What is a medical record coder?
A coder is a skilled non-clinical person who reads and interprets medical record documentation to identify all diagnoses, conditions, reasons for treatment, services and procedures performed and then transforms the verbal descriptions of these into numerical codes. Coders assess the quality and quantity of clinical documentation in order to accurately identify and capture all codeable and billable diagnoses, services, and supplies during an inpatient or outpatient encounter. The codes assigned for each encounter are then abstracted onto a claim form and submitted to insurance companies for physician and facility reimbursement for services rendered. Coders are very vital to the accuracy of information abstracted and submitted to insurance companies and state data repositories. Abstracted information is also used nation-wide in health care research, trending, marketing, healthcare cost containment, physician profiling, etc. If information is inaccurate, data used to make important decisi
