How to Choose the Right Medical Coder for the Job

Your reimbursement relies entirely on accurate reporting. Someone in your office must understand the code sets, coding guidelines, and the nuances of coding. Additionally, this person must possess the ability to communicate with physicians and other clinicians about how to document a service appropriately to substantiate a billed service. This is not just beneficial, but vital. The better someone on your staff understands these, the better your practice will fare.

The same holds true for a hospital. A professional coding team keeps the revenue cycle flowing.

Questions you should be asking if you are looking to add a professional coder to your staff are:

1. How do you know who to hire as a coder?
2. Do you need a certified coder?
3. Which certification should you look for?
4. How do you write an appropriate job description to attract the right type of coders?

A medical coder could have expertise in facility, also known as inpatient coding, or the coder could specialize in professional fee coding, also known as “pro fee” coding, coding for physicians, or physician office coding. Even these terms could take you down various paths.

Inpatient Coding

When people refer to themselves as inpatient coders, they’re saying that they code for facilities such as acute care hospitals, rehabilitation centers, or nursing facilities. Inpatient coding is based on the entire medical record for the patient’s stay at the facility. The services are itemized by the various departments in the record.

• Each service provided by a clinician is documented by that clinician to capture the information for the encounter with the patient.
• This information could be the vital signs taken by the nursing staff at regular intervals throughout the day or night.
• The documentation produced by a clinician seeing a patient on rounds would also be an example of the documentation found within the medical record.
• Physicians who perform procedures on the patient during the hospital stay, or the therapist providing therapy for the patient would also detail those services within the medical record.

All of this documentation is reviewed by the coder to pull out the appropriate revenue codes and then summarize the story of the stay with the appropriate DRG codes and DRG outliers (codes that recoup excessive costs) to best represent the patient and the care provided. This, of course, is a simplified definition of inpatient coding, as our focus in this article will be on outpatient coding.

Professional Fee Coding

Also referred to as outpatient coding, physician coding, and pro-fee coding, to name a few, professional fee coding refers to the coding of services provided by the healthcare professional—the physician or advanced practice provider (APP). Professional fee coding also describes coding for services performed by laboratories, radiologists, infusion companies, and testing facilities. In other words, professional fee coders work in family practice offices, large medical centers, pharmacies, laboratories, radiologist offices, ophthalmologists’ offices, dental practices, ambulance service companies, surgical practices, anesthesiology practices, specialty practices, and many more.

Professional fee coders review the documentation details of the service to determine the code choice. The documentation should include the details of a service as well as the rationale for why it was performed.

With this information, the coder reviews the CPT® manual to identify the codes for the services, or the HCPCS book for the appropriate supply or medication codes and then the ICD-10-CM manual for the appropriate diagnoses. They will then associate the diagnosis code(s) to the services performed for claim submission.

General Duties and Responsibilities of Medical Coders Include:

• Reviews documentation of various providers to determine accurate coding
• Codes all services following CPT® and CMS guidelines and local payer rules
• Identifies incomplete documentation and follows proper channels to alert physician/client of missing information
• Determines all appropriate diagnoses and assigns the most specific ICD-10 codes
• Follows all HIPAA regulations and upholds the highest standard of privacy requirements
• Understands “incident to” and documentation rules regarding midlevel providers and residents
• Develops professional working relationships with physicians

Coders should be educated in proper coding techniques, functions, and terminology, as well as the rules, regulations, and policies implemented by insurance companies and other payers. Having a background or core classes in healthcare terminology, anatomy, and physiology is necessary to identify the right information in the medical record to code appropriately.

Certification for Coders

AAPC and AHMIA are the two main organizations that certify coders and health information personnel. Both organizations offer various other specialty certifications involving technology, billing, and privacy. The table below gives you a sample of the different certifications available.

The specialty of your practice and your needs will help to decide which types of coders you should consider hiring. A candidate’s certification demonstrates that he or she has satisfied the requirements of the general or specialty designation.

As with most certifications and licenses in healthcare, passing an examination is just the first step. To maintain the designation, the individual must participate in and obtain a defined number of continuing education units, or CEUs. Physicians and nurses usually refer to these as Continuing Medical Education (CME) units. The type and number of certifications a coder holds will determine how many CEUs he must obtain each year, every other year, or within a defined period prescribed by the credentialing organization.

Learn More

Whether you’re working in billing, registration, reception, the back office, clinical areas, management, or interested in developing your coding knowledge and skills, Medical Coding Demystified: Coding 101 for Non-coders 2018 delivers the guidance you need to understand the inner workings of medical coding and how to get the most from your team.