In modern Western medicine, every diagnosis and every treatment, test or procedure is associated with a numeric code. Insurance approvals and reimbursements, primarily a computerized process, are contingent on such codes for efficiency and accuracy. Even approvals for inpatient length-of-stays can be related to the severity of the disease and number of complications as indicated by these codes. Clinical coder jobs are clerical careers in which medical records and insurance claims are reviewed and individuals trained, educated or certified in the procedure apply the correct and necessary codes. Such positions are found at every level of healthcare, and can code everything from outpatient physical exams, to inpatient surgery, to codes used for medical research.
Some clinical coder jobs are found in outpatient physician group practices and may or may not be a separate position from the practice's insurance claims clerks. The coder is responsible for ensuring that the correct disease-related codes are applied to a patient's appointment and the care he or she received at that time. Although the physician usually specifies a patient's primary diagnosis, a clinical coder may be responsible for reviewing the medical records to include secondary diagnoses and their codes. Tests or treatments — also coded — must be matched to the diagnoses and gender of the patient.
Inpatient clinical coder jobs cover a number of insurance issues and the coding can take place during the patient's hospitalization or after discharge. One of the first responsibilities is to ensure that the admitting diagnosis or diagnoses allow insurance coverage for the patient's length of stay. If complications arise, they must be added to the insurance invoice. All possible diagnoses must be captured through review of the medical record and doctors' notes, if necessary. For the U.S. governmental programs Medicare and Medicaid, billed treatments and diagnostic procedures must be considered reasonable and of medical necessity for reimbursement and this decision may be based upon whether or not a clinical coder has included an appropriate secondary diagnosis.
Specialized clinical coder jobs are limited in number and usually require additional training and education. They can include cancer registry coders who follow patients throughout their outpatient and inpatient care in order to provide information on the efficacy of certain treatments. Other clinical coders work for pharmaceutical companies during their drug phase tests. These employees review patient records and distill patient conditions, side effects, complications and treatments into specific coded categories.
Clinical coders are also known as medical records technicians, health information technicians, billing insurance claims clerks, and coding auditors. Most coder jobs require a high school diploma and some positions require a certificate or associate's degree in the specialty. There are a number of professional credentialing organizations that provide professional status to the career. Clinical coder jobs are expected to grow more quickly than average in the next decade.