What is Medical Coding?

By DeVry University

May 13, 2023

8 min read

If you’ve been treated by a hospital, physician’s office or medical center, chances are you’re familiar with the concept of medical billing and coding. But exactly what is medical coding and what does a professional in this field do?

To start, medical coding is the practice that transforms healthcare diagnoses, procedures, services and equipment into universal alphanumeric codes for medical billing purposes. Medical coders analyze information about diagnoses and procedures within medical records and other documentation – such as physician's notes, laboratory and radiologic results – then assign the appropriate codes and create a claim for submission to insurance carriers.

Medical coding also supports the operation of the healthcare system. Practitioners and facilities rely on the documentation of what's diagnosed, treated and learned about a patient's condition in order to streamline their processes and ultimately generate revenue. Proper documentation of patient diagnoses, testing and treatment allows healthcare providers to be reimbursed quickly and sustain a healthy cash flow.

Medical coding also helps practitioners quickly understand a patient's conditions and treatments during subsequent visits. This helps providers achieve better patient outcomes, especially in large medical practices or hospitals that serve large patient populations.

How to Become a Medical Coder

As with many career paths, there is no single way to become a medical coder that works for everyone. However, here are 5 simple steps that can help you along your journey:

1. Enroll in an undergraduate certificate program

Many medical coders have some sort of postsecondary education, which means they might have an undergraduate certificate, an associate’s or even a bachelor’s degree according to the U.S. Bureau of Labor Statistics. To get your education started, find a school that offers a program in medical billing and coding and enroll. Our Undergraduate Certificate in Medical Billing and Coding at DeVry is just this kind of program.

2. Complete your certificate program

After enrolling, complete and pass the courses in your undergraduate certificate program. To help you on your way, we recommend taking advantage of professor office hours, learning resources and any certification exam preparation that might be offered.

3. Pursue a professional certification

There are three major professional certifications in this field that you might want to consider: The American Health Information Management Association’s Certified Coding Specialist (CCS) and Certified Coding Associate (CCA), and AAPC’s Certified Professional Coder (CPC). At DeVry, preparation for these certification exams is built into our medical billing and coding certificate programs.

4. Look for potential job opportunities

Congratulations! You’ve earned your undergraduate certificate and professional certification. Now it’s time to start your job search. Build your resume or update an existing one, then identify job titles that interest you and browse them on employment websites. Our Career Services team at DeVry can help with your resume and job search while you're in school and after you graduate. Having clear goals regarding what type of environment you want to work in can be helpful in your job search as well.

5. Apply for positions regularly

It’s not uncommon to apply and interview for a few positions before getting hired. If you stay persistent and apply to multiple jobs, you’re more likely to find the one that fits your needs in terms of work-life balance and the environment you want to work in.

Important Medical Coding Skills

Because the accuracy of medical records is so crucial to insurance companies, hospitals, healthcare providers and patients, attention to detail and proficiency in the coding systems used at your particular healthcare facility are frequently the top requirements. Other skills and personality traits you would need to pursue this career include:

High ethical standards
Strong organizational skills
Patience
Effective time management skills
Robust oral and written communication skills

Types of Codes Used in Medical Coding

Here are some of the common medical coding systems used in the U.S.:

ICD-10-CM (International Classification of Disease, 10th Edition, Clinically Modified)

This 69,000-code set establishes and tracks medical necessity for services. It covers conditions and disease, poisons, neoplasms, injuries, causes of injuries and treatments performed when the injuries are incurred. While some codes are highly predictable, others can be a bit more – unusual.

ICD-10-PCS (International Classification of Disease, 10th Edition, Procedural Coding System)

Hospitals use this 130,000-alphanumeric code set to describe surgical procedures performed in operating rooms, emergency departments, etc.

CPT (Current Procedure Terminology)

The American Medical Association owns and maintains this code set, which includes over 8,000 five-character alphanumeric codes. They describe services provided by physicians, paraprofessionals, therapists, etc. at both outpatient and inpatient facilities.

HCPCS Level II (Health Care Procedural Coding System, Level II)

This code set is used by Medicare, Medicaid and other providers to document procedures and bill for supplies. It contains over 7,000 alphanumeric codes used for quality measure tracking, outpatient surgery billing, academic studies, etc.

NDC (National Drug Codes)

Developed by the Federal Drug Administration (FDA), this code set tracks and reports all packages of drugs. The smart codes enable suppliers, federal agencies and providers to identify medications that are prescribed, sold and used.

APC (Ambulatory Payment Categories)

The Centers for Medicare & Medicaid Services (CMS) maintains this code set to support the Hospital Outpatient Prospective Payment System (OPPS,) which is used for outpatient services in a hospital, such as minor surgery.

Medical Coding Certifications and Educational Requirements

As you get started on your career path, you might find that many medical coding jobs may require you to obtain a Certified Coding Associate (CCA) or Certified Coding Specialist (CCS) certification, in addition to earning an undergraduate certificate or degree in this field. Here are some key steps to help you pursue the medical coding training, education and credentials you need for a future in medical billing and coding:

Earning a Certificate or Degree

With your high school diploma or equivalent, you can pursue an undergraduate certificate or earn an associate or bachelor’s degree. Here are some healthcare programs you may be interested in:

Medical Billing and Coding Undergraduate Certificate:

This can be a quick path toward preparing to pursue a medical coding career. You can earn the certificate in as little as one year, as you look for employment and prepare to pursue industry recognized exams. The coursework focuses on health insurance and reimbursement, medical data classification, information processing and current procedural terminologies.
Healthcare Information Technology Associate Degree:

This program not only covers procedural and regulatory knowledge related to the field but also helps you obtain technical skills in coding and chart management software, health data content and structure, health services and information systems, as well as insurance and reimbursement procedures.
Health Information Management Bachelor’s Degree:

You'll learn how to implement new technologies and control costs in healthcare settings with coursework in advanced classification systems, data security, privacy management and more. You'll also be prepared to work in various healthcare settings such as hospitals, clinics, nursing homes and doctor’s groups.
- Health Services Management Bachelor’s Degree:
This program details the political, social, cultural, economic and technical influences that shape today’s healthcare system. Topics covered in this program include healthcare management, including health rights and responsibilities, healthcare policy, records management, insurance claims billing and healthcare financing.
- Healthcare Administration Bachelor’s Degree:
You'll learn how to improve the quality and efficiency of healthcare services while controlling costs. This degree program prepares you to pursue a career in healthcare policy, managed care, insurance, information systems and finance.

Industry-Recognized Certifications

After you have earned your degree or certificate, you may qualify to take one or more credentialing exams offered by the American Health Information Management Association (AHIMA). There are four options:

- Certified Coding Associate (CCA):
A nationally-recognized standard of achievement in health information management. While not required, AHIMA recommends six months of medical coding job experience before taking this exam.
Registered Health Information Technician (RHIT):

Although no work experience is needed, you'll need at least an associate-level education in health information management to pursue this credential.
Certified Coding Specialist (CCS):

This credential is for medical coders who want to pursue work in hospital settings. The exam tests for knowledge in terminology, disease processes and pharmacology, as well as expertise in the ICD-10-CM and CPT/HCPCS coding systems.
- Certified Coding Specialist Physician-Based (CCS-P):
This is for medical coders specializing in physician-based settings. The exam tests for mastery-level understanding and competency in the ICD-10-CM, HCPCS Level II and CPT coding systems.

Credentials such as CCA, RHIT, CCS and CCS-P need to be rectified every two years by completing continuing education units through activities such as attending AHIMA meetings, taking formal educational programs, attending teleseminars, delivering presentations, publishing academic work and conducting an independent study.

Commonly Asked Questions in Medical Coding

Is it difficult to become a medical coding professional?

How long does it take to become a medical coder?

Where do medical coders tend to work?

What are the benefits of acquiring medical coding certifications?

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