Registered Health Information Technician, St. Peter’s Hospital
Over 12 years in the field
Medical coding specialists are investigators. We hunt down the patient’s most important diagnostic, which is based on the lab procedures, signs and symptoms.
Coding involves a lot of rules and there are worldwide guidelines to follow. It seems like it should be more straightforward: here’s the diagnosis, find the code. But there are so many guidelines to follow to pick the correct code; it’s not as black and white as it appears.
I worked for a bank and my position was eliminated, so I went back to school. One of my classes was in medical terminology. I studied anatomy, physiology, medical transcription and coding. Another class covered health information laws like privacy, releasing information, confidentiality, going to court. I was lucky to find a facility that was willing to train me right out of school. But it takes about two years to become a proficient coder, to really know what you’re doing.
I come in, start reading the charts and then begin coding. The coding desk is set up ergonomically to read through charts and enter the documents as I go. We use paper charts, but some facilities are all online. Each person in our department is dedicated to one type of service: inpatient, outpatient surgery, ER. We all do the kind of coding we like, but we are cross-trained and we do back up. People have the opportunity to switch if they want to.
The physician documentation is not as clear as I would like at times. Sometimes I have to put bits and pieces together to find the answer, and then go back and ask the physician. I read the charts, but 10 or 20 percent of the time I have to ask the physician. The physician’s answer is only as good as my question. I get better answers with better questions. Over time, the physicians learn to document the issue before it comes to me so I don’t have to ask them.
Computer skills are essential. Coders work with computers all day, using different programs. You need to be able to learn new programs. Medical coding requires you to be very detail-oriented. Any experience following national or federal guidelines helps.
If you’re an independent decision-making, detail-oriented type who doesn’t require a lot of interaction with people, this is a good position. If you like talking to people, then coding is not what you want to do.
Medical coding sounds straightforward and simplistic: a patient has a disease and the coder gives the diagnosis a number. But it’s more complex than just assigning numbers. It’s detective work, uncovering a mystery.
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