Clinical coder
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Occupation | |
---|---|
Synonyms | Medical Coder, Clinical Coding Officer, Coder (informal) |
Occupation type | Procedural classification |
Fields of employment | Hospital, Clinic |
Related jobs | Medical billing, Nosology |
A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system. The health data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.
For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the
A clinical coder therefore requires a good knowledge of
In practice
The basic task of a clinical coder is to classify medical and health care concepts using a standardised
Clinical coding has three key phases: a) abstraction; b) assignment; and c) review.[5]
Abstraction
The abstraction phase involves reading the entire record of the
Assignment
The assignment phase has two parts: finding the appropriate code(s) from the classification for the abstraction; and entering the code into the system being used to collect the coded data.
Review
Reviewing the code set produced from the assignment phase is very important. Clinical coder must ask themselves, "does this code set fairly represent what happened to this patient in this health encounter at this facility?" By doing this, clinical coders are checking that they have covered everything that they must, but not used extraneous codes. For health encounters that are funded through a case mix mechanism, the clinical coder will also review the diagnosis-related group (DRG) to ensure that it does fairly represent the health encounter.
Competency levels
Clinical coders may have different competency levels depending on the specific tasks and employment setting.[6]
Entry-level / trainee coder
An entry-level coder has completed (or nearly completed) an introductory training program in using clinical classifications. Depending on the country, this program may be in the form of a certificate, or even a degree, which has to be earned before the trainee is allowed to start coding. All trainee coders will have some form of continuous, on-the-job training, often being overseen by a more senior coder.
Intermediate-level coder
An intermediate-level coder has acquired the skills necessary to code many cases independently. Coders at this level are also able to code cases with incomplete information. They have a good understanding of anatomy and physiology along with disease processes. Intermediate-level coders have their work audited periodically by an advanced coder.
Advanced-level / senior coder
Advanced-level and senior coders are authorized to code all cases including the most complex. Advanced coders will usually be credentialed and will have several years of experience. An advanced coder is also able to train entry-level coders.
Nosologist
A nosologist understands how the classification is underpinned. Nosologists consult nationally and internationally to resolve issues in the classification and are viewed as experts who can not only code, but design and deliver education, assist in the development of the classification and the rules for using it.
Nosologists are usually expert in more than one classification, including morbidity, mortality and case mix. In some countries the term nosologist is used as a catch-all term for all levels.[7]
Classification types
Clinical coders may use many different classifications, which fall into two main groupings: statistical classifications and nomenclatures.
Statistical classification
A statistical classification, such as ICD-10 or DSM-5, will bring together similar clinical concepts, and group them into one category. This allows the number of categories to be limited so that the classification does not become too big, but still allows statistical analysis. An example of this is in ICD-10 at code I47.1. The code title (or rubric)[8] is Supraventricular tachycardia. However, there are several other clinical concepts that are also classified here. Amongst them are paroxysmal atrial tachycardia, paroxysmal junctional tachycardia, auricular tachycardia and nodal tachycardia.
Nomenclature
With a nomenclature, for example SNOMED CT, there is a separate listing and code for every clinical concept. So, in the tachycardia example above, each type and clinical term for tachycardia would have its own code listed. This makes nomenclatures unwieldy for compiling health statistics.
Qualification and professional association
In some countries, clinical coders may seek voluntary certification or accreditation through assessments conducted by professional associations, health authorities or, in some instances, universities.[9] The options available to the coder will depend on the country,[9] and, occasionally, even between states within a country.[citation needed]
Professional bodies that provide certification for clinical coders may also represent other health information management professionals.
Australia
- Clinical Coders' Society of Australia (CCSA)[10]
- Health Information Management Association of Australia (HIMAA)[11]
Canada
- Canadian Health Information Management Association (CHIMA)[12]
Saudi Arabia
- Saudi Health Information Management Association (SHIMA)[13]
United Kingdom
Clinical coders start as trainees, and there are no conversion courses for coders immigrating to the United Kingdom.
The National Clinical Coding Qualification (NCCQ) is an exam for experienced coders, and is recognised by the four health agencies of the UK. Institute of Health Records and Information Management (IHRIM)[14] are the awarding body.
England
In England, a novice coder will complete the national standards course written by NHS Digital within six months of being in post.[15] They will then start working towards the NCCQ.
Three years after passing the NCCQ, two further professional qualifications are made available to the coder in the form of NHS Digital's clinical coding auditor and trainer programmes.[16][17]
Scotland
In 2015, National Services Scotland, in collaboration with Health Boards, launched the Certificate of Technical Competence (CTC) in Clinical Coding (Scotland). Awarded by the Institute of Health Records & Information Management (IHRIM), the aims of the certificate include supporting staff new to clinical coding, and providing a standardised framework of clinical coding training across NHS Scotland.[18]
The NCCQ is a recognized coding qualification in Scotland.
Wales
The NCCQ is a recognized coding qualification by NHS Wales.
Northern Ireland
United States
As of 2016[update], the typical qualification for an entry-level medical coder in the United States is completion of a diploma or certificate, or, where they are offered, an associate degree. The diploma, certificate, or degree will usually always include an Internet-based and/or in-person
There are several associations that medical coders in the United States may join, including:
- AAPC (formerly American Academy of Professional Coders)
- American Board of Health Care Professionals (ABHCP)[21][third-party source needed]
- American Health Information Management Association (AHIMA)[22][third-party source needed]
Some medical coders elect to be certified by more than one society.
The
The other main organization is American Health Information Management Association (AHIMA) which offers the Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), and the entry-level Certified Coding Associate (CCA). [23] [24]
Some U.S. states now mandate or at least strongly encourage certification from either AAPC or AHIMA or a degree from a college to be employed.[
See also
- Clinical medicine
- Current Procedural Terminology
- Diagnosis-related group
- Diagnostic and Statistical Manual of Mental Disorders (DSM)
- Health informatics
- International Classification of Diseases (ICD)
- Medical diagnosis
- Pathology Messaging Implementation Project
- WHO Family of International Classifications
References
- ISBN 0-7668-1207-3.
- ISBN 978-1-111-03518-1.
- ^ World Health Organization. Classifying health workers: Medical records and health information technicians. Geneva, 2010.
- ^ Department of Human Services, Victoria, Australia. Clinical Coders Creed. Health Data Standards and Systems Bulletin, Issue 13, 19 July 2000.
- PMID 18490784.
- S2CID 35531619.
- ^ Nosologist. Popular Science, posted 11.11.2004.
- ISBN 9789241548342.
In the context of the ICD, "rubric" denotes either a three-character category or a four-character subcategory.
- ^ a b Bramley, M; Reid, B. "Evaluation standards for clinical coder training programs" (PDF). Health Information Management Journal. 36 (3): 2007.
- ^ "Clinical Coders' Society of Australia". Retrieved 16 March 2015.
- ^ "Health Information Management Association of Australia Limited". Retrieved 16 March 2015.
- ^ "CHIMA: The Canadian Health Information Management Association". Retrieved 16 March 2015.
- ^ "IFHIMA 2019". ifhima2019.com. Retrieved 24 December 2019.
- ^ "IHRIM – Institute of Health Records and Information Management (IHRIM)". Retrieved 16 March 2015.
- ^ "National Clinical Coding Training Handbook 2016–17" (PDF). Clinical Classifications Service. Archived from the original (PDF) on 21 September 2016. Retrieved 9 April 2018.
- ^ "Delen: Home: CLINICAL CODING AUDITOR PROGRAMME". Retrieved 9 April 2018.
- ^ "Delen: Home: CLINICAL CODING TRAINER PROGRAMME". Retrieved 9 April 2018.
- ^ "Certificate of Technical Competence in Clinical Coding (Scotland)" (PDF). ISD Services. NHS Scotland. Retrieved 9 April 2018.
- ^ "Medical Coder – Academics". Illinois Central College. Retrieved 17 June 2019.
- ^ "Medical Coding Training Program & Classes | Midwest Technical Institute". Midwest Technical Institute. Retrieved 17 June 2019.
- ^ "ABHCP – American Board of Health Care Professionals".
- ^ "AHIMA Home – American Health Information Management Association". Retrieved 16 March 2015.
- ^ "Certifications". American Health Information Management Association. Retrieved 10 May 2020.
- ^ "Certified Coding Associate (CCA)". AHIMA. Retrieved 2021-02-02.
- ^ "Federal Requirements for Medical Billing Companies". smallbusiness.chron.com. Retrieved 17 June 2019.
- ^ "The Most Important Medical Billing Laws". www.mb-guide.org. Retrieved 17 June 2019.