By: Kendall Upton
Professional insights: Michael D. Miscoe
Medical coders play an integral part in the billing process for medical services. With a firm understanding of medical coding basics and a sharp eye for detail, they have to be sure they’re assigning the correct codes so that healthcare providers are properly reimbursed by insurance companies, recognizing that the proper result from an insurance company is, in some cases, no payment.
Despite best efforts, human error by either the coder or the payer is inevitable from time to time. So what happens if a provider or payer thinks there’s been an error that caused an over- or underpayment? When legal recourse for reimbursement errors ensue, legal teams need to consult medical coding experts to determine what the legally correct code is. This is where forensic medical coders come in.
What forensic medical coding is all about
To understand forensic medical coding, you have to understand the role of a medical coder first. Medical coders work for healthcare organizations and translate doctors’ notes and patient summaries into specific numeric or alphanumeric codes that reflect what kind of care the patient received and what conditions the care was provided for. Medical billers then use these codes to submit claims to insurance companies to receive payment for the services provided.
Forensic medical coders are experienced medical coders who use their expertise to help legal teams with coding and billing issues. Since forensic code analysis always occurs afterwards when there is a dispute, forensic coders are not directly involved in the coding and billing process.
Forensic medical coders are experienced medical coders who use their expertise to help legal teams with coding and billing issues.
“Forensic coding is what I would call ‘legally accurate coding,’” said Michael Miscoe, a professional coder and health lawyer with over 25 years as a forensic coding and compliance expert and consultant. In the simplest terms, forensic coders like Miscoe assist legal teams with discerning whether a medical procedure was or wasn’t coded correctly. However, arriving at a clear right or wrong conclusion is more complicated than you might think.
“The first thing you learn as a forensic coder is that there are no universal truths in coding. Coding is very local. It is local to every single payer. They all have or can have their own rules, and the reason for that is the HIPAA [Health Insurance Portability and Accountability Act] code set rule,” Miscoe said. “So the first thing you have to understand as a forensic coder is that the codes in their descriptions are standard. The rules for how the codes are used are not. If I’m coding for a personal injury claim in Florida, I might be using different code selection rules than if I was coding for a Blue Cross claim in Oklahoma.”
For even the most experienced medical coders, this can sometimes be difficult to comprehend. As coding students, you learn about the fundamental coding standards based upon Current Procedural Terminology (CPT) editorial panel guidance, the Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases (ICD). The right or wrong code may seem like a straightforward answer you could easily look up, but a forensic medical coder understands how to tease out which rules apply to each individual case.
“An easy synonym for forensic coding is rules-based coding. It’s similar to the process that they teach you day one in law school, they teach you the analytical process called IRAC: issue, rule, analysis, conclusion. Forensic coding follows that same model, except you’re rendering an opinion about a factual issue—what’s the right code, rather than a legal issue. But there are rules for how to code, and it gets really fun when there isn’t a rule,” Miscoe said. “The mistake that most coding experts make is they start with a conclusion based upon what they believe to be true, then they go look for a justification.”
How to become a forensic medical coder
Becoming a forensic medical coder begins with a strong foundation in medical coding education followed by many years of experience and some specialized training. That said, there is no singular path you must follow to be a forensic coder. Some forensic coders have wildly different professional backgrounds that all led them to the same career. Miscoe, for instance, has a bachelor’s degree in electrical engineering and later went to law school. Others may switch to coding from clinical careers as a doctor or nurse. The bottom line is that you must develop certain skills and expertise to become a code which can be achieved in a variety of ways.
Education requirements
Though it’s possible to move into a medical coding job with some prior healthcare administration experience in areas such as billing and finance, most new medical coders learn the ins and outs of the job through dedicated education programs. These include diploma and certificate programs as well as associate degree programs in medical coding and billing, which are typically offered by community and technical colleges. They can take anywhere from about nine months to two years to complete depending on the program. Alternatives include specific preparatory curricula from certifying organizations such as the AAPC (formerly known as the American Academy of Professional Coders). Bear in mind that these programs only teach coding fundamentals, as there are no formal education programs (other than a curriculum developed for the AAPC by Miscoe) for forensic coding specifically.
Though most standard medical coders may not need any more education to kickstart their careers, forensic coders need a more diverse skillset to be successful, which additional education can help with.
“My mentor would send me cases or I’d read stuff and then have questions about the basis for a legal decision, and he’d say, ‘Michael, that’s just one of those things that three years of law school will help you understand.’ I got so sick of hearing it that I finally went. People have asked me, ‘Do I have to become a lawyer to be a good coding expert?’ No, but it really helps.”
Even just auditing a college class or two can help develop some of those crucial skills.
“I always recommended people go take a college writing course pertaining to persuasive and argumentative writing. Usually it’s an advanced course, pull one out of a law school curriculum or something if they’ll let you take it or audit it. You can’t be an effective expert if you cannot articulate your opinions in writing. Therefore, it is essential that you develop solid writing skills” Miscoe said.
Experience
After completing your education, it’s all about getting experience in the field. Most standard medical coding jobs want candidates to already have a few years of relevant healthcare experience under their belt, so finding a job right after graduation may be challenging for younger professionals at the very start of their careers. Medical billing jobs tend to be a little more entry-level-friendly, so you may have to start there and work your way into a coding position later.
That said, many students in medical coding programs already have experience or are switching careers, so the experience piece may not be as much of an issue for some.
Once you get established in a medical coding job, Miscoe said it simply takes years of experience working through a wide variety of issues with numerous payers to develop the skills and expertise needed to be a forensic coder.
Professional certifications
No matter where you are in your coding career journey, professional certifications are also an excellent way to demonstrate not only your qualifications but your skills to employers. They also help beef up your resume so that you stand out among the competition. Since forensic medical coders are generally considered experts in their field, certifications are very important for establishing your baseline qualifications.
Both the AAPC and the American Health Information Management Association (AHIMA) offer some of the most widely recognized medical coding certifications available. Their entry-level certifications include:
“You need a core coding credential and then if you’re going to do expert work in a particular specialty, you should have that specialty coding credential as well,” Miscoe said.
As you progress in your career, you may want to consider earning some of these advanced certifications that require more experience and are more relevant for forensic medical coders:
“I also recommend you get the auditing credential and get the compliance credential. Compliance gets you closer to rules, not all of them, but compliance is based upon obviously complying with certain standards. And the auditing credential gets you closer to how to look in a record and apply whatever facts you find to the rule as part of that analysis step,” Miscoe said.
Essential skills for forensic medical coders
When thinking about how to become a forensic medical coder, it might be more helpful to identify the skills needed to thrive in this dynamic career and work towards honing them. Miscoe said that there are a couple of must-have proficiencies if you want to be successful as a forensic coder, including expertise in relevant medical knowledge, research and analysis, writing and testimony.
Firm understanding of medicine
“The trick to forensic coding, step one, you have to have subject matter expertise in the code rules, but you also have to have subject matter expertise in the medicine. You have to understand what the doctor’s doing,” Miscoe said.
You get some exposure to the need-to-know medicine, basic anatomy and medical terminology in a coding program, but you have to commit yourself to lifelong learning if you really want to become a master. For instance, Miscoe said he generally spends much more of his time reading medical literature than he does reading coding and reimbursement policies.
Because of this, people with clinical backgrounds such as doctors, nurses and other allied health professionals can make excellent coders since they are already intimately familiar with the medicine. This is essential for being able to understanding the work involved in the procedure being performed so that it may be coded correctly.
Research and analysis
Once assigned to a case, forensic coders must perform a lot of research.
“The second area that you must have subject matter expertise in is your research skills. You’ve got to be exceptional at finding what the payer’s rules are. You’ve got to be able to read a contract. You’ve got to find out what standards the doctor is liable, which under the contract, can include medical policies, provider manuals or other guidance.”
Miscoe said this process is very similar to the process that they teach you in law school:
Issue: Identify the legal issue or question at hand.
Rules: What are the rules (laws, policies, regulations, etc.) that apply to the issue at hand?
Analysis/Application: Analysis of the records and other evidence (testimonial, physical, analytical, etc.) to determine if the binding requirements were complied with.
Conclusion: Arrive at a conclusion based upon the analysis.
“First we have an issue. Next, we need to find the binding rules whether they be contractual, statutory, regulatory or a combination of the three. Once the binding standards have been identified and evaluated, the next step is to outline which parts of those standards apply to issue evaluated. Next comes the analysis, which means now I have to dig into the records and other evidence to determine if the conditions of payment have been satisfied. This is where you have to understand the medicine—really exceptional coders know more about the medicine than they need to know about the coding,” Miscoe said.
Writing
Whether you’re researching a case or preparing for legal testimony, a forensic medical coder must have exceptional writing skills.
“You have to learn how to write. If you cannot write, you are not going to survive as an expert because absent the ability to articulate your opinion in a very logical, step-by-step manner, you cannot convince a judge, jury or the other side that your opinion is objectively valid. So learning how to write effectively is a critical, core function for any forensic coding expert.”
Testimony
Miscoe said that forensic medical coders may only testify for about 2-5% of their cases, and the rest are resolved by settlement. Still, being able to provide testimony is a critical skill for a forensic coding expert. When it happens, you need to be prepared if you’re going to withstand the legal heat of a deposition or cross-examination at trial.
“At some point, somebody’s going to want to depose you and ask you questions about your opinion.” When a case advances to the deposition phase and beyond, you’re going to get grilled by the opposing legal team. A good forensic coder, Miscoe said, must learn to anticipate the questions likely to be raised and logic traps associated with those questions well before they are ever asked—even during the analysis of the issues and drafting of the expert report. “You’ve got to think three layers deep.”
A question many ask, then, is how do you learn to testify well?
Miscoe advises that those looking to progress into a role as a forensic expert prepare for testimony by doing ”coding or compliance lectures to physicians or people who are coders, people who are going to question you and challenge you. When you learn to deal with sharp shooters in the audience politely but authoritatively, that’s what prepares you for cross examination. Opposing counsel will often try to set you up with loaded questions and you have to be able to deconstruct the question before you start into the answer. It requires a degree of mental discipline, and you have to make your answers simple and logical, because you’ve got a jury who knows one millionth of what you know about coding. Maybe they know nothing at all, and you have to make it simple for them. The key is being able to use common sense analogies as a means of explaining complex coding and reimbursement concepts. Becoming a solid lecturer will help you prepare.”
Is this career right for me?
Forensic coders make up a very small fraction of the number of medical coders out there. In fact, calling it a niche within the field is practically an understatement. Miscoe said that the sheer amount of work you must do—researching cases, devouring relevant information, preparing expert reports, assisting with the preparation of deposition and cross-examination plans and so much more—is often enough to dissuade someone from pursuing this career.
That doesn’t mean forensic coding is an impossible career path, however. It just means that it takes a particular type of dedicated person to do well in this field.
“To me, it is the most fascinating field in coding,” Miscoe said. “What makes it fun is not only matching with another expert—because a lot of these cases become the battle of the experts—but it’s going through all of that and preparing your brain for a bunch of different permutations of an argument and questions that may or may not be asked so that you can secure agreement with your opinion from an adjudicator.”
If you’re still wondering if you’re cut out to be a forensic medical coder, consider asking yourself:
If you can answer yes to these questions, forensic medical coding may be a good fit for you.
“You’re going to win cases you’re supposed to lose. You’re going to lose cases that you’re supposed to win. But if your opinion’s solid, you’ve prepped your attorneys and you’re doing your job as an expert, you’re going to keep getting hired,” Miscoe said. “You also have to be willing to get fired a lot, because sometimes people ask you for an opinion that you can’t honestly give, and so the moment you start selling your opinion, you’re done.”
It’s a lot of work, but like anything, Miscoe said it does get easier over time.
“You get efficient because you’ve analyzed certain issues before. I’ve got 30 years’ worth of cases pertaining to a variety of issues where I can look at a case and go, okay, we did that before, we did this payer before. I’ve already got that analysis done, I just need to shepherd and make sure it’s still current and then we’re off to the races and I already have the argument written. As you get more efficient, there’s lower cost to the client. Then they appreciate that because you’re not learning an issue from scratch.”
Eventually you should be able to hire people to do a lot of that grueling grunt work for you, part of the reward for being in the business long enough.
…the sheer amount of work you must do—researching cases, devouring relevant information, preparing expert reports, assisting with the preparation of deposition and cross-examination plans and so much more—is often enough to dissuade someone from pursuing this career.
Salaries for forensic coders
According to the 2023 Occupational Employment and Wage Statistics from the U.S. Bureau of Labor Statistics (BLS), the median annual salary for medical records specialists—which includes medical coders—is $50,250. Unfortunately, they do not have data on typical salaries for forensic medical coders specifically, so this figure may not be entirely accurate.
The AAPC also has their own annual salary report which can be a helpful resource to get an idea of your earning potential as a medical coder. They reported that in 2023, individuals with the CPCO and CPMA credentials—both of which Miscoe recommends forensic coders pursue—earned an average annual salary of $89,010 and $77,692, respectively. As with any career, keep in mind that factors such as education level, experience, geographic location, employer type and more can all influence individual salaries.
Your earning potential as a forensic coder could be higher still. Miscoe said that some firms that provide coding experts charge close to a thousand dollars per hour for their services. Experts in business for themselves, if competent, can command $500 per hour or more. Unfortunately, until you get established, which takes years, Miscoe said you can’t count on having a consistent 40-hour work week. That said, once established, the monetary potential makes the substantial effort involved well worth it.
Parting words
Forensic medical coding is an incredibly niche specialty area within the larger field of medical coding, but it’s one that could be a great fit for coders who have a taste for the law and legal minutiae. You can’t go to school to become a forensic coder specifically, but you can develop the necessary skills and credentials while you gain experience over time. Finding an experienced mentor wouldn’t hurt, either. If you think you have what it takes to thrive in this demanding field, consider what education you may need to kickstart your career today.
