Surya Prasad Mar 03, 2025

What are the Roles and Responsibilities of a Medical Coder?

A medical coder is responsible for converting healthcare diagnoses, procedures, and services into standardized codes for billing, insurance, and record-keeping purposes. Medical coding professionals play a crucial role in the healthcare industry by ensuring that the coding process is accurate, compliant, and timely, which directly impacts the accuracy of billing procedures and the efficiency of insurance claims processing.

There is enormous scope in the area of medical coding. As per Mordor Intelligence, the medical coding market is expected to reach 39.01 billion by 2030. With the right certification in medical coding, you can pursue job roles from medical coding assistant to coding compliance officer.

If you are passionate about starting your career in Medical Coding, learn about the key roles and responsibilities of a medical coder. The table below highlights the roles and responsibilities of junior-level, intermediate-level, and senior-level medical coding professionals.

Roles and Responsibilities of a Medical Coder
Junior-Level Medical Coding Professional	Intermediate-Level Medical Coding Professional	Senior-Level Medical Coding Professional
Collecting & Reviewing Patient Information	Handle Coding for Complex Cases	Quality Control
Transcribe Patient Information	Coding Consultant to the Health Department	Maintaining Confidentiality and Security of Medical Data
Ensuring Coding Compliance	Offer Mentorship to Junior Medical Coders	Serves as a Resource for Coding Staff
Providing Insurance & Billing Support	Implement New Guidelines and Best Practices	Performing Internal and External Audits
Adapting to the Latest Trends in Medical Coding	Assist in Healthcare Research	Maintaining Transparency in the Medical Coding System

Roles and Responsibilities of Medical Coding Professionals

Let’s dive deeper into the major job roles and responsibilities of medical coders at each level.

Roles and Responsibilities of Junior-level Medical Coding Professionals

Billing and Coding Specialists, Health Information Technicians, Medical Coding Assistants, Medical Transcriptionists, and Junior Medical Coders are some of the entry-level job roles in Medical Coding. A Junior-level medical coding professional must be knowledgeable in

International Classification of Diseases, 10th Edition, Clinically Modified (ICD-10-CM)
International Classification of Diseases, 10th Edition, Procedural Coding System (ICD-10-PCS)
Health Care Procedural Coding System (HCPCS) Level-II
Medical Terminologies
Anatomy and Physiology

The following are the roles and responsibilities of junior-level medical coding professionals,

1: Collecting Patient Information

The primary responsibility of a Junior Medical Coder is to collect, research, and file patient information. They review patient records, physician notes, procedures, lab results, and radiology reports. By gathering and examining all these details, they ensure the clinical findings, drug prescriptions, and date of patient visits are properly documented.

2: Transcribe Patient Information

Medical coders gather patient information and convert it into universal alphanumeric codes that can be understood by medical professionals and insurance companies alike. A junior-level medical coder works alongside experienced medical coders to ensure patient data is encrypted, secured, and organized.

They transcribe patient information using ICD-9, ICD-10, and HCPCS coding systems. Junior Medical Coding professionals ensure all medical records are well-documented and send the documents to senior authorities for verification.

3: Ensure Coding Compliance

Junior medical coding professionals must maintain a clear communication channel with senior medical coders, healthcare professionals, and regulatory bodies to ensure accuracy and compliance with medical coding.

They have to follow the Coding Compliance Plan, a strategic framework to safeguard the integrity of Healthcare Revenue Cycle Management (RCM) processes. Junior-level Medical Coders ensure coding compliance to,

Reduce the risk of non-compliance penalties
Provide accurate reimbursement by insurance companies
Minimize revenue wastage of healthcare providers

4: Providing Insurance & Billing Support

Junior-level Medical Coding professionals provide insurance and billing support by,

Ensuring that the patient's insurance plan covers the diagnostic procedures and services provided.
To help healthcare providers understand the services that are eligible for reimbursement under the patient’s insurance policy.
Managing appeals when an insurer initially rejects a claim.
Reviewing and correcting the errors when the claim is denied.
Resubmitting the claim with necessary adjustments.

5: Adapting to the Latest Trends in Medical Coding

A Junior-level medical coding professional has to stay updated with the latest trends in medical coding to reach higher-level job positions. According to Dr. Gregory Gasic, Neuroscientist | Scientific Consultant| Co-founder, VMeDx

“AI will change how medical coding is done 24/7 by speeding up efficiency and accuracy and automating routine tasks. AI tools analyze medical records, extract key information, and assign appropriate codes at speeds and efficiencies no human coder could hope to match. As we adapt to these changes, medical coders will need to move toward more specialized positions that demand higher skill sets. Ushering in the opportunity to work in concert with AI helps professionals enhance their contributions and remain vital as the healthcare landscape shifts.”

Keep upskilling to stay relevant in the competitive medical coding job market. You can enroll in Medical Coding Courses to acquire the latest skills and enhance your career prospects.

Skills Required for a Junior-level medical coding professional

Analytical Skills
Problem-Solving Skills
Data Entry Skills
Communication Skills

Certifications for Entry-level medical coding professionals:

Certified Coding Associate (CCA) Certification by AHIMA
Certified Professional Coder (CPC) Certification by AAPC

Salary of an Entry-level Medical coder:

The global average salary of an entry-level medical coder is $47,740 per annum. The average salary of an entry-level medical coder in the UAE is AED 8000 P.M.

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Roles and Responsibilities of Intermediate-level Medical Coding Professionals

An Intermediate-level Medical Coder codes patient information independently and gets their work audited by a senior-level medical coder. Clinical Coder, Medical Coding Manager, Certified inpatient coder, and Certified outpatient coder are some of the mid-level medical coding professions. Other than ICD-10-CM, ICD-10-PCS, and HCPCS (Level-II), a mid-level medical coding professional must have specialized knowledge in,

CPT (Current Procedural Terminology)
CDT (Code of Dental Procedures and Nomenclature)
National Drug Codes (NDC)
MS-DRG (Medical Severity Diagnosis Related Group)
APC (Ambulatory Payment Categories)

The following are the roles and responsibilities of intermediate-level medical coding professionals,

1: Handle Coding for Complex Cases

Complex cases are those that require multiple diagnoses, treatments, and procedures. A mid-level medical coder deals with complex cases by,

Reviewing comorbidity, complications, and medical history of the patients.
Consulting with the physician or clinical staff about the intent behind selecting the treatment or procedure for the patient.
To check if additional scrutiny is required to ensure compliance, especially during high-cost surgical and diagnostic procedures.
Using modifier codes if the procedure was altered or the treatment requires additional time.

2: Act as a Coding Consultant to the Healthcare Providers

A mid-level medical coding professional acts as a coding consultant to the healthcare providers by,

Provide awareness to clinicians and healthcare providers on the importance of detailed documentation of medical reports.
Ensuring the coding procedure accurately reflects the medical services provided.
Ensuring coding practices align with the EHR system being used.
Give valuable advice on selecting the best codes to maximize reimbursement.

3: Offer Mentorship to Junior Medical Coders

Intermediate-level offer mentorship to junior-level medical coding professions in,

Overcoming challenges faced by entry-level medical coders in medical coding.
Understanding the expectations of the healthcare sector from a medical coder.
Identifying the proper codes and documenting them with supportive information.
Balancing multiple medical coding projects and complex cases.

4: Implement New Coding Guidelines and Best Practices

Medical Coders implement the latest and industry-best practices by,

Indulging a continuous learning process
Participating in training programs and webinars
Use specialized coding software to avoid outdated codes.
Work through mock scenarios to implement new guidelines
Provide regular feedback to comply with the updated coding requirements.

5: Assist in Healthcare Research

Mid-level Medical Coders assist in healthcare research by

Helping researchers in identifying global health trends
Helping researchers in tracking high-risk population
Identifying the effectiveness of public health policies.
Enabling data-driven research to improve patient care.
Pulling data on treatment effectiveness and side effects of clinical trials.

Skills Required for an Intermediate-level Medical Coding Professional:

Analytical Skills
Critical Thinking
Attention to Detail
Health Informatics
Time Management

Certifications for mid-level medical coding professionals:

The following are the top medical coding certifications for mid-level medical coding professionals,

Certified Medical Coder (CMC) Certification
Certified Outpatient Coder (COC) Certification
Certified Intpatient Coder (COC) Certification
Certified Coding Specialist- Physician Based (CCS-P)

Salary of a Mid-level Medical Coder:

The global average salary of a mid-level medical coder is $60,300 per annum. The salary of a mid-level medical coder in the UAE is AED 10,000 P.M.

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Roles and Responsibilities of Senior-level Medical Coding Professionals

Medical Coding Auditor, Lead Medical Coder, Coding Director, and Clinical Data Specialist are some of the senior-level medical coding job roles. In addition to knowing multiple medical coding standards, a senior-level medical coding professional must have advanced-level knowledge in,

Health Information Management (HIM)
Electronic Health Record (EHR) Systems
Clinical Documentation Improvement (CDI)
NCCI (National Correct Coding Initiative) Policies
Medical & Insurance Laws

1: Participate in Quality Improvement Initiatives:

Senior Medical Coding professionals ensure that coding is accurate, consistent, and compliant with relevant standards and regulations. They conduct stringent quality checks at multiple stages of the coding process. A senior-level medical coder must be well-versed in Procedure-to-Procdure (PTP) edits and Medically Unlikely Edits (MUE) to check duplications, omissions, and errors. Other key metrics used by Senior medical coders for quality check are,

Coding Accuracy Rate: Used for measuring the percentage of correctly coded claims out of the total claims received.
Error Rate: Used to measure the proportion of coding errors.
Turn Around Time (TAT): This is used to measure the time taken to code claims from receipt to submission.

2: Maintaining Confidentiality and Security of Healthcare Data:

It requires a seamless exchange of patient data between various parties to run a well-coordinated healthcare system. Senior Medical Coders establish interoperability by ensuring data accuracy and standardization. They maintain the security of patient/ healthcare data by,

Regularly monitoring Electronic Health Record System (EHR) access logs
Limiting EHR access to authorized personnel only
Implementing stricter user authentication and access EHR control measures
Facilitating interoperability across different electronic systems for accurate data exchange.

Maintaining confidentiality is crucial in medical coding. Breach in confidentiality can lead to legal consequences and loss of patient’s confidence in health care syetem. Senior-level medical coding professionals have to maintain the confidentiality of patient data and use the information only for legitimate purposes.

3: Serves as a Resource for Coding Staff:

Senior-level medical coding professionals provide expert guidance in maintaining the effectiveness of the entire coding process. With the ever-growing amount of data in the healthcare industry, senior medical coders act as a valuable resource in providing updates on the latest coding guidelines and changes in the standardization process.

4: Perform Internal and External Audits:

Senior-level medical coders perform external and internal audits of medical records.

External Audits: An external medical audit is an independent review of an organization’s medical codes by a third party, usually performed by a senior certified medical coding professional from outside the organization. External audits help in evaluating risks objectively and produce recommendations for implementing a proactive approach to correct any problems. It also helps in identifying shortcomings and skill gaps of the medical coders in the organization.
Internal Audits: Internal audits are conducted by the senior-level medical coder of the organization. They perform prospective (pre-bill) audits and retrospective (post-bill) audits. Internal audits improve the precision of coding practices, leading to better compliance and positive financial outcomes. Internal auditors set regular auditing schedules and identify fraudulent billing practices such as upcoding or downcoding. They help in maintaining integrity and protect the organisation from legal penalties.

5: Maintaining Transparency in the Medical Coding System

Senior-level medical coding professionals play a pivotal role in maintaining transparency in medical coding. They ensure the process of assigning medical codes to patient diagnoses is transparent and understandable to patients, healthcare providers, and other stakeholders.

Skills Required for a Senior-level medical coding professionals

Leadership Skills
Decision-Making Skills
Organizing Skills
Team Management Skills

Certifications for Expert-level medical coding professionals:

Having these two certifications enables you to take on higher-level responsibilities in the area of medical coding

Certified Evaluation & Management Coder (CEMC)
Certified Risk Adjustment Coder (CRAC)

Salary of a Senior Medical Coder:

The global average salary of a senior medical coder is $85,373 per annum. The average salary of a senior-level medical coding professional in the UAE is AED 15,000 PM.

To Sum Up:

Medical Coding is an evolving field that requires constant adaptation. The key to staying job-relevant in this tough field is to stay updated with the latest technologies used in Medical Coding. Stay connected with industry peers and participate in medical coding forums to adapt swiftly to changes in regulations and policies. Invest yourself in a continuous learning process to take on higher job responsibilities and reach new heights in the medical coding profession. If you want to switch your career from medical coding to other areas, there are healthcare management courses that you can consider pursuing!

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Surya Prasad

Medical Coding Trainer

Surya Prasad is a Certified Professional Coder with years of experience. Currently, she holds the position of Medical Coding Tutor at Edoxi Training Institute in Dubai, UAE, where she imparts her knowledge and expertise to aspiring professionals in the healthcare industry. With her extensive training and certifications, Surya Prasad is well-equipped to provide valuable insights and guidance to students and professionals pursuing careers in medical coding and healthcare management.

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