Medical Records Coder (Health Information Management) CSC (221-152-06)

PURPOSE: This program is designed to provide the technical knowledge and skills, along with the practical experience, needed for employment as a basic medical records coder. Assisted by specialized computer equipment and software, medical records coders analyze and interpret the patient’s record to determine the proper standardized codes that represent the patient’s diagnosis and treatment. These codes may be used for billing purposes, to create accurate standardized records to maintain health statistics. The need for medical records coders will continue to increase as the health field continues to address reimbursement challenges and move toward a focus on quality improvement related to health care services.

OCCUPATIONAL OBJECTIVES: Medical records coders work in hospitals, doctors’ offices, insurance companies, and government agencies.

ADMISSION REQUIREMENTS: General college curricular admission

PROGRAM NOTES: In addition to the general college curricular admission requirements, a program interview with the program head is required for advising prior to enrollment in the first HIM course. Courses need to be taken in the sequence listed or as advised. Students must repeat any course in which a grade lower than “C” is received.  This program accepts new students in the spring and fall semesters of each year. Students admitted will be approved for entry into HIM discipline courses when they have satisfied the following requirements:   

1. All applicants will need to complete the general education prerequisites (SDV 101, HLT 143, BIO 145, and ITE 152) with a grade of “C” or better. 

2. Students with prior college experience transferring in general education course requirements need to contact the program head for information. Students transferring in a partial number of courses must ensure all prerequisites are met prior to starting the Medical Records Coding HIM courses. 

3. Students planning to enroll in a fall semester are encouraged to have the program interview completed by the end of June. Students enrolling in a spring semester are encouraged to have the interview completed by the end of October.  

4. Permission codes are required for enrolling in HIM courses.  Permission codes will be provided by the program head after completion of the program interview. 

Upon satisfactory completion of this certification program, graduates will be eligible to take the nationally accredited exam offered by the American Academy of Professional Coders (AAPC). Successfully passing the exam and obtaining certification as a medical coder begins the journey towards an in-demand career within the healthcare industry.  The designation of Certified Professional Coder Apprentice (CPCA) is the medical records coding certification from AAPC.  This certification is nationally recognized by employers, physician societies, and government agencies. According to the U.S. Bureau of Labor Statistics, medical coding is one of the fastest growing professions in the nation and allows certified medical coders to be more marketable and earn more than non-certified coders.

STUDENT OUTCOMES FOR MEDICAL RECORDS CODER CAREER STUDIES CERTIFICATE: Students who complete the Medical Records Coder Career Studies Certificate will be expected to:

• Recognize and implement professional policies and procedures related to the legal and ethical use of medical information;

• Interpret health record documentation using knowledge of anatomy, physiology, clinical indicators and disease processes, pharmacology, and medical terminology to identify codable diagnoses and/or procedures, according to the ICD-10-CM, HCPCS II, and CPT-4 coding systems;

• Apply knowledge of major reimbursement systems in the United States to the preparation of universal billing claims; and

• Demonstrate behaviors and dispositions that are in accordance with AAPC professional ethics, including integrity, respect for privacy, and commitment to professional growth.

COMPUTER COMPETENCY REQUIREMENT: Students in this program must meet the college’s computer competency requirement by successfully completing ITE 152 . Students can also meet this requirement by passing the college’s computer competency exam administered in the testing centers on each campus, in which they will receive college credit for ITE 152 . Students not passing the computer competency exam may retake the exam. Either ITE 152  or the competency test must be completed in the first semester or students may not progress to the second semester.

FINANCIAL REQUIREMENTS: In addition to the regular college tuition and fees, the Medical Records Coder program requires the purchase of books and/or electronic resources.  These costs are approximate and subject to change:

NOTE: Graduates seeking CPC certification from AAPC should be aware of the following additional fees (these costs are subject to change): (1) AAPC annual membership ($210); and (2) AAPC’s CPC national certification examination fee is approximately $500.00 for two attempts. CPC Certification is not a requirement for graduation from the program. but is recommended within 120 days of completing the program. 

PROGRESSION THROUGH THE PROGRAM:  

1. Students who have a break in their enrollment must meet with a program faculty advisor to review current enrollment requirements.  In some cases, students may be required to retake courses or take additional courses required for the program when industry standards have changed.

2. Any student who receives a final grade lower than “C” in any course within the program must repeat the course.

ESSENTIAL SKILLS REQUIREMENTS: Students entering the Medical Records Coder certificate program must possess the following skills:

• Satisfactory speaking, reading, and writing skills to effectively communicate in English. 

• Satisfactory intellectual, emotional, and psychological health and functioning to exercise independent judgment and discretion in performing assigned tasks.

• Satisfactory time management of multiple priorities and stimuli to operate in fast-paced environments.

• Sufficient analysis, synthesis, and comprehension skills to follow detailed instructions and effectively code medical charts and records.