The medical coding professional (or coder) is responsible for translating healthcare providers’ diagnostic and procedural phrases into coded form. Coding professionals do this by reviewing and analyzing health records to identify relevant diagnoses and procedures for distinct patient encounters. This translation process requires interaction with the healthcare provider to ensure terms are translated correctly.
The job entails much more than simply locating diagnostic and procedural phrases in the coding manuals or with encoder software. It requires knowledge of disease processes and procedural techniques to consistently apply the correct codes. A medical coding professional works as part of a team to achieve the best quality patient care.
Coding professionals must possess a thorough understanding of the health record’s content in order to find information to support or provide specificity for coding. Certified medical coders are trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded.