HealthcareISCO 3252

Clinical coder

A clinical coder is a person who reads patients' medical records, interprets the clinical statements in them about diseases, injuries and procedures, and converts that information into health classification codes.

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Rate 5 of the 10 essential skills of this occupation (European ESCO data). No account needed.

manage healthcare users' data

maintain healthcare user data confidentiality

review patient's medical data

perform clinical coding procedures

medical terminology

About clinical coder

The coder works through a record written by clinicians for clinicians and establishes what was actually diagnosed, what was done and in what order. Clinical coding procedures are then applied: the correct code, at the correct level of detail, in the correct sequence, under the rules of the clinical coding system in use.

The codes are used to calculate reimbursement for treatment, to compile statistics and to monitor healthcare outcomes, so a systematic coding error changes what a hospital is paid and what the data appears to show.

The coder maintains the confidentiality of healthcare users' data, works in the electronic health record management system, manages healthcare users' data and follows organisational guidelines on documents and retention. The coder also communicates with clinicians when an entry in a record is unclear and has to be clarified by whoever wrote it.

European Skills Framework

Skills and knowledge areas required for this occupation based on European classification.

Essential (10)

medical terminologymedical terminologyThe meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.clinical codingclinical codingThe matching of clinical statements with standard codes of illnesses and treatments through use of a classification system.document managementdocument managementThe methodology of tracking, managing and storing documents in a systematic and organised manner as well as keeping a record of the versions created and modified by specific users (history tracking).manage healthcare users' datamanage healthcare users' dataKeep accurate client records which also satisfy legal and professional standards and ethical obligations in order to facilitate client management, ensuring that all clients' data (including verbal, wr...maintain healthcare user data confidentialitymaintain healthcare user data confidentialityComply with and maintain the confidentiality of healthcare users` illness and treatment information.use electronic health records management systemuse electronic health records management systemBe able to use specific software for the management of health care records, following appropriate codes of practice.communicate in healthcarecommunicate in healthcareCommunicate effectively with patients, families and other caregivers, health care professionals, and community partners.adhere to organisational guidelinesadhere to organisational guidelinesAdhere to organisational or department specific standards and guidelines. Understand the motives of the organisation and the common agreements and act accordingly.review patient's medical datareview patient's medical dataAssess and review relevant medical data of patients such as X-rays, medical history and laboratory reports.perform clinical coding proceduresperform clinical coding proceduresMatch and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.

Optional (11) — show

human physiologyhuman physiologyThe science that studies the human organs and its interactions and mechanisms.health records managementhealth records managementThe procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of rec...health care systemhealth care systemThe structure and function of health care services.human anatomyhuman anatomyThe dynamic relationship of human structure and function and the muscosceletal, cardiovascular, respiratory, digestive, endocrine, urinary, reproductive, integumentary and nervous systems; normal and ...healthcare analyticshealthcare analyticsThe use of qualitative and quantitative methods to analyse patterns in healthcare data to the aim of improving healthcare administration, quality in patient care and diseases diagnosis.medical informaticsmedical informaticsThe processes and tools used for the analysis and dissemination of medical data through computerized systems.archive healthcare users' recordsarchive healthcare users' recordsProperly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.collect healthcare user's general datacollect healthcare user's general dataCollect qualitative and quantitative data related to the healthcare user's anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests p...identify patients' medical recordsidentify patients' medical recordsLocate, retrieve and present medical records, as requested by authorized medical personnel.collect statistics on medical recordscollect statistics on medical recordsPerform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.manage digital documentsmanage digital documentsManage various data formats and files by naming, publishing, transforming and sharing files and documents and transforming file formats.

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Frequently asked questions

What does a clinical coder do?

Clinical coders read patients' medical records. They analyse and interpret medical statements about diseases, injuries and procedures. Clinical coders convert this information into health classification codes in order to calculate treatment reimbursements, to produce statistics and to monitor health care performance.

What skills does a clinical coder need?

A clinical coder needs 10 essential skills, including medical terminology, clinical coding, document management, manage healthcare users' data, maintain healthcare user data confidentiality.

Will AI replace clinical coder jobs?

The AI disruption score for clinical coder is 81/100 (very high risk). Skills most exposed to automation: medical terminology, document management, manage healthcare users' data. Most resilient: human anatomy, communicate in healthcare, human physiology.

AI Replacement Risk

81/ 100

Very High Risk

Low riskHigh risk

Skills most at risk from AI

medical terminology document management manage healthcare users' data

Skills resilient to automation

human anatomy communicate in healthcare human physiology

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Quick Facts

SectorHealthcare

ISCO GroupHealth associate professionals

Essential Skills10

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