A Typical Day as a Medical Coder and Biller Essay
As a medical coder you will be responsible for reviewing patient documentation for encounters that has been added to an Electronic Health Record by a provider. You will ensure the accuracy and integrity of the codes that are used. Additionally, you will review each medical record for compliance purposes and report issues that may be apparent. When there is a question, you will ask or query your provider to confirm that the medical record supports the code selection. It really begins with the medical coder as they are the gatekeepers or coding accuracy and compliance.
*Explore aspects of a coding position.
Include the following aspects in the assignment:
· Describe what you feel a day may be like once you become a coder
· What do you think will be most challenging?
· Summarize why it is essential to collaborate with clinical staff (MDs/APRNs) to resolve coding questions/discrepancies
· Provide an example of a time when it may be necessary to query a physician.
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Introduction: Medical coding and billing play a crucial role in the healthcare industry as it ensures that the patient’s medical history and treatment are accurately documented and billed. As a medical professor, it is essential to provide assignments that prepare students for the daily tasks and responsibilities of a medical coder and biller.
1. Describe what you feel a day may be like once you become a coder:
As a medical coder, a typical day may start with reviewing patient documentation, ensuring that the codes accurately reflect the medical procedures and services rendered. The coder will also verify the legitimacy of the codes by conducting audits for compliance purposes. Communication between clinical staff and coders is essential to ensure accuracy and completeness of patient information. Additionally, follow-up on rejected claims, modifying the codes to meet the guidelines, and resubmitting the claim may also be part of the daily routine.
2. What do you think will be most challenging?
One of the most challenging aspects of a medical coder’s job is keeping up with the ever-changing coding guidelines and regulations. The medical coder must be updated with the changes and be well-versed in the various coding systems, including ICD-10, CPT, and HCPCS codes. Additionally, ensuring coding accuracy while maintaining productivity standards can be challenging, especially in a high volume practice setting.
3. Summarize why it is essential to collaborate with clinical staff (MDs/APRNs) to resolve coding questions/discrepancies.
Collaboration with clinical staff, including doctors and advanced practice registered nurses, is critical in resolving coding questions and discrepancies. Clinical staff can provide valuable insight into the complexity of a patient’s care and help ensure that the codes accurately reflect the level of service rendered. This collaboration leads to a more accurate patient record and ensures that the bill reflects the services provided to the patient.
4. Provide an example of a time when it may be necessary to query a physician.
A time when it may be necessary to query a physician is when the documentation is incomplete or unclear, and the coder is unsure which codes to use. For example, if a physician notes a condition but failed to document characteristics that would help establish the severity of the patient’s presentation, such as the duration or the severity level of the signs and symptoms. A coder would have to reach out to the physician to clarify the information in the patient’s documentation that would inform the appropriate code selection.