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Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians who have earned a medical coding diploma or degree organize and evaluate these records for completeness and accuracy.

Medical Billing & Coding Technicians assemble patients' health information. They make sure that patients' initial medical charts are complete, that all forms are completed and properly identified and signed, and that all necessary information is in the computer. They regularly communicate with physicians and other health care professionals to clarify diagnoses or to obtain additional information.

Some medical records and health information technicians specialize in coding patients' medical information for insurance purposes. Technicians who specialize in coding are called health information coders, medical record coders, coder/abstractors, or coding specialists. These technicians assign a code to each diagnosis and procedure. They consult classification manuals and also rely on their knowledge of disease processes. Technicians then use computer software to assign the patient to one of several hundred diagnosis-related groups, or DRGs. The DRG determines the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system. In addition to the DRG system, coders use other coding systems, such as those geared toward ambulatory settings or long-term care.

Medical records and health information technicians' duties vary with the size of the facility where they work. In large to medium-sized facilities, technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptionists while a medical records and health information administrator manages the department. In small facilities, a credentialed medical records and health information technician sometimes manages the department.

Experienced medical records and health information technicians usually advance in one of two ways—by specializing or managing. Many senior technicians specialize in coding, particularly Medicare coding, or in cancer registry. Most coding and registry skills are learned on the job. Some schools offer certificates in coding as part of the associate degree program for health information technicians, although there are no formal degree programs in coding. For cancer registry, there were 11 formal 2-year certificate programs in 2005 approved by the National Cancer Registrars Association (NCRA). Some schools and employers offer intensive 1- to 2-week training programs in either coding or cancer registry. Once coders and registrars gain some on-the-job experience, many choose to become certified. Certifications in coding are available either from AHIMA or from the American Academy of Professional Coders. Certification in cancer registry is available from the NCRA.

In large medical records and health information departments, experienced technicians may advance to section supervisor, overseeing the work of the coding, correspondence, or discharge sections, for example. Senior technicians with RHIT credentials may become director or assistant director of a medical records and health information department in a small facility. However, in larger institutions, the director usually is an administrator with a bachelor's degree in medical records and health information administration.