What is a Certified Coder?

A medical coder is a healthcare administrator who assigns codes to patient procedure files in order to ensure that insurance companies are properly billed. An accredited medical coding certification organization, such as the American Academy of Professional Coders or the American Health Information Management Association, has credentialed a medical coder. Medical coders must pass a standardized exam in order to gain certification.

An organization may require a test taker to have at least a two-year associate’s degree in medical coding to be eligible for certification. Coder certification exams generally assess knowledge and skills in identifying and coding diseases, surgeries, outpatient procedures, rehabilitation therapies, and anesthesias. A medical coder must also demonstrate knowledge of insurance claims, such as determining which procedures are “medically necessary” and dealing with insurance claim denials, in order to become certified. Medical coders must be fluent in medical and anatomical terminology in order to be certified because they work with patient files.

Although a certified medical coder is not required law, some healthcare facilities may prefer to hire one because he or she has proof of coding knowledge and competence. Coders act as go-betweens for hospitals, doctors’ offices, and insurance companies. Certified coders must be able to translate doctors’ notes into codes for insurance company policies, so they must have both medical and insurance knowledge. They use standardized codes on an insurance reimbursement form to communicate specific patient medical procedures to insurance companies. Errors in coding can cause insurance claims to be paid late or even denied incorrectly, which is why clinics typically hire certified coders.

The American Medical Association’s Current Procedure Terminology (CPT) codes, which are numeric codes used in most physician offices, may be used. If a coder needed to bill an insurance company for outpatient psychotherapy, for example, he or she would use the code 90805 in a reimbursement computer program. Coders may also need to be familiar with the Healthcare Common Procedure Coding System (HCPCS), the reimbursement system used Medicare and Medicaid. A0030, for example, would be typed to bill Medicare for an ambulance service.

A certified coder can work in a variety of settings in the healthcare industry, including nursing homes, hospitals, and outpatient clinics. They can also work as independent contractors for smaller, privately owned businesses that cannot afford to hire full-time coders. Certified coders can also work in law offices as resources for investigating insurance claims that have been wrongfully denied.