Medical Coding Auditors: Who They Are and How to Become One

Day-to-Day Duties

Here’s what a day in the life of a medical coding auditor might look like:

• Act as an expert coding resource and super user
• Review patient records for coding accuracy
• Identify coding errors and compliance issues
• Review payor denials and facilitate appeal letters
• Assist with onboarding and training new coders
• Provide feedback and education to coders and medical staff as needed
• Communicate regularly with revenue cycle management leadership
• Generate audit reports and track trends
• Stay current with coding guidelines

Work Environments

Medical coding auditors work in the following environments:

• Hospitals and health systems
• Private medical practices and clinics
• Medical billing and consulting firms
• Insurance companies and payers

Recommended Starting Point

Strong coding auditing skills start with solid coding experience. It’s recommended to build your career as a certified medical coder first, ideally spending years becoming well-versed in the field and in different healthcare settings. This hands-on experience allows you to relate to coders, understand the challenges they face, common pitfalls, why coding mistakes happen, and how to prevent them.

Degrees and Coursework

A degree is not always required to become a medical coding auditor, but some employers prefer candidates with healthcare-related education. That could be a medical coding certificate, an associate’s degree, or a bachelor’s degree in health information management, health administration, or a related field.

You’ll also need current coding certifications, such as Certified Coding Specialist (CCS), Certified Coding Associate (CCA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).

Additionally, most employers require at least five years of coding experience.

Top Certifications to Consider

• RHIT/RHIA: Both RHIT and RHIA certifications are great options for professionals in health information management, whether you’re focused on hands-on patient data as a technician or managing systems and compliance at an administrative level. Many employers accept these credentials for auditing roles.
• Certified Professional Medical Auditor (CPMA): This certification, offered by the American Academy of Professional Coders (AAPC), is specifically for those seeking to specialize in auditing. It covers audit methodology, compliance issues, and proper documentation requirements. Still, a CPMA is not always a requirement for working as a coding auditor.
• CCA/CCS: These credentials are foundational certifications that demonstrate your coding competency. While not auditing-specific, they’re often required and show you have the coding knowledge base that auditing builds upon.
• CPC: The CPC focuses on outpatient coding and is widely recognized in physician practices and outpatient settings. If you plan to audit in these environments, this certification provides the specialized knowledge you need to succeed.

How to Qualify for Certification

To qualify for most coding certifications, you’ll typically complete an accredited program or coursework. The program requirements vary by certification and the professional organization offering the certification. Once you meet the educational criteria, you’ll take an exam that tests your knowledge of coding guidelines, anatomy, medical terminology, and healthcare regulations.

Entry-Level Coding Roles First

Successful coding auditors typically begin their careers in entry-level coding roles. Think medical coder, billing specialist, or claims reviewer. These positions give you hands-on experience with International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS).

You’ll learn how to read medical records, understand physician documentation, and navigate the coding guidelines. The goal is to gain exposure to different types of records to help you understand the full scope of coding challenges you’ll likely later be auditing.

Transitioning Into Auditing

Once you’ve gained coding experience, consider taking on quality control tasks, working closely with supervisors, or shadowing experienced auditors.

Some coders transition by becoming coding trainers or mentors first, which builds the feedback and analytical skills you’ll need as an auditor. Obtaining a specialized certification, such as CPMA, and staying current with coding updates can also help build credibility as an auditor.

Final Thoughts: Is Medical Coding Auditing Right for You?

If you’ve spent some years mastering coding and feel ready for a new challenge, medical coding auditing could be the next step that pushes your expertise further. It’s a role that requires attention to detail, strong analytical skills, and the ability to provide constructive feedback.

Transitioning into auditing takes experience, certification, and continuous learning, but the career opportunities and salary potential make it well worth considering.