Five Tips for Being a Successful Clinical Coder

New to coding or struggling to find your way in this challenging profession? Richard Strickland, qualified clinical coding trainer, auditor and coder speaks about his experiences and what it takes to be a successful coder.  

“Like everyone, I fell into coding after working in medical records at my local Trust. I wanted something a bit more permanent so researched and thought, ‘well that sounds interesting!’ 

Throughout my almost 14-year career in Clinical Coding though, I never really stopped to pay attention to why some excel, and others seem to struggle.

This got me thinking, what five skills or traits sort the best from the rest?

Here are my top five, but let me know what you think the most important trait of a coder is. 

1. Flexibility and adapting quickly to change  

Working in a coding department often involves time pressures and various deadlines around your work. You may suddenly get a request for case notes that will require coding quickly whilst still being accurate and thorough. Plus, you may have to switch workloads throughout the day. Being flexible will allow you to remain cool under pressure ensuring your coding is tip top.  

2. Attention to detail 

How easy is it to miss a word in a set of notes that would be an essential modifier in the index or to accidentally put K02.9 in procedures (unspecified transplantation of heart) rather than in the diagnosis (Dental caries, unspecified), where you meant to put it? Oops! The best coders have a superhuman level of attention to detail not missing a thing, like the comma that has been missed before ‘not missing’. Attention to detail can make the difference in an audit or an exam. One simple technique is to quickly scan the descriptions of your codes before you click submit. You might spot the odd typo.

3. Communicate effectively 

As you progress in your coding career you will rely on your communication skills more and more, often having to liaise with staff at all levels. Whether it’s tactfully getting hold of a clinical record or other information on a patient’s episode, or being able to explain coding rules to clinical or management staff, it’s essential to have good written and verbal communication.  

4. Act like a detective  

It’s not always obvious why a patient is in hospital and sometimes the information will be limited, so being able to analyse all the information you have in front of you and come to a conclusion is essential to the coding process. You’ll often get snippets of information in all different places in your source documentation so don’t leave a stone unturned before you piece the information you have gathered to build an accurate clinical picture of the patient’s visit or stay in hospital.  

This is also the same for the application of the standards, make sure you use the many resources available to you to help!  

5. Have an inquisitive mind 

I think the most important trait of a coder is the want to learn. I am still learning. That’s because there is so much to learn working in clinical coding, and it’s not limited to the classifications or coding standards! As coders you will learn an awful lot of anatomy, physiology, disease processes and medical and surgical procedures. A lot of the team here at Monmouth joke that we are almost as clued up as doctors! 

With medicine advancing all the time you will be continually learning throughout your career. Having an inquisitive mind and being open to learning new things will help you greatly.”