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• A coder starts to review the chart to code the diagnosis, and an abstractor screens the chart to fill in missing interactions, dates and billing elements. A clinical documentation specialist reviews the entire electronic medical record for missing treatment entries and required billing elements.
Coding Certificate - Lone Star College
About a dozen people work in the first stage of actually compiling the document that becomes the bill. Hospital staff collect the medical chart, often paper, to scan and merge it with the existing electronic record. The result is an electronic medical record with hundreds -- perhaps thousands -- of entries for people to assign codes for billing purposes. All of the text is summarized in codes -- the universal language of medical billing.
If you're a newbie in the world of medicine, you might want to start off targeting doctors in a single specialty, such as psychiatrists, chiropractors, cardiologists or dentists. These providers' practices involve a narrower range of diagnoses and procedures than a family practitioner, general surgeon or internist, so you'll have fewer new codes tossed in your lap at the get-go. This is a good, starting-from-scratch strategy, but don't let it dictate or limit your contacts. Most MIBs (medical insurance billers) find that the first client they land, through whatever means, is the specialty they end up going with.