Who Participates in Medical Coding?

Coding is a team effort, with the certified medical coder leading the way.

 

Front Desk/Receptionist

Medical coding starts with a patient making an appointment to see their physician. The receptionist makes the appointment – without the appointment the coding process would fail to start.

 

Physician or Healthcare Provider

Next, is the physician, or healthcare provider. They diagnose the patient based on their symptoms (complaints), and in some cases blood tests, x-rays, or any number of other test(s).

 

Certified Medical Coder

Then the medical record makes its way to the certified medical coder. The coder translates the written clinical documents into codes. This coding process allows the physician or healthcare provider to receive payment for the services they have provided to the patient.

 

Certified Professional Medical Auditor

Certain instances (not always) require the medical record to be reviewed by a certified auditor. If the coder is new then the auditor, to ensure the coding is correct, will review the charts. The auditor also checks random charts – this helps the coder stay on their toes, never knowing when one of their charts will be audited. An auditor also reviews and corrects if necessary the medical record when the claim is denied for payment.

 

Clinical Documentation Assessment

If the auditor finds an error or several errors that may become a repeat problem with the coder, then Clinical Documentation Assessment Services are clearly needed. Medical records are reviewed and may be corrected by this third party service. Clinical Documentation Services also offer refresher courses in medical coding, or a specific area of medical coding, to help the coders learn how to correct the errors they are making.

 

Certified Compliance Officer

The compliance officer has several roles; the most important role is the investigation of incidents of fraud or abuse. A common problem is “upcoding”, meaning the physician receives more money from the payee for services they did not perform. The auditor calls in the compliance officer when a coder continually codes in a manner that is not compliant with the government laws, guidelines, rules and regulations that have been put in place for medical coding.

 

Denial Management Specialist

The denial management specialist is a certified medical coder who is extremely knowledgeable and has years of experience. This coder goes through the denied medical chart and determines the reason(s) why the claim was denied and then rectifies the claim and resubmits the claim to the insurance company.