If you have a sore throat that just won't go away, you visit your doctor.
She listens to your symptoms, examines your neck and chest, takes a swab of
your throat and orders you to get some blood work done at the lab down the
Each of these procedures is recorded in your medical records. A medical
coder then looks over that record and applies codes so that payment can eventually
be made for the services provided.
Medical coders use an international system of codes. "Almost every country
in the world codes and abstracts clinical information, which is submitted
to the World Health Organization [WHO]," says Gail Crook. She is the executive
director of a health record association.
"WHO, many decades ago, devised a clinical coding system for diagnostic
This set of codes is called the International Classification of Diseases
(ICD). The ICD is used to classify the diagnoses and procedures in order to
bill the patient or the patient's insurance provider. Medical codes are also
assigned to assess the clinical care of the patient and can be used to support
medical research activity.
Medical coders must have a thorough knowledge of medical terminology, tests,
procedures and surgical operations in order to correctly assign codes to each
Most medical coders work in hospitals. Others work in physician offices,
for insurance companies and in long-term health-care facilities.
"The majority work in the hospital setting, but more are being hired in
physician offices," says Joe Santos. He is a certification specialist at the
American Health Information Management Association (AHIMA).
Medical coders can work regular office hours, whether in a hospital setting
or in a physician's office. "It can tend to be on the isolated side," says
Shirley Davis. She is a professor of health information management and medical
coding in Florida. "You have to like being by yourself much of the time."
A physically challenged person can do the work of a medical coder. "We've
certainly had deaf students and students in wheelchairs go through our program,"
says Davis. "However, sight is important in this work."
Make sure the right codes are applied to each procedure
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Medical Records and Health Information Technicians
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