  • Getting Information
  • Processing Information
  • Documenting/Recording Information
  • Interacting With Computers
  • Organizing, Planning, and Prioritizing Work
  • Mostly Sitting

  • Repetitive

  • $74,182

    Average Salary

What Does A Medical Record Coder Do

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.

Duties

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

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How To Become A Medical Record Coder

Health information technicians typically need a postsecondary certificate to enter the occupation, although some may need an associate’s degree. Certification is often required.

Education

Postsecondary certificate and associate’s degree programs in health information technology typically include courses in medical terminology, anatomy and physiology, health data requirements and standards, classification and coding systems, healthcare reimbursement methods, healthcare statistics, and computer systems. Applicants to health information technology programs may increase their chances of admission by taking high school courses in health, computer science, math, and biology.

A high school diploma or equivalent and previous experience in a healthcare setting are enough to qualify for some positions, but most jobs for health information technicians require postsecondary education.

Important Qualities

Analytical skills. Health information technicians must be able to understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records.

Detail oriented. Health information technicians must be accurate when recording and coding patient information.

Integrity. Health information technicians work with patient data that are required, by law, to be kept confidential. They must exercise caution and a strong sense of ethics when working with this information in order to protect patient confidentiality.

Interpersonal skills. Health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel.

Technical skills. Health information technicians must be able to use coding and classification software and the electronic health record (EHR) system that their healthcare organization or physician practice has adopted.

Licenses, Certifications, and Registrations

Most employers prefer to hire health information technicians who have certification, or they may expect applicants to earn certification shortly after being hired. A health information technician can earn certification from several organizations. Certifications include the Registered Health Information Technician (RHIT) and the Certified Tumor Registrar (CTR), among others.

Some organizations base certification on passing an exam. Others require graduation from an accredited program. Many coding certifications also require coding experience in a work setting. Once certified, technicians typically must renew their certification regularly and take continuing education courses.

A few states and facilities require cancer registrars to be licensed. Licensure requires the completion of a formal education program and the Certified Tumor Registrar (CTR) certification.

Advancement

Health information technicians may advance to other health information positions by receiving additional education and certifications. Technicians may be able to advance to a position as a medical or health services manager after completing a bachelor’s or master’s degree program and taking the required certification courses. Requirements vary by facility.

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Medical Record Coder Jobs

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Medical Record Coder Demographics

Gender

Female

87.0%

Male

10.9%

Unknown

2.1%
Ethnicity

White

59.7%

Hispanic or Latino

14.7%

Black or African American

12.8%

Asian

7.6%

Unknown

5.1%
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Languages Spoken

Spanish

60.0%

Igbo

20.0%

French

20.0%

Medical Record Coder Education

Schools

University of Phoenix

18.0%

Temple University

6.0%

Arapahoe Community College

6.0%

Bryant and Stratton College

6.0%

Monroe Community College

6.0%

Rasmussen College

6.0%

Norfolk State University

4.0%

Sinclair Community College

4.0%

Ultimate Medical Academy - Clearwater

4.0%

Santa Barbara City College

4.0%

Strayer University

4.0%

Ferris State University

4.0%

Solano Community College

4.0%

Remington College - Dallas Campus

4.0%

California College-San Diego

4.0%

Duke University

4.0%

Kean University

4.0%

The Academy

4.0%

Georgia Northwestern Technical College - Floyd County Campus

2.0%

Palmer College of Chiropractic

2.0%
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Majors

Health Care Administration

41.5%

Computer Information Systems

17.1%

Business

10.4%

Management

3.0%

Health/Medical Preparatory Programs

3.0%

Medical Assisting Services

3.0%

Nursing

3.0%

Physiology And Anatomy

2.4%

Information Technology

2.4%

Accounting

2.4%

Education

1.8%

Insurance

1.8%

Health Sciences And Services

1.2%

Secretarial And Administrative Science

1.2%

Human Services

1.2%

Cell Biology And Anatomical Science

1.2%

History

1.2%

Psychology

0.6%

Information Sciences

0.6%

Public Health

0.6%
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Degrees

Other

32.8%

Associate

25.3%

Bachelors

25.3%

Certificate

8.1%

Masters

5.4%

Diploma

2.2%

Doctorate

1.1%
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Top Skills for A Medical Record Coder

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  1. Medical Record Documentation
  2. Procedure Codes
  3. Diagnosis
You can check out examples of real life uses of top skills on resumes here:
  • Identified the primary and secondary diagnoses and primary and secondary procedure codes (when applicable) for every outpatient encounter.
  • Review the medical record to assure specificity of diagnosis, procedures and appropriate/optimal reimbursement for professional charges.
  • Educate health care professional and other coders on coding documentation guidelines.
  • Conducted quality improvement on incomplete emergency room and inpatient records to improve documentation in accordance with HCFA guidelines.
  • Apply the seven levels of compliance to coding, abstraction and sequencing of ICD/CPT/HCPCS code.

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Top Medical Record Coder Employers

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Jobs From Top Medical Record Coder Employers

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