A clinical coder – also known as clinical coding officer, diagnostic coder, medical coder or medical records technician – is a health care 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 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.
- 1 In practice
- 2 Competency levels
- 3 Education and professional qualification
- 4 Classification types
- 5 Professional associations
- 6 See also
- 7 References
- 8 External links
The basic task of a clinical coder is to classify medical and health care concepts using a standardised classification. Most clinical coders are employed in coding inpatient episodes of care. However, mortality events, outpatient episodes, general practitioner visits and population health studies can all be coded.
Clinical coding has three key phases: a) Abstraction; b) Assignment; and c) Review.
The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation notes.
The assignment phase has two parts: finding the appropriate code(s) from the classification for the abstraction; and entering the code into the system being used to collect the coded data.
Reviewing the code set produced from the assignment phase is very important. Clinical coder must ask themselves, "does this code set fairly represent what happened to this patient in this health encounter at this facility?" By doing this, clinical coders are checking that they have covered everything that they must, but not used extraneous codes. For health encounters that are funded through a case mix mechanism, the clinical coder will also review the diagnosis-related group (DRG) to ensure that it does fairly represent the health encounter.
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.
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.
Education and professional qualification
In some countries, clinical coders may seek voluntary certification or accreditation through assessments conducted by professional associations, health authorities or, in some instances, universities. The options available to the coder will depend on the country, and, occasionally, even between states within a country.
As of 2016; the typical qualification for an entry-level medical coder in the United States is completion of a diploma or certificate, or, where they are offered, an associate degree. The diploma, certificate, or degree will usually always include an Internet-based and/or in-person internship, at some form of a medical office or facility, at the conclusion. Some form of on-the-job training, or at least oversight, is also usually provided in the first months on the job, until the coder can earn an intermediate or advanced level of certification and accumulate time on the job. For further academic training, a baccalaureate or master's degree in medical information technology, or a related field, can be earned by those who wish to advance to a supervisory or academic role. That option would be recommended for those wishing to teach medical billing or coding at a college or university, community college, or technical or vocational institute, or who wish to become heads of medical billing and coding departments, especially if the doctor's office or clinic, or other facility (among other working options, a medical school or hospital, a skilled nursing facility or other nursing home, a psychiatric facility, an assisted or independent living facility, a rehabilitation facility, a rest home or domiciliary or boarding house, etc.) is very large and receives complex cases, such as a referral facility or a Level I trauma teaching hospital center. A nosologist (medical coding expert) in the U.S. will usually be certified by either AHIMA or the AAPC (often both) at their highest level of certification and specialty inpatient and/or outpatient certification (pediatrics, obstetrics/gynecology, gerontology, oncology are among those offered by AHIMA and/or the AAPC), have at least 3-5 years of intermediate experience beyond entry-level certification and employment, and often holds an associate, bachelor's, or graduate degree.
The AAPC offers the following entry-level certifications in the U.S.: Certified Professional Coder (CPC); which tests on most areas of medical coding, and also the Certified Inpatient Coder (CIC) and Certified Outpatient Coder (COC). Also in the American Health Information Management Association (AHIMA) offers the entry-level Certified Coding Associate (CCA); which is, like the AAPC's CPC, a wide-ranging introductory test.
Some U.S. states, though decidedly not the majority, as it is a very recent trend, now mandate or at least strongly encourage certification or a degree from a college- or at the minimum, some evidence of competency beyond the record of on the job training- and/or from either the AAPC or AHIMA, to be employed. Some states have registries of medical coders, though these can be voluntary listings- which is, for those few who do, most often the case- and so not mandatory. This trend was accelerated in part by the passage of HIPAA (which enforces among other things, patient privacy and access to and the form of medical records) and the Affordable Care Act (U.S. President Barack Obama's health care reform law); and similar changes in other developed and developing countries, many of which, especially in the Western developed countries, and beyond, use the ICD-10 for diagnostic medical coding, which is a quite complex system of codes. The change to more regulation and training has also been driven by the need to create accurate, detailed, and secure medical records- especially patient charts, bills, and claim form submissions, that can be recorded efficiently in an electronic era of medical records where they need to be carefully shared between different providers or institutions of care, which was encouraged and later required by legislation and institutional policy.
Clinical coders may use many different classifications, which fall into two main groupings: statistical classifications and nomenclatures.
A statistical classification, such as ICD-10 or DSM-5, will bring together similar clinical concepts, and group them into one category. This allows the number of categories to be limited so that the classification does not become too big, but still allows statistical analysis. An example of this is in ICD-10 at code I47.1. The code title (or rubric) is Supraventricular tachycardia. However, there are several other clinical concepts that are also classified here. Amongst them are paroxysmal atrial tachycardia, paroxysmal junctional tachycardia, auricular tachycardia and nodal tachycardia.
With a nomenclature, for example SNOMED CT, there is a separate listing and code for every clinical concept. So, in the tachycardia example above, each type and clinical term for tachycardia would have its own code listed. This makes nomenclatures unwieldy for compiling health statistics.
In many countries clinical coders are accommodated for by both professional bodies specific to coding, and organisations who represent the health information management profession as a whole.
- Clinical Coders' Society of Australia (CCSA)
- Health Information Management Association of Australia (HIMAA)
- Institute of Health Records and Information Management (IHRIM)
- Professional Association of Clinical Coders UK (PACC-UK)
There are several associations that medical coders in the United States may join, including:
- American Health Information Management Association (AHIMA)
- AAPC (formerly American Academy of Professional Coders)
The AHIMA and AAPC societies' accredited programs will generally train medical coders at a sufficient level to work in their respective states. Some medical coders elect to be certified by both societies.
AHIMA maintains a list of accredited medical coding certificate (and health information management associate, bachelor's, and graduate programs, through a link on the AHIMA accredited programs page, to CAHIIM) here.
- Clinical medicine
- Current Procedural Terminology
- Diagnosis-related group
- Diagnostic and Statistical Manual of Mental Disorders (DSM)
- Health informatics
- International Classification of Diseases (ICD) / ICD-11 (in development) / ICD-10 / ICD-9-CM
- Medical diagnosis
- Pathology Messaging Implementation Project
- WHO Family of International Classifications
- Marie A. Moisio (2000). A Guide to Health Insurance Billing. Thomson Delmar Learning. ISBN 0-7668-1207-3.
- Michelle A. Green and JoAnn C. Rowell (2011). Understanding Health Insurance, A Guide to Billing and Reimbursement, 10e. Cengage Learning. ISBN 978-1-111-03518-1.
- World Health Organization. Classifying health workers: Medical records and health information technicians. Geneva, 2010.
- Department of Human Services, Victoria, Australia. Clinical Coders Creed. Health Data Standards and Systems Bulletin, Issue 13, 19 July 2000.
- Wooding A (2004). "Clinical coders and decision making". HIM J. 33 (3): 79–83. PMID 18490784.
- Walker S (2006). "Capturing health information—a perspectives paper". HIM J. 35 (3): 13–22. PMID 18195424.
- Nosologist. Popular Science, posted 11.11.2004.
- Bramley, M; Reid, B. "Evaluation standards for clinical coder training programs" (PDF). Health Information Management Journal. 36 (3): 2007.
- "3. How to use the ICD". International statistical classification of diseases and related health problems (10th revision, 2010 ed.). Geneva: World Health Organization. 2011. p. 19. ISBN 9789241548342.
In the context of the ICD, "rubric" denotes either a three-character category or a four-character subcategory.
- "Clinical Coders' Society of Australia". Retrieved 16 March 2015.
- "Health Information Management Association of Australia Limited". Retrieved 16 March 2015.
- "CHIMA: The Canadian Health Information Management Association". Retrieved 16 March 2015.
- "IHRIM - Institute of Health Records and Information Management (IHRIM)". Retrieved 16 March 2015.
- "PACC-UK - Home". Retrieved 16 March 2015.
- "AHIMA Home - American Health Information Management Association". Retrieved 16 March 2015.