Are you a story teller, do you love putting stories together, do you love reading stories, do you love stories?
You may be a medical coder
Providers are story tellers– what happens during the encounter are written in the EHR/EMR so that medical coders can then relay the story to insurance companies.
As medical coders we have to be able to be great story readers and story tellers
No one is in the encounter except for the provider and the patient. Providers need to be able to convey everything that happened during the encounter, so that when the coder reads the documentation it is as if the coder was also in the exam room during the encounter.
Specificity is important, laterally is important, not abbreviating and taking shortcuts is important
Coders want to give their providers the benefit of doubt however if it isn’t documented it didn’t happen, I don’t care how close you are to your provider and you know his/her routines and think it doesn’t matter if it is documented, it does matter. It is always better to have too much documentation than not enough.
In many circumstances providers actually code their own encounters and the certified coder is responsible for spot checking their code selection, remember it is okay to make changes if the code selected isn’t correct. If you the coder know it isn’t correct but submit it anyway you will also be liable if there is fraud/abuse with the claim forms.
Remember that providers tell us (coders) the story of the encounter then we translate their story into medical codes which then tells the insurance companies the story of the encounter.
You the coder are the deciding factor if there will be a happily ever after to the story!