What Is a Medical Coder?

A medical coder translates details from a patient’s medical documents, such as physician's notes, lab reports, procedures, and diagnoses into universal medical codes to maintain accurate medical records. Healthcare providers and insurance companies use these standardized codes for billing and record-keeping.

This administrative role is an important one within the in-demand healthcare industry. Learn more about what a medical coder does and whether this career path is right for you.

What is medical coding?

Medical coding is the process of taking a patient’s health care information like medical procedures, diagnosis, necessary medical equipment, and medical services information from the physician's notes. A medical coder transforms this information into universal medical alphanumeric codes. 

There are three types of universally known medical alphanumeric codes: 

• International Classification of Diseases (ICD): The World Health Organization (WHO) created this internationally used code. The classification system is largely used for the purpose of health recording and data collection, among other uses. These codes can classify symptoms, diseases, illnesses, and causes of death. 

• Current Procedural Terminology (CPT): CPT codes identify medical, surgical, and diagnostic procedures and services within the US. The American Medical Association (AMA) developed this system, which includes three categories: procedures and contemporary medical practices, clinical labs, and emerging technologies. 

• Healthcare Common Procedure Coding (HCPCS): The Centers for Medicare and Medicaid Services (CMS) developed this coding system to help with processing insurance claims for Medicare or other providers. Coders use them to note medical procedures, products, supplies, and services. 

Medical coding's primary use is to ensure medical billing and insurance carriers pay and process claims correctly, but the system is also valuable for research purposes and basic medical record-keeping for patients.

Each code tells insurance companies, researchers, and health care providers the exact diagnosis, procedure, and/or medical service provided. In short, these codes act as a universal way to quantify health care visits and make physician’s notes less abstract for insurance carriers and future health providers. 

Responsibilities of a medical coder

One of the core responsibilities of a medical coder is to ensure the accuracy of the medical records you transcribe and the codes you use. Other medical coder job requirements include proficiency in a variety of medical codes and adherence to the medical coding code of ethics.

 Some of the day-to-day responsibilities of medical coding jobs include:

• Transcribing patient information into appropriate medical codes 

• Examining medical documents and records for missing information 

• Conducting chart audits 

• Collecting, researching, and filing patient medical information

• Ensuring all documents are grammatically correct 

• Complying with medical coding guidelines and policies 

Medical coding vs. medical billing   

Medical coding differs from medical billing in that medical billing deals with financial transactions between insurance carriers and health care providers. A medical biller is in charge of processing insurance claims, generating bills, and managing balances and payments for health care providers.

Medical coding, on the other hand, only pulls billing information and details from a patient’s record to translate into medical coding. So, while both professions deal with medical records, they are in fact entirely different jobs. 

Medical coding salary

A medical coder working in the US makes an average of $46,660 annually or $22.43 an hour [1]. This salary average includes all medical records and health information specialists, so it's possible you can earn more than this average depending on where you work, the certifications you hold, your level of professional experience, and the hours and/or shifts you work. 

Job outlook

Medical coders are in relatively high demand. According to the US Bureau of Labor Statistics, the profession can expect to see a 7 percent growth rate, which is considered average growth. The BLS also predicts an additional 12,300  jobs will be added between 2021 to 2031 [1].

Skills needed

Insurance carriers, health care providers, and patients all rely on the accuracy of medical records. Therefore attention to detail is a must, as is proficiency in the coding systems you will be using at your particular health care facility. 

Consider these key skills if you want to become a medical coder: 

• Attention to detail

• Time management

• High ethical standards

• Organizational skills 

• Patience  

• Strong communication skills 

• Knowledge or ability to learn software systems quickly

Education requirements

You do not need any previous experience in medical coding to become a medical coder; however, many certification programs require at least one year of professional work experience. If you need to gain professional experience prior to certification, consider applying for positions like billing assistant where you’ll gain indirect insight into the medical coding process.  

Certifications

A medical coding certification is a credential in health care coding and billing. It shows you've learned a specific medical coding system, or systems, along with the basics of how to translate patient medical data into codes.

If you choose to earn a medical coding certification, you have many options. You may obtain certification in general coding or a specialty medical coding certification. You can also choose to stack multiple certifications.

The most important thing to remember is to choose an accredited program such as the Practice Management Institute (PMI), the American Health Information Management Association (AHIMA), or the American Academy of Professional Coders (AAPC). Each one of these accredited organizations has its own set of certifications, each with variations in the medical coding system taught and the application (i.e., type of health care facility).

You can earn general coding certifications like a Certified Medical Coder (CMC) certificate or a Certified Professional Coder (CPC-A) certificate, or a specialty coding certifications such as urology or pediatric care. The certification you choose can help you to achieve your ideal career path.

Though certification is optional in many cases, a study conducted by the American Academy of Professional Coders (AAPC) found that certified medical coders earned 27 percent more than medical coders without certification [2]. 

You can complete a certification program at any time throughout your career in medical coding. Some people earn their certificate to get a medical coding job while others earn certifications after completing their associate degree. Some people earn their bachelor’s degree, but it’s not typically a requirement. Each employer will have its own specific training requirements. 

How to become a medical coder

Getting started in medical coding requires the following steps.

1. Meet the basic prerequisites.

The basic prerequisites for getting a medical coding job are to complete medical coding training. This can be done in the form of an associate degree program in medical coding, a certificate in medical coding from an accredited organization, or on-the-job in-house training by an employer. To be eligible for training, you’ll need your high school diploma or GED. 

2. Complete medical coding training.

If you are choosing to earn your associate degree in medical coding, look for a reputable program offered at a community college or vocational school. There are in-person and online options.

If you would rather earn a certificate in medical coding, think about where you’d like to work. Then try to gain professional experience in that particular health care field, as many certificate programs require some prior experience in medical coding and/or an associate degree.

3. Obtain your medical coding certification. 

You can obtain your medical coding certification after completing an associate degree in medical coding or with no degree at all. Entry-level certifications can help you get a medical coding job. You can obtain specialty medical coding certifications at any point in your career as a medical coder. A complete list of all medical coding certifications is available through the three major national accrediting organizations: PMI, AHIMA, or AAPC. Most certification programs include a final exam that you must pass to earn your certificate.  

4. Brush up on medical coding skills.

Once completing training or obtaining medical coding certification, take time to brush up on the top in-demand skills you’ll need as a medical coder. For example, you can enroll in a course on medical software or reimbursement models like those offered on Coursera. You can also request additional training materials from your employer specific to its needs as a health care provider. 

5. Look for a job.

When the time has come to find a job, ask yourself what area of the health care industry you’d enjoy and what you're qualified for. Is there a specialty like pediatrics that interests you? Do you want to apply for jobs in your area to get some professional experience first? You may also be interested in a remote medical coding job.

How long does it take to become a medical coder?

It takes about two years to become a medical coder if you choose to earn your associate degree. It may take anywhere from nine to 20 months to become a medical coder if you choose to enroll in a certification program.

Where do medical coders work?

Medical coders may work in physicians’ offices or other health care facilities. They may work in offices or remotely. Here's a full list:

Consulting services: A medical coding consultant may work in a variety of health care offices, and they may travel or work remotely. Their job is to check the accuracy of medical records. They may also train other medical coders. 

Government agencies: The federal government is a major employer of medical coders. They may employ medical coders for federal agencies such as the Army National Guard, US Air Force, and the Department of Veterans Affairs. 

Hospitals and clinics: Hospitals and clinics are among the most common places for a medical coder to work. They typically have multiple billing departments that require many medical coders. 

Insurance companies: Insurance companies may hire medical coders to check for the accuracy and verification of medical claims that come in from health care providers. Medical coders working in these environments should be quite proficient in medical coding. 

Nursing homes and assisted living facilities: Nursing home medical coders work in assisted living facilities, hospice care centers, residential nursing homes, and other facilities that serve senior citizens. They may work with different types of medical codes specific to senior services. 

Remote work: Medical coding is a service some health care providers outsource. Some medical coders are able to work remotely. Requirements include proper training, access to the internet, and a reliable computer. Some remote medical coders are full- or part-time employees, while others work as contractors or freelancers. Typically, employers have HIPAA privacy and security requirements since you'll be accessing people’s medical records.

Get started today

Medical coding is a highly accessible career with room to grow. Enroll in a medical coding program and get your certification to begin. Both online and in-person programs are available. You might be interested in Yale's Introduction to Medical Software to get acquainted to software in the health care field.