Medical Coding And Records

About Medical Coders And Records Technicians

Medical Records Technicians are the individuals responsible for assembling and maintaining the medical records of patients who receive health care. These records, which are vitally important in treating the patient, contain a compilation of the following information:

• Medical history
• Observations
• Surgical interventions
• Treatment outcomes
• Descriptions of symptoms
• Results of examinations
• Reports of x-rays and MRIs
• Results of laboratory tests
• Diagnoses
• Treatment plans

Technicians verify the completeness of a patient's initial medical chart and make sure that all forms are properly filled out and authenticated. They regularly consult with physicians and other health care professionals for clarification of patient diagnoses and to obtain any additional information required for a patient's records. Technicians also tabulate data for future analysis, provide documentation when needed for use in legal actions, and compile information used to classify reimbursement status of medical procedures by insurance companies.

Medical Records Technician Responsibilities

Medical records technicians organize and maintain patient records in a manner consistent with the requirements of all components of the health care system: medical, administrative, regulatory, legal, and ethical. A partial list of their duties includes the following:

• Process patient admission and discharge documents
• Review records for accuracy, completeness, and compliance with regulations
• Enter data into computers regarding demographic characteristics, disease history, diagnoses, and treatments
• Release information to persons and agencies according to regulations
• Protect the security of medical records to ensure that confidentiality is maintained
• Develop health record indexes and storage and retrieval systems to collate information

The specific day-to-day duties of a medical records technician will vary with the nature of the facility for which he/she works. In small facilities, a credentialed medical records technician usually assumes a variety of technician duties which often includes management of a department. In larger or medium-sized facilities, there are usually several technicians and very often, each will specialize in one aspect of health information. In these types of settings, management duties are usually assumed by an administrator. Examples of specialists in this field include the following:

• Medical Record Coders specialize in coding patients' medical information for insurance purposes. Based on their knowledge of disease processes, these technicians assign a code to each diagnosis and procedure. They then utilize specialized computer software to classify the patient as belonging to one of several hundred "diagnosis-related groups" (DRGs). The DRG classification determines the amount of reimbursement the hospital will recover from the patient's medical insurance carrier or from Medicare to cover the cost of the procedure. Coders are also responsible for using a variety of coding systems other than DRG to enter classifications for other applications such as doctor visits, ambulatory settings, or long-term care.
• Cancer Registrars specialize in the registry of cancer patients. Based on reviews of a patient's records and pathology reports, they assign codes for the diagnosis and treatment of cancers and also certain benign tumors. Registrars will enter information into regional or national databases and then follow up by conducting annual checks on patients in the registry to track and/or update their treatment, survival, and recovery. Information in the registry is used by physicians and public health organizations for a number of reasons including the derivation of survivor and success rates of various types of treatment, identification of geographic areas having high incidences of certain cancers, and the targeting of potential participants for clinical drug trials.

Most medical records technicians work a standard 40-hour week, although some overtime may be required. Those who are employed in hospital settings are often required to work evening or night shifts and/or work on weekends, due to the fact that hospital health information departments are usually open around the clock seven days a week.

Technicians typically do their work in pleasant and comfortable office settings. Unlike their counterparts in most health-related occupations, technicians usually have little or no direct contact with patients. There is some degree of stress in the job due to the ongoing demands for accuracy and the need to pay close attention to detail. Also, technicians are susceptible to the types of discomforts commonly experienced by people who work at computer monitors for prolonged periods of time; notably muscular pain and eyestrain.

To be successful in this job, individuals need good communication skills in order to effectively interface with insurance companies and other establishments. Technicians also need to be detail-oriented and extremely diligent, as accuracy is essential to the job. To an increasing extent, proficiency with computer use is becoming an extremely valuable asset for this profession.

Employment Outlook

The U.S. Department of Labor Bureau of Labor Statistics (USDL BLS) projects employment of medical records technicians to increase faster than the average rate of growth for all occupations over the upcoming decade. A principal factor driving this growth is the rapid proliferation of new tests, treatments, and procedures that need to be carefully scrutinized not only by health insurance companies, but also by other stakeholders such as regulatory agencies, courts, and consumers themselves. Sustaining the anticipated job growth is recent Federal legislation which mandates the use of electronic medical records, requiring more technicians to enter patient information into computer databases.

Job growth is expected to be especially robust in physicians' offices, particularly for large group practices. Employment prospects in home health care services, outpatient care centers, and nursing and residential care facilities are also expected to thrive. Although job growth in hospitals will not be quite as pronounced as in other settings, new jobs will continue to appear in hospitals as well.

Technicians with a strong background in medical coding will be in especially high demand to accommodate the ever-increasing amount of paperwork involved in filing insurance claims. Also, the influx of electronic health records is causing employers to strongly favor technicians who are prepared to work in an increasingly electronic environment.

Medical Records Technician Training, Certification, and Licensing

In order to enter this field, individuals generally need at least an associate degree from a community or junior college. Ideally, the degree program should be accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). There are numerous postsecondary educational institutions which offer flexible course scheduling and/or online distance learning courses. Specific coursework helpful to students who aspire to this profession include anatomy and physiology, medical terminology, legal aspects of health information, health data standards, data coding, statistics, database management, and computer science.

Most employers prefer to hire job candidates who are qualified as Registered Health Information Technicians (RHIT). In order to achieve this designation, individuals must hold an associate degree from a CAHIIM-accredited program. In addition, candidates must also pass a written examination offered by the American Health Information Management Association (AHIMA). Some employers also show a preference for candidates who have prior experience in a health care setting.

Although there are no formal degree programs in coding, a number of schools offer certificate programs in coding or include coding as part of the associate degree program for medical records technicians. A few schools offer formal certificate programs in cancer registry which are approved by the National Cancer Registrars Association (NCRA). Some schools and also some employers offer intensive training programs, lasting one or two weeks in duration, in either coding or cancer registry. Most coding and registry specialists start out as general medical records technicians who advance by learning their coding or registry skills on the job.

There are several organizations that offer certifications in coding. Two of these are the Board of Medical Specialty Coding (BMSC) and the Professional Association of Healthcare Coding Specialist (PAHCS). Another organization, the American Academy of Professional Coders (AAPC), offers three distinct certification programs in coding. Certification in cancer registry is available from the NCRA. Most certifications must be renewed periodically, and in order to do so, continuing education units must typically be acquired.

Resources for Medical Records Technicians

• American Health Information Management Association
• Healthcare Information and Management Systems Society
• American Academy of Professional Coders
• Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Board of Medical Specialty Coding (BMSC)
• Professional Association of Healthcare Coding Specialist (PAHCS)
• International Federation of Health Records Organizations
• National Cancer Registrars Association
• National Standards for Health Information Privacy

Major Employers of Medical Records Technicians

Approximately 40% of all medical records technicians work in hospitals. Most of the rest are employed in doctors' offices, home health care services, outpatient care centers, and nursing care facilities. Other employers include public health departments and insurance firms.

Schools for Medical Coders And Records Technicians are listed in the column to the left.

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