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A Day in the Life of a Hospital Coder

I come in to the Medical Records Department of my hospital at my scheduled time and swipe my employee card to sign in to work. I take off my jacket, sit down, turn on my computer, sign in at the hospital computer system, and start the software I will need during the day. Because I am sharing a desk with another coder working the earlier shift, I need to clean my desk before and after my workday. I pull out my office supplies and books from my locked drawer.

Then I go to the medical records shelf and pull out my first batch of patient charts to be coded. The inpatient (IP) and the same-day-surgery (SDS) records have not been computerized yet. Most days I code inpatients and same day surgeries, but sometimes I also pitch in to help the ER coder. The ED reports are all available in electronic format. Soon the IP and SDS records will be computerized, as well.

I open my first patient chart, and read through it picking up the patient's diagnoses and procedures done during the hospital stay. I also abstract other information from the chart, for example, discharge codes, physicians' names, dates of surgeries, DNR status, type of anesthesia used, and if any restraints were used.

I start searching for the right codes with my encoder and/or codebooks and then enter them into the computer system. For inpatient cases, I need to check the final DRG assignments to ensure optimal coding. For hospital outpatients, I need to be aware of the CCI edits. As I go through the computer data entry screens, I also enter the other data I have abstracted from the charts. When in doubt, I check the Coding Clinic newsletter, CPT Assistant newsletter, Coders' Desk Reference for Procedures book, or other references for additional information about the correct code assignment. I also glance into my medical dictionary, medical abbreviations book, or anatomical charts if needed. Many cases are pretty straight forward to code, but every so often I encounter a difficult chart that takes a long time to code correctly (hopefully it doesn't come back in the audit to bite me). There goes my productivity count! Coding has a lot of gray areas that are open for debate among coders. With very complex or unusual cases, coding guidelines can be confusing to interpret.

I finish coding the current medical record, close the case, and start a new one. This cycle of reading, note taking, and computer entry repeats with each chart until I get my first 10-minute break in the middle of my first four hours of work. Then I can get up and stretch my legs and the rest of my body. My lunch break is 30 minutes, just enough to eat my dinner. I need to swipe my employee card when leaving and returning from my dinner break.

During the second half of my eight-hour workday, I get another 10-minute break. Otherwise, I spend the whole day sitting at my computer, reading charts, and using the computer to either search for information or to enter data into the system. My work involves very little moving around. Some coders complain of stiffness, headache, backache, neck pain, or arm pain from the constant sitting and computer use.

Hospital coding is fairly independent work. If I have a challenging case to code, I can ask the other coders for their opinion. However, there is no time for idle chat because all coders are on tight production schedules. Besides, our supervisor would frown upon it. Hospital coders are expected to meet their daily quantity and quality standards. At scheduled times, we have an external auditor come in and audit our coded charts. The results of these coding audits are maintained by the department supervisors and affect our job evaluations.

At the end of my workday, I check my productivity for the day by either doing a manual count of the types of charts I’ve coded, or running a computer report on them. I shut down my computer, clean my desk, and swipe my employee card to clock out of the hospital employee system. Time to go home and relax!

Coders work in many different settings, so their workdays are varied. This is just an example. When I was working as a hospital coder, this was my typical day. My days were pretty much all alike.