A medical coder assigns CPT, HCPCS and/or ICD9 codes to patient charts in order for a medical biller to submit a claim to the insurance company for reimbursement. It’s very important that each code be to the highest specificity to accurately describe the procedure performed and diagnosis rendered. CPT and ICD9 books should be available at all times in order to assign codes. Accurately coding will also help other physicians and providers when treating that patient as well.
A medical transcriptionist listens to the dictation from a provider and types what they hear into a report template. Dictation is spoken into a small recording device that can later be retrieved remotely by the transcriptionist .Once complete, the report is electronically signed by the provider and then placed in the patient’s chart and copies distributed to the referring physicians. The chart itself can be paper or in an electronic medical record which is becoming more common.