| Detail | For this role |
|---|---|
| Department | Hospital Administration |
| Level | Entry level |
| Reports to | Medical Records Officer |
| Direct reports | None |
| Experience | Fresher with a coding certification, or up to 3 years in medical coding |
Medical Coder job description template
Copy this job description, replace the text in square brackets and post it on your careers page or a job portal.
Job title: Medical Coder
Department: Hospital Administration
Reports to: Medical Records Officer
Location: [City], [office, branch or site]
About the role
A Medical Coder assigns standard codes to the diagnoses and procedures recorded in a patient's file. Working from discharge summaries and case sheets, they apply ICD-10 diagnosis codes and procedure codes accurately so bills, insurance claims and hospital statistics are correct. The role sits in the medical records or coding team and needs a good grasp of anatomy, disease terms and coding rules. In an Indian hospital the medical coder clears the daily coding queue, queries doctors on unclear notes, and keeps coding accurate enough for both revenue and reporting.
Key responsibilities
- Read discharge summaries, case sheets and operation notes, and assign accurate ICD-10 diagnosis codes for each patient record.
- Assign procedure and surgery codes correctly so bills, claims and hospital statistics reflect the actual treatment given.
- Query treating doctors when documentation is unclear, incomplete or does not support a diagnosis.
- Clear the daily coding queue so discharged records are coded within the agreed turnaround time.
- Check that codes match the clinical documentation to avoid over-coding or under-coding.
- Support insurance claims by providing codes that meet payer and government scheme requirements.
- Keep up to date with coding guideline changes and apply them consistently across records.
- Flag documentation gaps that repeatedly cause coding delays to the medical records officer.
- Maintain coding accuracy through self-checks and cooperate fully with coding audits.
- Compile coded data for disease and procedure statistics when the records team needs it.
Requirements
- A life sciences, nursing or paramedical degree, or a B.Pharm
- A certified coding course such as CPC or CIC is a strong advantage
- Sound knowledge of medical terminology and anatomy
- Fresher with a coding certification, or up to 3 years in medical coding
KRAs and KPIs for a Medical Coder
Key result areas for the appraisal form, each with a KPI you can measure every month or quarter.
| Key result area | How to measure it |
|---|---|
| Coding accuracy | Coding accuracy at or above the agreed level, such as 95 percent on audit |
| Turnaround | Records coded within the agreed time after discharge, backlog kept low |
| Query discipline | Coding queries raised and closed within the agreed time for unclear notes |
| Claim support | Codes meet payer requirements, coding-related claim rejections kept low |
| Productivity | Daily records coded meet the agreed count without loss of accuracy |
| Guideline compliance | Latest coding guidelines applied, no repeat of flagged coding errors |
Skills and tools
Tools used day to day: Medical coding encoder software, ICD-10 code books, Hospital Information System (HIS), MS Excel, Insurance and TPA portals.
Reporting line and career path
Next roles: Senior Medical Coder, Coding Team Lead, Medical Records Officer
Interview questions for a Medical Coder
- How do you decide the correct code when a discharge summary lists several conditions?
- A doctor's note does not support the diagnosis you need to code. What do you do?
- What is the difference between the principal diagnosis and a secondary diagnosis in coding?
- How do you avoid up-coding while still capturing everything the record supports?
- How do you keep coding accurate and fast when the daily queue is heavy?
- How do you keep patient information confidential while coding records?
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What does a medical coder do?
A medical coder assigns standard ICD-10 diagnosis codes and procedure codes to the treatments recorded in a patient's file. Working from discharge summaries and case sheets, they make sure bills, insurance claims and hospital statistics are accurate. They query doctors on unclear notes, clear the daily coding queue, and keep coding accurate for both revenue and reporting.
What qualifications do you need to become a medical coder in India?
A life sciences, nursing or paramedical degree, or a B.Pharm, is the usual base. A certified coding course such as CPC or CIC is a strong advantage and often required for coding jobs. Sound knowledge of medical terminology and anatomy matters most, and freshers with a certification are hired for entry roles.
What is the difference between a medical coder and a medical records technician?
A medical coder assigns diagnosis and procedure codes to records for billing, claims and statistics. A medical records technician assembles, files, retrieves and scans records and tracks incomplete files. Coding needs medical terminology and coding rules, while the technician role focuses on handling and organising the physical and scanned records.