Difference between medical scribe and medical coding

Navigating the medical industry can sometimes feel like wading through a sea of jargon and technical terms. Two roles that are often misunderstood are those of a “medical scribe” and a “medical coder”. Both of these positions are critical to the functioning of healthcare facilities, yet their responsibilities are considerably different. Understanding their specific roles and functions can shed more light on the complexities and operations of the healthcare sector.

A medical scribe is a healthcare professional dedicated to assisting physicians and other practitioners by documenting patient information during clinical interactions. They are the physician’s “right hand,” taking the responsibility of medical data documentation off the physician’s shoulders. As such, they enable the physicians to focus entirely on providing the best possible patient care without worrying about paperwork.

On the other hand, a medical coder plays a behind-the-scenes but equally crucial role. They translate clinical reports and physicians’ notes into a coded language. This coded format is universally recognized and is used for insurances, record keeping, billing and overall management of patient care. Using specific coding systems, such as the International Classification of Diseases (ICD), medical coders transform verbal descriptions of diseases, injuries, and procedures into alphanumeric designations.

The roles of a medical scribe and medical coder are distinct, but both undeniably contribute to the streamlined operation of modern healthcare systems. As we delve deeper into the differences between these roles, a clearer picture will emerge of how each contributes to the critical goal of delivering high-quality patient care.

Role of a Medical Scribe

A medical scribe is a healthcare professional who assists physicians by documenting patient information during clinical interactions. Their primary role is to create detailed reports of patient’s visits, symptoms, medical histories, and treatment procedures. They also enter this data into Electronic Health Records (EHRs) in real-time.

Scribes often accompany physicians during patient appointments and are responsible for accurately documenting the details of each encounter, which are essential for diagnosing and devising treatment plans. They also manage patient charts, ensuring that they are fully updated.

In addition, they perform administrative tasks such as communicating with different departments of the healthcare facility and other physicians. However, despite their ability to understand medical terminologies and disease processes, they do not directly involve themselves in patient care; they simply document the medical experience.

In essence, a medical scribe supports physicians by managing patient documentation and administrative tasks, enabling physicians to focus more efficiently on patient care.

Role of a Medical Coder

Medical coders are key players in the healthcare industry, entrusted with reviewing and interpreting medical documentation. Their aim is to convert this information into universally recognized codes essential for billing, insurance, and records.

This task requires knowledge of medical terminology, disease, and procedures, as well as understanding the coding systems like International Classification of Diseases (ICD) and Current Procedural Terminology (CPT).

The process begins with reviewing patient medical records and identifying relevant diagnoses, medical procedures, and equipment. Medical coders then translate these details into the appropriate codes.

Their work ensures that insurers get the diagnostic and procedural data they need for reimbursement. Moreover, it supports research in tracking diseases and managing health crises.

Medical coders are also responsible for adhering to regulations about health information and patient confidentiality, ensuring patient data’s accuracy and privacy. They collaborate with healthcare providers to clarify any unclear information in the patient’s medical records before coding.

Background Knowledge and Skills needed for a Medical Scribe

In order to perform their roles effectively, medical scribes need to have a comprehensive background in certain areas and possess specific skills. Below is an analysis of the key knowledge areas and skills that a medical scribe should have:

• Medical Terminology: It’s essential for a medical scribe to have deep knowledge of medical terminologies. They should be conversant with names, descriptions, and abbreviations of diseases, symptoms, surgical procedures, medical equipment, and anatomy.
• Use of Electronic Health Records (EHR) Systems: The modern healthcare industry heavily relies on digital systems for patient records. Thus, medical scribes should be adept at using EHR systems to input and manage patient data accurately.
• Understanding Clinical Procedures: Medical scribes often accompany doctors during patient encounters. Therefore, understanding clinical procedures, clinical documentation, and workflow in different specialities helps the scribe create accurate and detailed patient records.
• Strong Communication Skills: Since they act as a liaison between doctors and other medical staff or patients, strong interpersonal and communication skills are critical.
• Typing and Computer Skills: Fast and accurate typing skills are crucial as they need to document patient encounters in real-time. Along with this, familiarity with medical software and general computer skills are a requirement.
• Attention to Detail: This ensures that all documentation is accurate and complete, which is essential for quality patient care and medical decision-making.
• Knowledge of Privacy Regulations: Understanding the Health Insurance Portability and Accountability Act (HIPAA) is essential as the job involves dealing with sensitive patient data.
• Ability to Work in a High-stress Environment: Medical settings can often be fast-paced and stressful. Therefore, a medical scribe should be able to manage stress effectively and maintain a high level of productivity.

These skills and knowledge areas help medical scribes effectively support physicians and positively contribute to the overall administration of patient care.

Background Knowledge and Skills needed for a Medical Coder

To successfully execute their role in a healthcare setting, medical coders are expected to have specific knowledge and skills. The following is an in-depth analysis of the fundamental knowledge base and skills for a medical coder:

• Understanding of Medical Terminology: Medical coders need to have a comprehensive understanding of medical terminologies, covering anatomical vocabulary, disease names and symptoms, abbreviations, and medical procedures.
• Coding Knowledge: Expertise in coding systems, primarily the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT), is crucial for medical coders.
• Basic Anatomy and Physiology: A strong foundation in the basics of anatomy and physiology helps coders understand doctors’ diagnoses and treatments, enabling accurate and efficient coding.
• Understanding of Healthcare Regulations: Coders need to be familiar with healthcare regulations, especially those pertaining to confidentiality and ethical coding practices, such as the Health Insurance Portability and Accountability Act (HIPAA).
• Computer Literacy: With an increasingly digitized healthcare sector, medical coders need to be proficient with computer systems and medical coding software.
• Attention to Detail: Given that coding accuracy directly impacts the healthcare facility’s financial process, coders need to be meticulous and detail-oriented.
• Strong Communication Skills: Medical coders often interact with physicians, insurance companies and administrative staff to ensure accurate patient billing information, requiring strong interpersonal and communication skills.
• Continuous Learning: The field of medical coding is ever-evolving, with updates in coding regulations and systems. Thereby, the coder should have a willingness to continually update their knowledge in the field.

In summary, these unique knowledge areas and skills set medical coders apart, enabling them to make significant contributions to the efficient management of healthcare facilities.

Comparison between the Training and Education required for both Medical Scribe and Medical Coding

The education and training requirements for a Medical Scribe and a Medical Coder differ in various ways due to the distinct nature of the roles they fulfill.

Medical Scribe Training and Education

Typically, medical scribes are required to have a high school diploma, but many hold college degrees, often in health-related fields. Aspiring medical scribes often choose to study biology, pre-med, or nursing to gain foundational knowledge of medical terminology and procedures. However, the role doesn’t explicitly require specific education in healthcare fields.

Internally, healthcare institutions often provide on-the-job training for medical scribes, during which they learn about health information technologies, electronic health records, and specific communication skills. They also gain familiarity with diagnoses and treatment plans to document effectively.

Certain organizations offer certification programs for medical scribes, like The American College of Medical Scribe Specialists and The Scribe America’s Scribe Training Program. These may not be universally mandated but can be beneficial for career advancement.

Medical Coder Training and Education

As opposed to medical scribes, medical coders often need more specialized training and certifications because of their intricate and regulatory work nature. The majority of coders hold a post-secondary certificate or associate degree in medical coding, health information technology, or a related field. These programs cover medical terminology, anatomy and physiology, and crucially, extensive training in different coding systems like ICD and CPT.

In addition to a degree or certificate, many employers prefer certified coders. Certifications, such as the Certified Professional Coder (CPC) offered by the American Academy of Professional Coders and the Certified Coding Specialist (CCS) by the American Health Information Management Association, are highly valued.

On-going education is essential for medical coders as coding standards frequently change. They should stay current with these changes to maintain their certification and adapt to their evolving role.

Medical scribes play a fundamental role in healthcare settings and, like any job, have their fair share of advantages and challenges.

Advantages of Being a Medical Scribe

• 1. Learning Opportunity: Serving as a medical scribe allows individuals to gain first-hand clinical experience and a profound understanding of the healthcare industry. This becomes especially beneficial for those planning to advance their careers as physicians, nurse practitioners, or physician assistants.
  2. Improve Patient Care: By taking over the responsibility of documentation, scribes allow physicians to focus primarily on the patient, fostering a better provider-patient relationship.
  3. Skill Development: Rapid typing, multitasking, familiarization with medical terminologies, note-taking skills, and exposure to electronic health records are some skills scribes acquire during their time in healthcare settings.
  4. Networking: Working closely with physicians, nurses, and other healthcare professionals provides opportunities for building professional relationships and networking.

Challenges for Medical Scribes

• 1. High-Stress Environment: Medical scribes often work in fast-paced, high-stress environments where they must manage multiple responsibilities simultaneously.
  2. Intensive Training: Scribes are required to learn and adapt quickly through intensive training programs to gain proficiency in using EHR systems and comprehension of medical terminologies.
  3. Long and Irregular Hours: The nature of healthcare means scribes may be required to work long shifts, including overnight, weekends, and holidays.
  4. Limited Career Advancement: Without further education or certification, there can be limited opportunities for progression directly from the scribe role.
  5. Low Pay: Compared to other healthcare jobs, medical scribes often earn lower salaries, especially when starting.

Despite these challenges, many people find the role of a medical scribe to be a rewarding step in their healthcare career due to the unique experiences, skill-building opportunities, and invaluable insight into patient care it offers.

Impact of Medical Scribes and Medical Coders on the Healthcare System

Through their unique roles and responsibilities, both medical scribes and medical coders significantly impact the healthcare system.

Medical scribes bear the responsibility of documenting patient encounters in real-time – a role that has transformative effects on physician productivity and patient care. By handling the administrative task of charting, medical scribes free up physicians, enabling them to devote more time and attention to their patients. This supports a more personalized healthcare experience, leading to better patient outcomes. Simultaneously, the quality of the medical documentation improves, which benefits the continuity of care as well as research and population health studies.

Medical coders, on the other hand, create a crucial liaison between healthcare providers and insurance companies. By accurately translating patient data into recognized codes, they assist in ensuring that healthcare providers are correctly reimbursed for their services. Medical coders also contribute to the organization and accessibility of patient data, thus benefiting epidemiological studies and public health decisions.

Our medical scribe service, Ambula, embodies these impacts on the healthcare system by providing a high-quality, efficient service aiding physicians with their administrative tasks. As a reliable partner in care, Ambula’s trained medical scribes offer real-time, precise documentation, ultimately enabling healthcare providers to perform at their optimal clinical efficiency.

Not only does Ambula help lighten the administrative burden, but our service also ensures increased face-to-face interaction time with patients, leading to more meaningful physician-patient relationships and enhancing overall patient satisfaction.

Irrespective of the healthcare setting, Ambula is committed to adapting to specific requirements, showcasing the flexibility and dedication that healthcare providers can depend on.