What Is a Medical Coder?

A medical coder translates details from a patient’s medical documents, such as physician's notes, lab reports, procedures, and diagnoses, into universal medical codes to maintain accurate medical records. Health care providers and insurance companies use these codes for billing and record-keeping.

This is an administrative position within the health care industry, so a large part of the medical coder role includes working with the documentation and transcription of essential medical documentation within a health care setting.

What is medical coding?

Medical coding takes a patient’s health care information from the physician's notes, such as medical procedures, diagnoses, necessary medical equipment, and medical services, and transforms it into universal medical alphanumeric codes. 

There are generally three types of universally known medical alphanumeric codes: 

• International Classification of Diseases (ICD) 11th revision (ICD-11): The World Health Organization (WHO) created and manages this internationally used code. The classification system is primarily used for health recording and data collection, among other uses. These codes can classify symptoms, diseases, illnesses, and causes of death. 

• International Statistical Classification of Diseases - Canada (ICD-10-CA): This classification is the WHO’s guidelines adapted to Canada’s particular data needs by the Canadian Institute for Health Information.  

• Canadian Classification of Health Interventions (CCI): The Canadian Institute for Health Information created this system for use throughout the health care system, regardless of setting or provider. It is intended to be used with IDC-10-CA. 

Medical coding's primary use is to ensure medical billing and insurance carriers pay and process claims correctly. Still, the system is also valuable for research purposes and basic medical record-keeping for patients.

Each code tells insurance companies, researchers, or other physicians the exact diagnosis, procedure, and medical service provided. In short, these codes are a universal way to quantify health care visits and make physician’s notes less abstract for insurance carriers and anyone with access to your medical records. 

Responsibilities of a medical coder

One of the core responsibilities of a medical coder is to ensure the accuracy of the medical records you transcribe and the codes you use. Other medical coder job requirements include proficiency in various medical codes and adherence to the medical coding code of ethics.

  Some of the day-to-day responsibilities of medical coding jobs include:

• Transcribing patient information into appropriate medical codes 

• Examining medical documents and records for missing information 

• Conducting chart audits 

• Collecting, researching, and filing patient medical information

• Ensuring all documents are grammatically correct 

• Complying with medical coding guidelines and policies 

Medical coding vs. medical billing   

Medical coding differs from medical billing in that medical billing deals solely with financial transactions between insurance carriers and health care providers. A medical biller is in charge of processing insurance claims, generating bills, and managing balances and payments for health care providers.

On the other hand, medical coding only pulls billing information and details from a patient’s record to translate into medical coding. So, while both professions deal with medical records, they are, in fact, entirely different jobs. 

Medical coding salary 

A medical coder working in Canada makes a median wage of $30.26 an hour [1]. This median salary includes all medical records and health information specialists. 

You may earn more than the median, depending on where you work, your certifications, your level of professional experience, and the hours and shifts you work. 

Job outlook

Medical coders are in relatively high demand. According to Job Bank Canada, the job outlook through 2026 has incomplete data. Still, medical coders have a “Moderate” outlook in Alberta, a “Very Good” outlook in Saskatchewan and Manitoba, and a “Good” outlook in Ontario and British Columbia [2].

Skills needed

Insurance carriers, health care providers, and patients rely on the accuracy of medical records. Therefore, attention to detail is a must, as is proficiency in the coding systems you will use at your health care facility. 

Consider these key skills and personality traits needed for medical coding jobs: 

• Attentive to detail

• Efficient with time management

• High ethical standards

• Organizational skills 

• Patience  

• Strong communication skills

•  Knowledge or ability to learn software systems quickly

Experience requirements

You don’t need any previous medical coding experience to become a medical coder; however, some certification programmes require experience before enrolling. If you need to gain professional experience before certification, consider applying for positions as a billing assistant where you’ll learn more about the medical coding process.  

Certifications

You can become a medical coder by completing a medical billing and coding certification program, which is generally a two-year program. A medical coding certification is a credential in health care coding and billing. It shows you've learned a specific medical coding system or systems, along with the basics of translating patient medical data into codes.

You have many options if you choose to earn a medical coding certification. You may obtain certification in general coding or a specialty medical coding certification. You can also earn multiple certifications.

When choosing your certification, the most important thing to remember is to select an accredited program, such as the Canada Institute of Management and Technology  (CIMT), or the Canadian College of Health Information Management (CCHI). Each accrediting organization has its own set of certifications, each with variations in the medical coding system taught and the application, such as the type of health care facility.

You can earn general coding certifications, like a Certified Medical Coder (CMC) certificate, a Certified Professional Coder (CPC-A) certificate, or one of the many specialty coding certifications, ranging from urology to pediatric care. The certification you choose can help you to get on your ideal career path for medical coding jobs or boost your income. 

Certification is generally optional for medical coders in Canada, although it can demonstrate to your employer that you are proficient in the skills needed to succeed in the position. Some employers require their medical coders to have earned certification through the Canadian Health Information Management Association. 

You can complete a certification program at any time during your career in medical coding. Some people earn their certificates to get a medical coding job, while others earn certifications after completing their associate degree. People seeking a medical coding degree sometimes earn a bachelor’s degree, but it’s not typically a requirement.  Each employer will have its specific training requirements. 

How to become a medical coder

Getting started in medical coding requires just a few steps. Here’s how you can start today:  

1. Meet the basic prerequisites.

Completing medical coding training is the basic prerequisite for getting a medical coding job. You can do this through a two-year college diploma programme in health information management, health record technology, or a certificate in medical coding from an accredited organization. To be eligible for training, you’ll need your secondary school diploma. 

2. Complete medical coding training.

If you opt to earn a degree in medical coding, look for a reputable programme accredited by the Canadian College of Health Information Management. You can take in-person and online courses. 

If you instead earn a certificate in medical coding, think about where you’d like to work. Then, try to gain professional experience in that particular health care field, as many certificate programs require some prior experience in medical coding or an associate degree. If you work with a company that provides on-the-job training, focus on completing that required training and look into adding a professional certificate afterward. 

3. Obtain your medical coding certification. 

You can obtain your optional medical coding certification after completing an associate degree in medical coding or without a degree at all. Entry-level certifications can help you get a medical coding job, and you can earn specialty medical coding certifications anytime during your career as a medical coder. 

As outlined above, the two major national accrediting organizations—CCHI and CIMT—offer a complete list of all medical coding certifications. Most certification programs include a final exam, which you must pass to earn your certificate.  

4. Brush up on in-demand medical coding skills.

Once you complete training or obtain a medical coding certification, brush up on the top in-demand skills you’ll need as a medical coder. For example, you can enrol in a course on medical software or reimbursement models like those offered on Coursera. You can also request additional training materials from your employer that are specific to your needs as a health care provider. 

5. Find a job. 

When finding a job, ask yourself what health care industry you’d enjoy and what you're qualified for. Is there a specialty, like pediatrics, that interests you? Do you want to apply for jobs in your area to gain professional experience? Keep in mind that you may also find remote medical coding jobs.

How long does it take to become a medical coder?

It takes about two years to become a medical coder. Depending on where you go to school, there may be variations in program formatting and requirements that affect the duration of your training. However, most recognized programs take two years to complete.  

Where do medical coders work?

Medical coders may work in physicians’ offices or other health care facilities, like outpatient care centers, surgical centers, or government-owned medical facilities. They may work in offices or remotely. 

• Consulting services: A medical coding consultant may work in various health care offices, and they may travel or work remotely. Their job is to check the accuracy of medical records. They may also train other medical coders. 

• Government agencies: The federal government is a significant employer of medical coders. They may employ medical coders for federal agencies like the Canadian Army, Royal Canadian Air Force, and Veterans Affairs. 

• Hospitals and clinics: Hospitals and clinics are among the most common places for a medical coder to work. They typically have multiple billing departments that require many medical coders. 

• Insurance companies: Insurance companies may hire medical coders to check the accuracy and verify medical claims from health care providers. Medical coders working in these environments should be proficient in medical coding. 

• Nursing homes and assisted living facilities: Nursing home medical coders work in assisted living facilities, hospice care centers, residential nursing homes, and other facilities that serve senior citizens. They may work with different types of medical codes specific to senior services. 

• Remote work: Some health care providers outsource medical coding, and some medical coders can work remotely. Requirements include proper training, access to the internet, and a reliable computer. Some remote medical coders are full—or part-time employees, while others work as contractors or freelancers. 

Get started today

Medical coding is a highly accessible career with room to grow. Enrol in a medical coding program and get your certification to begin. Online and in-person programs are available; earning a certificate online is easy. Get started today in this in-demand career.