Clinical coder

Health information professional responsible for coding medical records

Clinical coder

Occupation
Names
Pronunciation
Occupation type	Profession
Activity sectors	Healthcare
Specialty
Competencies	Knowledge of medical terminology, anatomy, physiology, disease processes, pharmacology, medical procedures, health information management
Education required	Certificate, Diploma, Associate degree, Bachelor's degree

A clinical coder, also known as a medical coder, is a health information professional whose main duties involve the analysis of clinical statements and the assignment of standard codes using a classification system. The codes are used for various purposes including healthcare reimbursement, clinical research, and statistical analysis.

Responsibilities

Clinical coders review clinical statements and assign standard codes from a classification system. The most commonly used classification systems include the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). These codes are used to ensure that healthcare providers are reimbursed correctly for their services, to facilitate clinical research, and to support healthcare planning and management.

Education and Training

Clinical coders typically require formal education in health information management or a related field. This can include a certificate, diploma, associate degree, or bachelor's degree. In addition to formal education, clinical coders must have a strong understanding of medical terminology, anatomy, physiology, disease processes, pharmacology, and medical procedures.

Work Environment

Clinical coders work in a variety of settings including hospitals, clinics, insurance companies, and government agencies. They may work as part of a larger health information management team or independently. The work often involves the use of specialized software to input and manage coded data.

Importance

The role of clinical coders is crucial in the healthcare industry. Accurate coding is essential for the proper reimbursement of healthcare services, which in turn affects the financial health of healthcare providers. Additionally, coded data is used in clinical research, which can lead to improvements in patient care and the development of new treatments.

Related Pages

• Health information management
• Medical transcription
• Health informatics
• International Classification of Diseases
• Current Procedural Terminology

See Also

• Health information technician
• Medical transcriptionist
• Health informatics