Occupations and Terms of Reference › Medical coder
Universal terms of reference · POS-150 · version 1.0 · status: draft · next review 2027-10-27
Medical coder
To code diagnoses and procedures accurately, so that care is recorded correctly, funding and statistics are right, and audits can be trusted.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You code clinical records. You assign diagnosis and procedure codes using the agreed system, query unclear notes with clinicians, and check accuracy.
Reports to: Medical records manager.
Leads or supervises: No direct reports.
What you do on a typical day
- Code diagnoses and procedures from records.
- Query unclear notes with clinicians.
- Check coding accuracy with audits.
- Keep up to date with the coding rules.
- Report coding trends to the records manager.
Working conditions and demands
- Detailed, desk-based work.
- Needs good relations with clinicians.
- Coding rules change.
What good looks like
- Coding is accurate and timely.
- Queries are answered promptly.
- Coding audit results meet standard.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Patients are treated with dignity, respect and privacy at every step.
- Accurate information is given to patients and families, in a language they understand.
- Confidential information is protected and used only for care, legal and agreed purposes.
- Safety comes first: errors are reported, reviewed and learned from without blame.
- Medicines, records and appointments are handled to the standard, every time.
- Anyone can raise a concern without fear of reprisal.
- Waiting and flow are managed fairly, with patients kept informed.
- Work is done to written procedures, and deviations are reported.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-150 |
| ISCO-08 | 3343 (skill level 4) |
| ESCO | to map |
| Department | Patient administration |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-148. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Medical records manager | Coding standards. |
| Clinicians | Queries on diagnoses and procedures. |
| Insurance claims officer | Claims and funding. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Coding | Codes records accurately and on time. | Coding audit at standard 95% or more | Monthly | C-01 | T-04 | POL-DATA | 2 |
| Queries | Resolves clinician queries promptly. | Queries answered within 5 working days | Weekly | C-02 | T-08 | – | 2 |
| Rules | Keeps up to date with coding rules. | Training completed yearly | Annually | C-01 | T-04 | – | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Code selection within the coding rules | Disputed codes with financial impact (records manager and finance manager) |
| Code selection within the coding rules | Coding disputes (records manager) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Medical coding certificate (national or recognised) | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Medical coding or health information experience | 2 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | C-01 |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | – |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | – |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-02 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Diagnosis and procedure coding | Codes common cases | Codes complex cases | Designs coding standards | Coding audit | Every 12 months | T-04 |
| C-02 | Clinician queries | Raises queries | Resolves queries | Designs query processes | Query review | Every 12 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Coding audit at standard | 95% or more | coding audit | Monthly |
| PI-02 | Queries answered in time | 95% or more | query log | Weekly |
| PI-03 | Coding training current | 100% | training records | Annually |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Medical coder | 2 years (recommended) | Q-01 | C-01 practitioner, C-02 foundation | T-04 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |